Human factors update. Is it always the fault of the pilot?

Transcription

1 Human factors update Is it always the fault of the pilot?

2 Human factors Passenger: Sorry, our plane was late. At run up the pilot was concerned about the function of the engine. We had to taxi back and..

3 Human factors get another pilot

4 1986 assembly of ICAO, Resolution A26-9 To improve safety in aviation by making States more aware and responsive to the importance of human factors in civil aviation operations through the provision of practical human factors material and measures developped on the basis of experience in the States Importance Instruction Improvement

5 Human factors update: Topics Background Causes of accidents Classification Physiology Psychology Cockpit design

6 Accidents: the good news

7 Swiss Air Force (Press/Media) - Am 8. September 2016 stürzt ein Super Puma am Gotthardpass ab und gerät in Brand. Die beiden Piloten sterben, der Flughelfer wird verletzt. - Einen Monat zuvor zerschellt im Gebiet des Sustenpasses ein F/A-18-Kampfjet. Der Pilot wird tot geborgen. Der Flugverkehrsleiter hatte eine zu tiefe Flughöhe angeordnet. - Am 9. Juni stürzt F5-Tiger-Kampfflugzeug der Patrouille Suisse bei einem Training vor einer Flugshow in den Niederlanden ab. Der Pilot kann sich mit dem Schleudersitz retten. - Auch mit dem PC-7 ist es in der Vergangenheit zu mehreren Zwischenfällen gekommen. Zuletzt an der Ski WM in St. Moritz. Ein Flugzeug der PC-7- Fliegerstaffel zertrennt das Zugseil einer Seilbahnkamera. Die Kamera fällt in den Zielraum und landet im Schnee. Verletzt wird niemand.

8 Airprox incidents (Skyguide) Analysis of Human Factor Causes in Air Traffic Incident Reports in Switzerland Celine M. Muehlethaler, Chiara P. Knecht and Yolanda Schuetz Centre for Aviation, School of Engineering, Zurich University of Applied Sciences, Winterthur, Switzerland EAAP congress, Malta, 2014

9 Prozent der Unfälle Statistics (often used slide) Jahr Fliegerische Fertigkeiten Regel Verletzungen Entscheidungs Fehler Wahrnehmungs Fehler Post processing (SUST) Does not help in understanding why the accident happend Social pressure? Environment?

10 Human Factors Analysis and Classification System (HFACS) Swiss Cheese Model Secondary analysis process Labelling understanding Only understanding may lead to prevention

11 Hazardous events in US Pilots (Hunter, 1995) Low fuel incidents: 20 35% Fly VFR into IMC: 22% Become disoriented: 16% Vertigo in IMC: 5-9% Turned back due to weather: 71-77%

12 Fundamental factors for good instruction (1) You have calculated that a VFR cross-country flight will take one hour. What is the legal minimum requirement for fuel in terms of time? On a VFR flight, are you allowed to fly above an unbroken cloud layer if you meet all cloud separation requirements? Look at the attitude indicators below. In each case, decide which way you would have to roll your airplane to get the wings level with the horizon.

13 Fundamental factors for good instruction (2) Look at the VOR indicator below. Which way would you turn to intercept the inbound radial to the VOR?

14 Fundamental factors for good instruction (3) Assume you are on a normal approach and the runway looks like illustration A below. Later in your flight, you are approaching a runway which looks like illustration B below. How would you judge your approach to runway B (high, good, or low)?

15 Fundamental factors for good instruction (4) Read the following numbers Now cover them with your hand and write them out from memory. What are the regulations concerning drinking and flying? If you are having marital or relationship problems, will your ability to fly safely be affected?

16 Human factors: Physiology Altitude effects Fatigue/Sleepiness Nutrition Chemical Agents Illusions

17 Illusions (Vestibular, Vision)

18 Drugs

19 Effect of alcohol

20 Nutrition/Hypoglycemia Lindseth et al High-fat and high-carbohydrate diets had better cognitive flight performance scores than the pilots who consumed the highprotein diets

21 Gewichtsabnahme in Prozent Dehydration in gliding pilots Gewichtsdifferenz in Prozent pro Flug Flüge Drechsel S, 2013

22 Flugunfall Saanen

23 Flugunfall Saanen

24 Myths and facts Myth Experts who make errors performing a familiar task reveal lack of skill, vigliance, or conscientiousness Fact Skill, vigilance, and conscientiousness are essential but not sufficient to prevent error Myth If experts can normally perform a task without difficulty, they should be able to perform that task correctly Fact Experts periodically make errors as a consequence of subtle variations in task demands, information available and cognitive processing

25 Causes of accidents The cause is simply the last thing that happened before the crash There are no single causes for accidents Causes are facilitators of accidents

26 Understanding accidents Pilot Skills Medical Attitude Social Pressure PAX Aircraft Environment

27 SHEL Model Software Manuals Checklists Liveware Pilots ATCOS Mechanics Environment Weather Hardware Aircraft

28 Psychology Stress Attitudes/Hazardous thought patterns Aeronautical decision making Risk awarness Cockpit design

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30 Hazardous thought patterns Anti-authority Impulsivity Invulnerability Macho Resignation

31 DECIDE (Benner 1975) D etect the fact that a choice must be made E stimate the significance of the choice C hoose a safe outcome I dentify plausible actions D o the best option E valuate the effect of the action

32 Pilot Judgment Model (Jensen 1995) Problem vigil (Expect the unexpected) Recognition (changes will affect the safety of the flight) Diagnosis Alternative identification Risk assessment Background factors (competition, social pressure) Decision-making Action

33 Detailed decision model Perception: Where should I look? Recognition: What do I see? Interpretation: What does it mean Response selection: What should I do? Execution: Can I do it? Evaluation: What happend

34 Biases in decision making (1) Self-serving bias Overestimating personal abilities and underestimation situational demands Confirmation bias The tendency to search for or interpret information in a way that confirms one s perception Serial position effect Information presented early is remembered better than information presented later Loss-aversion bias The strong tendency for people to prefer avoiding losses rather than acquiring gains

35 Biases in decision making (2) Valence effect of prediction bias The tendency to overestimate the likelihood of good things happening and to underestimate the chance of bad things happening False consensus effect bias The tendency for people to overestimate the degree to which others agree with them Anchoring bias The tendency to rely too heavily, or anchor, on one trait or piece of information

36 Contributing factors Social pressure Experience with aircraft Thought patterns Macho: I can do it Invulnerability: It won t happen to me Risk perception Decision making

37 Safe flight in GA Nice flight Some landings Goal +/- flight instructor Training? Weather? DABS NOTAM Risk

38 Learning and Forgetting (ex. gear/flaps) Cognitive Associative Autonomous

39 Risk factors Skills, Experience Pilots with little experience have smaller goals Weather Mountains Competition Age??

40 Cockpit design

41 EFIS Disadvantages Many manufacturers Large manuals Basic navigational skills Time for use

42 FLARM

43 Why accidents happen > 80% of the accidents in GA are caused by human factors Not only young pilots Not only unexperienced pilots VFR flights Personal flights

44 Cooperative efforts to improve safety Weather hazard index Reorganize weather briefings Exams: Scenario based questions Training for flight instructors on risk assessment Develop better displays (fuel indicator) Training which adresses the issues involved in crash survivability Role-playing simulations to resist social pressures Membership in flying clubs

45 Summary Pilots do not really feel that they are at risk Fatigue, drugs, visual illusions Lack of aptitude or abilities Organizational and interpersonal issues Feeling of invulnerability Advanced technology not always improves flight safety

46 Literature Human Factors for General Aviation (Trollip/Jensen, 1991) Aviation Psychologie and Human Factors (Martinussen/Hunter, 2017) Basic Aviation Knowledge (BAK-Ordner), Menschliches Leistungsvermögen PPL (Huber, 2015)

47 Danke für die Aufmerksamkeit