Safety Stand Down 2013 Building a Safety Community
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Transcript of Safety Stand Down 2013 Building a Safety Community
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Presented to: T BAA By: Tampa FAASTeamDate: April 17, 2013
Federal AviationAdministration
• Federal Aviation• AdministrationSafety Stand Down
2013
Building a Safety Community
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Agenda0745 – 0845 Breakfast0845 - 0950 Welcome and Introductions0950 - 1000 Break1000 – 1050 Human Factors
Dr. Karen D. Dunbar 1050 – 1100 Break1100 – 1200 Loss of Control
Dennis H. Whitley1200 – 1245 Lunch1245 – 1300 Tribute To Flight Attendants1300 – 1445 Miracle on the Hudson
Doreen Welsh1445 – Closing remarks - Adjourn
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Welcome
• Exits• Restrooms• Emergency Evacuation• Breaks • Sponsor Acknowledgment• Other information
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Sponsors
Altra MedicalDJ Public Relations Inc.ExecuJet Charter ServiceFederal Aviation AdministrationFederal Aviation Administration Safety TeamHillsborough County Aviation AuthorityJETEX Flight Support
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Sponsors
NBAAOSI Restaurant Partners LLCRockwell CollinsSt. Petersburg - Clearwater Int. AirportStandard AeroSignature Flight Support
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Sponsors
Landmark AviationTampa Air Traffic Controllers Tampa International Airport Fire DepartmentTampa Jet CenterWest Star AviationWINSLOW Life RaftWorld Fuel
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Tampa FSDO Personnel• Amanda Cromie
– FSDO Manager• Jose Figueroa
– Front Line Manager• Patrick Seggerman
– Front Line Manager• James Minary
– FAASTeam Program Manager
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Florida FSDO Borders
• Alabama FSDO SO09
• North Florida FSDO
• SO15 & SO35 • South
Florida FSDO SO19
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
• North Florida
FSDO SO35
Florida FSDO Borders
Tampa FSDO SO35
Orlando FSDO SO15
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
FSDO Information– CFI and DPE Oversight– Flight Schools– Charter Companies– Film Production– Accidents & Incidents– Complaints– Repair Stations – Mechanic Schools– IA Mechanics – Special Flight Permits– Field Approvals
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Contact us
• http://faa.gov• Field & Regional Offices• Flight Standards District Offices (FSDO)• Select State• Select Office
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Wings Credits• 3 Knowledge Credits for this Stand Down
– Preregistered?• Initial roster
– Not Preregistered?• Sign in with legible faasafety.gov email
• No Account?– See a Rep today
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration 13
1
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
The Safety Stand Down
• Military Origins– Response to Safety Issue– Temporary Operations Halt– Devote time to Safety
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
The Safety Stand Down• Human Factors
– Investigates interaction between humans and systems– Evaluates fit between user, equipment and environment– Considers capabilities and limitations – Focus on task, demands, equipment and information
• Loss of Control– Number 1 Factor in fatal accidents
• Appch. & Ldg. LOC Workgroup– Findings & Recommendations
» Technology» Human Factors
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
LOC Workgroup Findings
• Lack of single – pilot CRM skills• Unstabilized approaches• Flight after extended periods of not flying• Inappropriate go-around procedures• Insufficient transition training• Over reliance on automation• Flight after use of drugs• Lack of Aeronautical Decision Making Skills
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
FAA Information Session• Presented by:
– FAA Southern Region– Tampa Florida FAASTeam
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Introduction to Human Error
• Presented by:Dr. Karen D. DunbarFAA Safety TeamRepresentative
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Federal AviationAdministrationHuman Error
Making Sense of Accident Reports
Presented to:
FAASTeam 2013 Safety Stand Down
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Overview
• Error Fundamentals• System aspects of error• Application of Error Fundamentals
• Gold Seal Key Concepts
SSD 2013
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
A. Human
B. Universal
C. Inevitable
D. A bad thing
To Err is:
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
In so far as I am able, I agree to suspend thoughts of judgment and retribution with respect to the characters in the stories I am about to hear or relate; and to the presenter of this seminar. I will seek to understand why events occur rather than to identify and punish those
Certificate of Agreement Safety Stand Down 2013
SSD 2013
who were responsible for those occurrences. I understand that this agreement has no legal effect whatever and, in any case, applies only during this seminar unless I choose to continue with this way of thinking in the future.
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
The 5 Ws
WhoWhatWhenWhereWhy
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
The 6th W
WhoWhatWhenWhereWhyWhat’s to be done about it?
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Four questions are easy
WhoWhatWhenWhereWhyWhat’s to be done about it?
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
The Accident Report
WhoWhatWhenWhereProbable CauseSafety Recommendation
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
The Accident Report
WhoWhatWhenWhereMoose on FieldMoose proof fence
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Hindsight BiasHindsight
OutsideViolation
BreakdownLost the Bubble
FailureError
Bad Judgment
Incident EvolutionTime(Sidney Dekker 2006)
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Incident EvolutionTime
Inside
-Easy-Profitable
-Loyalty
-Prod-uctive
-Flexible
-CommonSense-Better -Skill
-Creative-Perfect
-Good Idea-Judgment
-Experience
-BestOption-Quick
(Sidney Dekker 2006)
Hindsight Bias
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SSD 2013
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Ever have one of those days?
• Take a wrong turn on a familiar route
• Set out for work when you intended to go to the store
• Lock keys in car or house
• Can’t find the keys to lock in car or house
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
People cannot easily avoid those actions they did not intend to commit
James Reason & Alan Hobbs (2003)
SSD 2013
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
People cannot easily avoid those actions they did not intend to commit
James Reason & Alan Hobbs (2003)
Blaming people for their errors is emotionally satisfying but remedially useless.
We’re still accountable for our mistakes though.
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Mikey’s story• Late night with interrupted sleep• Altered routine• Preoccupation with work
• How big an error?– Consequence was huge– Error was common
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
People cannot easily avoid those actions they did not intend to commit
SSD 2013
We all operate within systems
Sometimes without knowing it
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Vehicular Child Fatalities Passenger Side Airbags vs Hyperthermia
Deaths
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Vehicular Child Fatalities Passenger Side Airbags vs Hyperthermia
Deaths
36
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Vehicular Child Fatalities Passenger Side Airbags vs Hyperthermia
Deaths
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Accident Chain of Events
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Accident Chain of Events
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Accident Chain
Unsafe Acts
Preconditions
Cultural Influences
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Unsafe Acts
Cultural Influences
Preconditions
Leaving Mikey in car
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Pre-conditions
Cultural Influences
Pax side airbag
Fatigue
Warm Weather
Preoccupation Leaving Mikey in car
Sleeping Child
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Cultural Influences
Child care responsibilityWork ethicPax side airbag
Fatigue
Sleeping Child
Warm Weather
Preoccupation Leaving Mikey in car
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Child care responsibilityWork ethicPax side airbag
Fatigue
Warm Weather
Preoccupation
Safety significant errors can occur at all levels of the system
Leaving Mikey in car
Sleeping Child
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
The Swamp
Unsafe Acts
Preconditions
Cultural Influences
Adapted from Reason (1990)
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Adapted from Reason (1990)
Coming Soon Bayou Junction
Housing Development
Unsafe Acts
Preconditions
Cultural Influences
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
People
Structure/Organization
Technology
Tasks
The General Aviation System
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
200
01950
196
0 197
0 198
0 199
0
U.S. General AviationSource NTSB
0
10
20
30
40
50
60A
ccid
ents
/100
,000
flig
ht h
ours
Accidents=Approximately 7/100,000hrsFatal Accidents=Approximately
2/100,000hrs
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Human Error is Both Universal and Inevitable
It is the Downside of Having a Brain
James Reason & Alan Hobbs (2003)
SSD 2013
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
A Simplified “Blueprint” of Mental Functioning
Input Functions
Senses
Feedback Loops
Filter (Attention)
Conscious Workspace
Long-term memory(Knowledge base)
Output Functions
Hands, Feet, etc.
James Reason & Alan Hobbs (2003)
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Conscious Workspace Long-term Memory
General Problem SolverLimited CapacityContents AvailableSequential ProcessingSlow and LaboriousEssential for new Tasks
Vast Collection of ProgramsNo Limits to Size or DurationUnconsciousParallel ProcessingRapid and EffortlessHandles Familiar Routines and Habits
James Reason & Alan Hobbs (2003)
Trial and Error Programming
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
A
CBCB
A
Conscious Work Space
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Long-term Memory
2 + 2 = …..knock knock “...................?”Mary had ..................The sky is ……..Grass is …..
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Lnog-trem Meromy porgarms rley haevly on vsuisaul ifnoramiton and ptatren rcoegiontin hbaets.
Plitos are paticrculry aedpt at ptatren rcoegiontin and ulusaly taht wokrs wlel for tehm but oaccsillony taht hmaun tenendcy cuseas prelombs.
Rnunnig a falmialr porgarm in rospense to a difefernt stitauion or rnunnig a corrcet porgarm ipormprely can rsuelt in dsisater.
We are creatures of hbaet
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SSD 2013
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Count the F’s
FINISHED FILES ARE THE RESULT
OF YEARS OF SCIENTIFIC
STUDY COMBINED WITH THE
EXPERIENCE OF MANY YEARS
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Count the F’s
FINISHED FILES ARE THE RESULT
OF YEARS OF SCIENTIFIC
STUDY COMBINED WITH THE
EXPERIENCE OF MANY YEARS
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3?
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Count the F’s
FINISHED FILES ARE THE RESULT
OF YEARS OF SCIENTIFIC
STUDY COMBINED WITH THE
EXPERIENCE OF MANY YEARS
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3 or 6?
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Choice Point needing conscious attention
New Path
Wrong Path Taken
Usual Onward Path
Skill-based Slip
Highly Routine Sequence
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Directly to Work
Mikey’s story
Turned left at Pereira Drive He should have turned
right at Pereira
Day Care Then work
His office's parking lot at the Department of
EducationFrom: Home
To: Work
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
People cannot easily avoid those actions they did not intend to commit…
SSD 2013
but they can gain a better understanding of when they’re likely to err.
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Error/Environment Logging
Log errors by date
Describe environment
Include health, fatigue, stress
Look for patterns
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
StressWalking the line
$
6 In.
8 In. 20 Ft.
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
StressWalking the line
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Extreme Stress Makes You StupidPe
rfor
man
ce
Increasing Stress
Perf
orm
ance
Increasing Stress
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Managing the Managable
2 hour flight @ 10 gph. = 20 gal.
+ 1 hour reserve = 30 gal.
Fuel on board = 25 gal.
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Managing the Managable
Call for fuel & top off
Enough fuel for the return tripJust enough time to make the luauLaunch with the fuel you haveAmple time before meetingMust fuel before returnConsider ditching evil partner
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
A. What?
B. Why?
C. When?
D. What’s to be done about it?
The Ws that are hardest to answer are:
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
A. PCs but not MACs
B. Conscious Workspace
C. Long Term Memory
D. MACs but not PCs
Programming is an attribute of:
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
A. NTSB & FAA Investigations
B. Central Nervous System
C. Long Term Memory
D. Conscious Workspace
“Trial and Error” is an attribute of:
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Winners never quit ……
Quitters never….
Plan the flight & ……
You’ll never get anywhere if you don’t have a ….
When in doubt; stick to the ……
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Get-there-itus
Plan Continuation Bias“The continuation of an original plan even with the availability of information that suggests that the plan should be abandoned.”
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
If the flight’s not conforming to the plan …..
It doesn’t pay to wait for things to get better.Address small problems earlyBefore they become big ones
SSD 2013
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Errors are not intrinsically bad
We are “hardwired” to make errors
Bad News Good News
James Reason & Alan Hobbs (2003)
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Federal AviationAdministration
The Recipe for Disaster
Human Error + Unforgiving Activity= Disaster
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James Reason & Alan Hobbs (2003)
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
James Reason & Alan Hobbs (2003)
You cannot change the human condition,
What’s to be done about it?
but you can change the conditions in which humans work. (and play)
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Federal AviationAdministration
How many people?
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Federal AviationAdministration
or this one ….. ?
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
583 fatalities – 64 survivorsTenerife 27 March 1977
The Best People Tend to Make the Worst Mistakes
SSD 2013
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
James Reason & Alan Hobbs (2003)
Many Errors Fall into Recurrent Patterns
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
One More Thing
•Confirmation Bias
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
One More Thing
Confirmation Bias
You
Common-sense Consistent Capable CorrectCoherent Clever
Other Drivers
Ignorant IneptIdiot IncompetentImpolite Ill-mannered
Fundamental Attribution BiasJames Reason & Alan Hobbs (2003)
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Federal AviationAdministration
People cannot easily avoid those actions they did not intend to commit
• James Reason & Alan Hobbs (2003)
SSD 2013
You can’t understand why accidents happen if you assume the pilots involved were idiots.
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Federal AviationAdministration
A. Confirmation?
B. Hindsight?
C. Plan Continuation?
D. Fundamental Attribution?
The human biases that may negatively influence accident investigations are:
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
A. Anti-authority attitude
B. Sense of invulnerability
C. Past record of performance
D. Confirmation Bias
The best people make the worst mistakes because of their:
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Federal AviationAdministration
A. The Preconditions level
B. The Unsafe Acts level
C. All levels
D. Cultural Influences level
Safety-significant errors can occur at _______ of the system:
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Federal AviationAdministration
A. Should be avoided
B. Improve performance
C. Inhibit performance
D. Require medication
Moderate stress levels:
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
A. Lowest - Highest
B. Highest - Lowest
C. Lowest - Appropriate
D. Appropriate - Highest
Effective interventions should target the _______ level, but are usually most effective at the _____ level of a system.
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Reading List• Managing Maintenance Error
– James Reason and Alan Hobbs• Set Phasers on Stun and The Atomic Chef
– Steven Casey• Understanding Human Error
– Sidney Dekker• Deep Survival
– Laurence Gonzales• The Limits of Expertise
– Key Dismukes• Sway
– Brafman & Brafman
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Up next:
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Up next:
90
Loss of Control
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Federal AviationAdministration
Up next:
91
Let’s take a little break
Loss of Control
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Loss of Control Panel
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Moderated by:Dennis H. WhitleyFAA Safety TeamLead Representative
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Loss of Control Panelists• Mr. Jack Tunstill
– CFII St. Petersburg• Mr. Mike Windiman
– CFII Plant City
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Federal AviationAdministration
Fatal LOC Accidents 2001-2010
94
Man
euve
ring
App
roac
h
En
rout
e
Init.
Clim
b
Unk
now
n
Take
Off
Unc
ontro
lled
Des
cent
Land
ing
Em
er. D
esce
nt
Em
er. L
andi
ng
Em
er. A
fter T
.O.
LOC Accidents 10-Year Period
0
50
100
150
200
250
300
350
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
The PAVE Checklist
• Pilot• Aircraft• enVironment• External Pressure (s)
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LOC Panel Case Study Number 1
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• Pilot– Private Pilot– Total Time ……319– Time in type …. 1
• Aircraft– Jodel D-9
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LOC Panel Case Study Number 1
97
• enVironment– General Dewitt Spain, TN (M01)– Runway 16/34 225 MSL 3,800 x 75’– Left Base to Final Runway 34 – Weather (MEM – 11 nm SSE)
• VFR Few @ 7,000/10 SM• Wind Variable @ 3
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Federal AviationAdministration
Discussion
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Federal AviationAdministration
LOC Panel Case Study Number 2
99
• Pilot– Private Pilot– Total Time ……604– Time in type ….248
• Aircraft– Cirrus SR 22
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 2
100
• enVironment– Aero Plantation, NC (NC21)– Runway 6/24 634 MSL 2400 x 60’– Left Base to Final Runway 6 – Weather (EQY – 6.5 nm East)
• Wind 320@11, Gust 22
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310@11, G22
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LOC Panel Case Study Number 2
102
• Parachute– Deployed, but not fully
extracted.
• Autopsy Findings– Diphenhydramine– Pseudoephedrine– Zolpidem
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Discussion
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 3
104
• Pilot– Private Pilot– Total Time ……975– Time in type ….44
• Aircraft– TBM 700
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
LOC Panel Case Study Number 3
105
• enVironment– Cobb County Field, GA (KRYY)– Runway 9/27 1078 MSL 6311x100’– Final Approach to Runway 9 – Weather
• 5,500 BKN, 10 SM• Wind 120@6
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LOC Panel Case Study Number 3
107
• Autopsy Findings– Alfuzosin
• Prostate – Bisoprolol *
• Beta blocker– Quinine
• Arthritis– Tramadol
• For moderate to severe pain
* Known to AME
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Discussion
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Safety Stand Down 2013April 17, 2013
Federal AviationAdministration
Dedication
Niel Armstrong 1930 - 2012
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Federal AviationAdministration 110
The End?• Safety never ends
– Assess & manage risk– Train to maintain – Set the example
• You are vital members of the safety community– Continue on course– Climb to greater heights– Invite others to join