Categorizing Human Performance Hazards for Safety Management Systems Dr. Bill Johnson Chief Scientific and Technical Advisor Maintenance Human Factors Bill-dr.johnson@faa.gov 678.777.3873 Federal Aviation Administration
Presentation Plan HF Challenges in Flt. Operations? SMS to the Rescue? PEAR : A way to consider HF Hazards New Thoughts and Actions Q&A 2 of 44
Top 10 Challenges - ALL Category Name % Vote # Score Culture/Leadership 24 524 Tech Documentation 16 356 Fatigue 11 248 Voluntary Reporting 6 134 ROI 5 120 HF Training 5 108 Pressure/Stress 4 99 Oversight & Regulations 4 95 Professionalism 3 64 Other 3 61
www.humanfactorsinfo.com www.humanfactorsinfo.com 4 of 44
Presentation Plan HF Challenges in Flt. Operations? SMS to the Rescue? PEAR : A way to consider HF Hazards New Thoughts and Actions Q&A 5 of 44
Safety Management Systems Should: Formalize data collection Prompt deeper root cause analysis Identify hazards and opportunities for continuing safety Keep a focus on human factors. (PEAR) Measure HF! Allocate new resources to HF hazards Show how HF interventions return the investment (Safety & Money) Federal Aviation Administration 6 of 44
Presentation Plan HF Challenges in Flt. Operations? SMS to the Rescue? PEAR : A way to consider HF Hazards New Thoughts and Actions Q&A 7 of 44
Whatever Works for You: The Models 8 of 44
People who perform the job Environment for work - Organizational and physical Actions (tasks) performed as part of the job Resources like equipment, tools, procedures, and more 9 9 of 44
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People Example factors Physical Size Gender Age Strength The five senses Physiological Health Nutrition Lifestyle Alertness/fatigue Psychological Experience Knowledge Training Attitude Emotional state Psychosocial Interpersonal relations Ability to communicate Empathy Leadership Chemical dependency 11 11 of 44
PEAR Can Address a Lot of Issues! 12 12 of 44
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People Examples 14 of 44
Ryanair 737-800 (September, 2005) B-737 made three un-stabilized approaches, in thunder storms, to separate Italian airports. Final landing was saved by low-time 1 st Officer. Captain did not report that infant son had died that week.
Fatigued & Cold Medicine = Bad Day
Environment Examples 17 of 44
Aloha Airlines B737-200 Kahului, Hawaii, U.S.A. 1988 Upper fuselage separation
Alaska Airlines MD-83 Port Hueneme, CA, US 2000 Horizontal Stabilizer Jackscrew Failure 19 of 54
Action Examples 20 of 44
AeroPeru Lima, Peru 1996 Tape left on static ports 757-200
Hilos B-737 Grammatiko, Greece 2005 Flight crew incapacitation/fuel starvation 737-300 22 of 54
A320-200 at Perpignan, France (November 2008) Pilots from XL Airways and Air New Zealand XL was returning A/C after 2 year lease Acceptance check ride Did not adhere to pre-agreed flight schedule Did not reserve airspace for necessary testing 2 of 3 AOA sensors were inop due to improper cleaning Crew were not trained for acceptance test missions.
BA 319 Heathrow 2013 24
Be the Passenger 25
The Good News
Post Mx and Preflight Checks?? 27
Resource Examples 28 of 44
American Airlines DC-10 Chicago, Illinois, U.S.A 1979 Engine fell after take-off
Charlotte, NC: Air Midwest Flight 5481, Jan 2003 Resource Issues: technical documentation, training, personnel resources, busy schedules, fatigue training 30 of 44
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Are the challenges real? 32
December 07, 2011 AeroStar 350-B2 Tour of the Hover Dam
Additional Information Following 100 Hr. Inspection Fore/aft Servo was replaced Post maintenance check flight flown 2 revenue tour flights flown Flight time since maintenance was 3.5 hours
Cause The main rotor fore/aft servo flight control input rod was not connected. Bolt, washer, locking nut, and cotter pin were missing. 35
Fatigue Issues Mechanic claimed 5 hours of sleep Inspector claimed 7 hours of sleep
Presentation Plan HF Challenges in Flt. Operations? SMS to the Rescue? PEAR : A way to consider HF Hazards New Thoughts and Actions Q&A 38 of 44
Compliance Philosophy?. When deviations from regulatory standards do occur, the FAA s goal is to use the most effective means to return an individual or entity..to full compliance and to prevent recurrence..faa recognizes that some deviations arise from factors such as flawed procedures, simple mistakes, lack of understanding, or diminished skills. The agency believes that deviations of this nature can most effectively be corrected root cause analysis and training, education or other appropriate improvements to procedures FAA Order 8000.373, June, 15 Federal Aviation Administration 39 of 44
Compliance Philosophy for Inspectors the Aircraft Flight Standards approach to oversight and compliance is evolving to stress an engaged, solutionoriented, outcomes-based approach. The goal is to identify deviations from standards and correct them as effectively, quickly, and efficiently as possible.this approach will more effectively address inadvertent deviations and conserve FAA enforcement for intentional, reckless, criminal, and uncooperative behavior....accordingly, AFS leaders, managers, and supervisors will support inspectors when they use critical thinking to exercise sound professional judgment and take actions in accordance with this notice. FAA Order 8900.323. Federal Aviation Administration 40 of 44
Compliance Philosophy: Components
Aviation Safety Action Program (ASAP) Formalized Voluntary Reporting System Not unanimous but without blame Panel includes: Mgmt., Labor, and FAA No-Nos are: (Criminal Activity, drugs/alcohol, intentional falsification) See FAA AC120-66B
Employee Groups Represented 43 of 43
Presentation Summary HF Challenges in Flt. Operations? SMS to the Rescue? PEAR : A way to consider HF Hazards New Thoughts and Actions Q&A Google: Aviation Pros Johnson 44 of 44