1. Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training Kathy H Abbott, PhD, FRAeS Federal Aviation Administration Capt. John M. Cox, FRAeS Safety Operating Systems 27 April 2010

2. 2 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Pilots Are Unique People

3. 3 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Old ViewNew View Human error is the cause of accidents Human is the most unreliable component Improve safety by restricting human action Human error is the effect of deeper issues Human is necessary to create safety Improve safety by understanding (and leveraging) human performance From Dekker 2002 Human Error and Aviation Safety

4. Risk Mitigation – Where? Designer Error PilotDesign Engineer Envelope Protection TCAS/ ACAS Flight Director Pilot ErrorFlexibility/ Adaptability Cat III Autoland Circling Approaches

5. 5 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Overview Flight Path Management and Flight Deck Automation – where can training be improved? WHY do errors occur? Looking beyond error at the “sharp end”

6. 6 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Flight Path Management and Flight Deck Automation – where can training be improved? Performance-based Operations Aviation Rulemaking Committee (PARC) and Commercial Aviation Safety Team (CAST) PARC/CAST (preliminary results) FAA International Rudder Survey Recent accidents/incidents

7. 7 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Flight Deck Automation Working Group Joint under the Performance-based Operations Aviation Rulemaking Committee (PARC) and Commercial Aviation Safety Team (CAST) Current design, training and use of flight path management systems in transport airplanes in “121-like” operations Preliminary results from: –734 incidents from Aviation Safety Reporting System (ASRS) within scope –46 major incidents and accident reports within scope –normal ops via Line Operations Safety Audit (LOSA)

8. 8 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010

9. 9 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 X X X X X X X

10. 10 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Potential Areas for Improved Pilot Training Manual handling Flight path management systems Unusual attitude avoidance, recognition and recovery Speed and energy management Use of rudder Managing malfunctions Managing distractions Crew coordination and communication

11. 11 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Turkish Airlines Flight TK 1951

12. 12 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Adapted from Reason

13. 13 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Legal

14. Regulatory

15. 15 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Organization

16. 16 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Equipment Design Training Procedures

17. 17 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Pilot

18. 18 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Data Collection? Investigations? Training?

19. 19 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Operators, Regulators, Manufacturers, Training Organizations… It is about training all the people

20. 20 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010 Old View New View Revised Human error is the cause of accidents Human is the most unreliable component Improve safety by restricting human action Human error is the effect of deeper issues Human is necessary to create safety Get away from blame and ask “why”? Improve safety by understanding (and leveraging) human and organizational performance Human Error and Aviation Safety

21. 21 Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training WATS 27 April 2010