SAFE WINGS. This issue HUMAN FACTORS IN AVIATION AMERICAN AIRLINES FLIGHT 383. * For Internal Circulation Only

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1 * For Internal Circulation Only SAFE WINGS Flight Safety Magazine of Air India, Air India Express and Alliance Air Issue 70 March 2018 This issue HUMAN FACTORS IN AVIATION AMERICAN AIRLINES FLIGHT 383

2 SAFE WINGS March Edition70 EDITORIAL Airline travel is now considered the safest mode of transport. However when accidents do occur they are often catastrophic. Accidents rarely have a single causal factor. That is why the SHELL model was developed. In this issue we have featured an article on Human Factors and an accident indicating breakdown in this interface. ACKNOWLEDGEMENTS The posting of stories, reports and documents in this magazine does not in any way, imply or necessarily express or suggest that all the information is correct. It is based on details gathered from various sources and is for information purpose only. The Flight Safety Department is making this material available in its efforts to advance the understanding of safety. It is in no way responsible for any errors, omissions or deletions in the reports. 1 P a g e

3 March Edition 70SAFE WINGS Human Factors in Aviation It is not true that accidents only happen to people who are irresponsible or "sloppy."seventy per cent of today's civil aviation accidents are caused by human factor. Error is a normal and natural part of everyday life it is generally accepted that we will make errors daily. Some people refer to the terms human factors and human error as if they are the same. Human factors is a field of scientific knowledge drawing from established disciplines such as ergonomics, physiology, psychology and engineering. Human error is really the outcome or consequence of our human performance limitations. Human error can be divided into either intentional or unintentional actions.» Intentional actions those actions that involve conscious choices. These actions are largely due to judgement or motivational processes.» Unintentional actions those in which the right intention or plan is incorrectly carried out, or where there is a failure to carry out an action. These actions typically occur due to attention or memory failures. Slips are errors made when you don t pay attention, or your plan is incorrectly carried out. Lapses occur as a result of you failing to carry out an intended action, usually due to a memory failure Mistakes occur when you plan to do something, and carry out your plan accordingly, but it does not produce the outcome you wanted. This is often because your knowledge was inadequate, or the rules you applied in deciding what to do were inappropriate. Violations involve deliberately (and consciously) departing from known and established rules or procedures. How to avoid, trap & Mitigate errors Monitor crosscheck Communicate Effectively Workload management Vigilance Automation management 2 P a g e

4 SAFE WINGS March Edition70 Frequently update & share oursituational Awareness Brief Effectively Use SOP s When a team leader has an overbearing, dominant and dictatorial style of management, the team members will experience a steep authority gradient. Team members will view such leaders as overly opinionated, stubborn, and aggressive. When such conditions exist, expressing concerns, questioning decisions, or even simply clarifying instructions will require considerable determination as any comments will often be met with criticism. Team members may then perceive their input as devalued or unwelcome and cease to offer anything; and, in extreme cases, cease to participate completely. Steep Authority gradients act as barriers to team involvement, reducing the flow of feedback, halting cooperation, and preventing creative ideas for threat analyses and problem solving. Only the most assertive, confident, and sometimes equally dominant team members will feel able to challenge authority. Authoritarian leaders are likely to consider any type of feedback as a challenge and respond aggressively; thereby reinforcing or steepening the gradient further. While dealing with Authority gradient we need to overcome Hierarchy Fear of being wrong Consequence Etiquette promoting TRM(Team Resource Management) Be punctual Of primary importance is dressing smart, smelling good, and looking professional so you re welcomed into the group and not shunned by your co workers. Be hygenic and keep the workplace clean, neat and organized. Leaving it orderly is important. Respect personal space Try to learn not test the other s knowledge. Share information, Discuss! Try to teach, not project knowledge. Present relevant information at correct time. Avoid probing personal information or being prejudicial. Try not to not gossip or backbite colleagues, you will be indebted to them sooner or later. 3 P a g e

5 March Edition 70SAFE WINGS Support the other crew members weakness, share your strength. Do not endlessly Crib about your job and company. Remember they both feed you. Avoid discussing irrelevant contentious issues such as politics and religion Project the company and profession in positive light, always. Be an asset in the work place and not a Liability to the other co-workers. Usage of CRM in an Adverse situation Crew resource management(crm) is a set of training procedures for use in environments where human error can have devastating effects. Its focus is to improve safety by focusing on interpersonal communication, leadership, and decision making in the workplace. A CRM expert named Todd Bishop developed a five-step assertive statement process that encompasses inquiry and advocacy steps: 1. Opening or attention getter - Address the individual. "Captain Kumar," or "Suresh," or Sir or however the name or title that will get the person's attention. 2. State your concern - Express your analysis of the situation in a direct manner while owning your emotions about it. "I'm concerned that we may not have enough fuel to fly around this storm system," or "I'm worried that this seal will give way." 3. State the problem as you see it - "We're showing only 40 minutes of fuel left," or "This building has a lightweight wooden roof, and it may be a fire hazard." 4. State a solution - "Let's divert to another airport and refuel," or "I think we should pull some tiles and take a look with the thermal imaging camera before we permit anyone inside." 5. Obtain agreement (or buy-in) - "Does that sound good to you, Captain?" To handle interventions in an adverse situation, a new measure is proposed to be added to CRM training known as Graded assertiveness. 4 P a g e

6 SAFE WINGS March Edition70 1) "P.A.C.E." is the acronym used to define this new set of survival skill: P-Probing for a better understanding; Sir, If you don t mind can you explain why we are doing this? A-Alerting Captain of the anomalies; Captain, I think we are high. C-Challenging suitability of present strategy; Sir, I feel that we should go around I am not comfortable. E-Emergency Warning of critical and immediate dangers; Captain, If we not divert in the next 2 mins we will land below minimum reserve fuel at alternate or Captain Go- Around Now. Handling Emergencies: Use acronym N.I.T.S In an Office situation: N-Nature of emergency: e.g. There is a Bomb in the building I-Intention: e.g. We have to evacuate T-Time Available: e.g. Within 5 minutes S- Special Instruction: e.g. Call Bomb Squad, Fire department, Inform CEO, Safety Department etc. In a Flight situation: N- Nature of emergency: e.g. Unextinguished Engine Fire I-Intention: e.g. Diversion to.. T-Time available: e.g. We have 30 minutes to land S- Special Instruction :e.g. Professionalism Checklist a. Brief Cabin crew and passengers b. Inform ATC that Fire services will be required and evacuation on Runway c. Tell ATC to inform company 1. Do you always report for duty rested and prepared? 2. Are you continuously refreshing your knowledge? 3. Are you rigorously following checklists and proscribed procedures? 4. Do you discipline yourself to stay at least 10 minutes ahead of the aircraft? 5 P a g e

7 March Edition 70SAFE WINGS 5. Do you use quiet moments in the cockpit productively (i.e., to recheck the flight management system or flight plan)? 6. Do you thoroughly brief and communicate with everybody, including other crewmembers and air traffic control? 7. Do you fly with precision? 8. Do you always push for a higher standard of professional flying? 9. What do you expect from others? Do you mentor new employees? 10. Do you ask for and give honest feedback? 10 Ways to Be Professional 1. Competence. You re good at what you do and you have the skills and knowledge that enable you to do your job well. 2. Reliability. People can depend on you to show up on time, submit your work when it s supposed to be ready, 3. Honesty. You tell the truth and are upfront about where things stand. 4. Integrity. You are known for your consistent principles, honestly and do what is right. 5. Respect For Others. Treating all people as if they mattered. 6. Self-Upgrading. Rather than letting your skills or knowledge become outdated, you seek out ways of staying current. 7. Being Positive. No one likes a constant pessimist. Having an upbeat attitude and trying to be a problem-solver makes a big difference. 8. Supporting Others. You share the spotlight with colleagues, take time to show others how to do things properly, and lend an ear when necessary. 9. Staying Work-Focused & Disciplined Not letting your private life needlessly have an impact on your job, and not spending time at work attending to personal matters. 10. Listening Carefully. People want to be heard, so you give people a chance to explain their ideas properly. 6 P a g e

8 SAFE WINGS March Edition70 The primary focus of any human factors initiative is to improve safety and efficiency by reducing and managing human error made by individuals and organisations. The Shell Model S = Software: i.e. the procedures and other aspects of work design H = Hardware: i.e. the equipment, tools and technology E = Environment: i.e. the environmental conditions during work Indu P G About The Author:- Indu is a graduate Engineer and postgraduate MBA in Aviation Business Management. Currently she is spearheading her efforts with Flight Safety of Air India Express as a Sr. Officer L = Liveware: i.e. the human aspects L = Liveware: i.e. the interrelationships between humans The SHELL model emphasises that any breakdown or mismatch between two or more components can lead to human performance problems. For example, an accident where communication breaks down between pilots in the cockpit, or engineers at shift handover, would be characterised by the SHELL model as a livewareliveware problem. Situations where pilots or engineers disregarded a rule would be characterised as liveware-software problem. 7 P a g e

9 March Edition 70SAFE WINGS INVESTIGATION REPORT ON AMERICAN AIRLINES FLIGHT 383, A BOEING 767, UNCONTAINED ENGINE FAILURE AND SUBSEQUENT FIRE AT CHICAGO O HARE INTERNATIONAL AIRPORT INCIDENT 28 October 2016, during the takeoff roll, the flight crew heard a loud bang and initiated a highspeed rejected takeoff, stopping the aircraft on the runway. Fire and thick black smoke were present on the right side of the aircraft. The flight attendants initiated an emergency evacuation and all 170 passengers and crew were successfully evacuated the aircraft, but 21 people were injured, one seriously. The airplane was substantially damaged from the fire. FINDINGS The uncontained engine failure resulted from a high-pressure turbine (HPT) stage 2 disk rupture. The HPT stage 2 disk initially separated into two fragments. One fragment penetrated through the inboard section of the right wing, severed the main engine fuel feed line, breached the fuel tank, traveled up and over the fuselage, and landed about 2,935 ft away. The other fragment exited outboard of the right engine, impacting the runway and fracturing into three pieces. 8 P a g e

10 SAFE WINGS March Edition70 Investigators found that defect had been developing microscopic cracks in the disk of General Electric CF6-80C2B6 engine for as many as 5,700 flight cycles (one takeoff and one landing), prior to the accident. Evacuation procedure The investigators also found that the evacuation of the airplane occurred initially with one engine still operating. The flight crew shut down the affected right engine, and they shut down the left engine during their evacuation checklist. But the evacuation began before the checklist was complete. Normally, the cabin crew would communicate with the flight crew to coordinate. But in this accident, there were no communications between the cabin and the cockpit before or during the evacuation. As a result, flight attendants initiated the evacuation with the left engine still running. The one seriously injured passenger was blown over by jet blast from that engine. Public responsibility Flying public: Follow your crew s instructions. In this case, as in some prior evacuations, some passengers retrieved their baggage despite flight attendant instructions to leave it behind. One passenger even resisted a flight attendant attempting to take away a carry-on bag in a burning airplane. Things can be replaced. People can t. Pilots and flight attendants need your cooperation, as a passenger, to perform safe and orderly evacuation. They ll tell you when, where, and how to exit and to leave your baggage behind. Lessons learnt: 1. Whatever the emergency, always remember that the plane has a number of passengers and cabin crew sitting behind and they are unaware of the situation. Do not keep them in the dark. : Communicate.(Liveware-Liveware) 2. Follow the checklist and correct sequence. (Liveware-Software) 9 P a g e

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12 We give utmost importance to your valuable comments and feedback. Please do mail us at or PROMISING A SAFER SKY, AIR INDIA, AIR INDIA EXPRESS & ALLIANCE AIR Editorial: Capt V Kulkarni, Bhavish B S Designed by Bhavish BS