Embed Size (px)
DESCRIPTION
human factor
Citation preview
HumanFactorsChecklist
ByDrAnthonyCiavareliiandThomasSather
NavalPostgraduateSchool
AdaptedbyKentLewisSignalCharlie
Sensory‐PerceptualFactors
• Misjudgeddistance,clearance,alGtude,speed,etc…
• FalsePercepGonsduetovisualillusion– ContributorycondiGons:
• Featurelessterrain(desert,water,drylakebed) • Dark• Blackholeapproach• No/falsehorizon• Mountainousterrainorslopingrunway• Rotordownwasheffects
• Rotordownwasheffects
• Anomalouslighteffects
• LowcontrastobjectorpoorilluminaGon
• Lookingintobrightsunorshadows
• FalsepercepGonduetovesGbularillusions– Corioliscrosscoupling(spiningsensaGonduetovesGbular
oversGmulaGon)
– Somatogravic(ginducedfalsepitchupordown)– Somatogyral(falsesensaGonofangularrotaGon)
– Gexcess(errorinperceivingactualangelofbank)
• SpaGalDisorientaGon/VerGgo– TypeI:Unrecognizedormisoriented(lossofaVtudnalorientaGonwithoutawareness)
– TypeII:Recognized(verGgoortheleans)– TypeIII:IncapacitaGng(e.g.g‐inducedvesGbular‐ocularcoupling)
• CondiGonsthataffectsenseofbodyposiGonoraircraXaVtude:
1. Lossofvisualcues/aVtudereferences2. AcceleraGonrelatedillusions3. AdversephysiologicalcondiGon(drug,dehydraGon,
faGgue)
• LossofSituaGonalAwareness– Types:1. GeographicdisorientaGon(offnavigaGonrouteor
map,lost)2. GenerallossofSA(didnotperceivehazards)
3. ErroneoussituaGonassessment(misinterpretedsituaGonorcondiGon)
4. Perceptualtunnelling
5. FailedtopredictoranGcipatechangingcondiGons6. Falsehypothesis7. ConfirmaGonbias
8. Workloadtask/Gming
• AdenGonFailure– Types:1. Missedflightchecklistitems,calloutorcrew
challenge2. Failedtomonitorflightprogressormaintain
instrumentscan3. FailedtorespondtocommunicaGonsorwarning4. ControlacGonerrors(motorresponseslipor
memorylapse)a) Forgottoset/move/resetswitch(lapse)b) UnintenGonalacGvaGon(slip)c) ControlsubsGtuGon(slip)d) Controlreversal(slip)e) Controladjustment/precisionerror(slip)
CondiGonsthatinfluenceAdenGonandSituaGonAwareness1. InadenGon2. Channelizedortaskfixated(perceptualnarrowing)3. DistracGon(internal,external)4. Taskoverload(excesstaskingwith/withoutmission
performanceGmepressure)5. CogniGveworkload(problemsolvingworkloadorinformaGon
overload)6. HabituaGon(old/previouslearnedhabitinterference)7. ExcessstressorfaGgue8. Excessmissiontaskingorworkload9. InadequatebriefingorpoorflightpreparaGon10. Inadequatetrainingorexperienceforthemission11. NegaGvelearningtransfer(i.e.newaircraXtransiGon)12. Adverseweather/meteorologicalcondiGons13. AdverscockpitenvironmentalcondiGons14. TacGcalsituaGonordisplayinformaGonoverload15. LowaircrewmoGvaGonorpoorflightvigilance16. Poorcockpitdesign(controldisplaylocaGonordataformat)
Sensory‐PerceptualRiskManagement
• ProvideconGnuededucaGonforpilotsandairsafetyreps
• EngageFAAAMEsandindustryaeromedicalorganizaGons
• Establishweathergo/nogodecisioncriteria• UGlizemissionanalysismatrix
• EstablishSOPsandprotocolsforknownhighriskmissions(night,weather,faGgue,training)
MedicalandPhysiologicalFactors
• SelfMedicated• Underinfluence• Knownillness• Excesspersonalstress• FaGgue• NutriGon• G‐LOCorgexcess• HypoxiaorhypervenGlaGon• Other
– CondiGonsthatleadtoadversemedical/physiologicalstate
1. MissionfaGgue(ondutyover12hours,latenightorearlymorning0200‐0600
2. CumulaGvefaGgue(excessphysicalormentalworkload,circadiandisrupGonorsleeploss)
3. CumulaGveeffectsofpersonaloroccupaGonalstress(exceedspersonalcopinglimits)
4. EmergencyflightcondiGon/workloadtransiGon5. MedicalorphysiologicalprecondiGons
(precedingstateofhealth,fitnesslevel,hangover,dehydraGon,etc…)
MedicalandPhysiologicalFactorRiskManagement
• DocumentmedicalandphysiologicalqualificaGons
• Protectaviatorsunderhighstressduetohumanfactors
• Sharehumanfactorshazardreportsofphysiologicalincidents
• Useaeromedicalteamresources
• UseCIRPandEAP
KnowledgeorSkillFactors
• Inadequateknowledgeofsystems,procedures(Knowledgebasederror)
• Poorflightcontrol,airmanshiporpooraccuracyofflightmaneuvering(Skillbasederror)
• Misuseofrulesorincorrectperformanceofcockpittask(Rulebasederror)
– Types:A. Failedtoperformrequiredprocedure(s)B. Usedwrongprocedureorrule(s)C. Missedstep(s)inaprescribedsequenceD. Performedstepsoutofsequence
• CondiGonsthatleadtopooroperaGonalperformance
1. Belowrequiredproficiencyorcurrencystandards2. Poorperformancetrendand/ordocumentedflight
apGtudedeficiencies
3. Lowflighthours(totalorintypemodel)4. LackedessenGaltrainingforspecifictasks5. LackedrecentmissionorflightcondiGons
(instrument,night,weather,etc)
6. TransiGonpilot7. MarginalAviator(documentedhistoryofpoor
performanceorflightviolaGons)
KnowledgeandSkillFactorRiskManagement
• Establishproficiencyandcurrencystandards• Enforcestandardsinajustmanner
• Assesstrainingprogramagainststandards
• Documenttrainingresults
• Useremedialtraining
• Removeorprotectmarginalaviators
PersonalityandSafetyAVtude
• Padernofoverconfidence• PadernofexcessmoGvaGon• AngerorjobfrustraGon• Hotdogging• AsserGveornon‐asserGve• Lackedconfidencetoperformtaskormission• YieldedtooperaGonalpressuretoperforminhazardoussituaGon(fromcommandorpeers)
• ContribuGngfactorsthatleadtopoorsafetyaVtude
1. Habitualhighrisktaker2. Overconfidence3. Marginalorhighriskaviator4. ExcessmoGvaGon(nolimits)
5. Poorcommandclimateorsafetyculture(lackofadequatesupervision)
PersonalityandSafetyAVtudeRiskManagement
• IdenGfychronichigh‐risktakers• Usejudiciouscrewassignmentandscheduling
• Conductperiodichumanfactorsreview
• UseHumanFactorsBoardtomanageatriskaviators
JudgmentandRiskDecisionFactors
• KnowinglyacceptshighrisksituaGons• Misjudgedactualriskofmission(complacency)• Didnotmonitorflightprogress/condiGons• IncorrecttaskprioriGes• Knowinglydeviatedfromsafeprocedure• IntenGonallyviolatedsafetystandardorregulaGon• Knowinglyexceededpersonallimits• KnowinglyexceededaircraXlimits• Knowinglyexceededprescribedmissionparameters• Yieldedtosocialpressure
• CondiGonsthatcontributetoinappropriateriskjudgment
1. Hotdogorhighriskaviator2. ExcessmoGvaGon
3. Uncontrolledlifestress4. TooasserGveornon‐asserGveinterpersonalstyle5. Influencedbypoorcommandclimateorsafety
culture(lackofadequatesupervision)
JudgmentandDecisionFactorRiskManagement
• Enforcego/no‐gocriteria• Illustratejudgmentbyexample
• ProvidecrewjudgmenttrainingandevaluaGon
• Monitorandcorrecthighriskbehavior
• DeveloppersonalSOPs(mins)
CrewCoordinaGonFactors
• Inadequatemissionplan,brieforpreflight• FailedtocommunicateplanorintenGons• Failedtousestandardlanguage• MisunderstoodorunacknowledgedcommunicaGons(readbackhearback)
• Inadequatechallenge,crosscheckormonitoring• Withheldvitalsafetydata• PICfailedtoleadanddelegate• PICfailedtouseallavailableresources• Interpersonalconflict
• CondiGonsthatcontributetopoorcrewcoordinaGon• InadequatetrainingincommunicaGonsandcrewcoordinaGon
• InadequateSOPforuseofcrewresources• WeaksupportfromcommandforaircrewcoordinaGondoctrine
• Aircrew/cockpitrankandexperiencegradients• Commandsafetyculturedoesnotsupportcrewconcept
CrewCoordinaGonFactorRiskManagement
• EstablishCRMprotocolsandSOPs• ProvideCRM(Team)training
• ConstructmissiontaskSOPs(crewtasks)
• BriefanddebriefCRMevents(ASRS)
• UsespecifictrainingtoteachandlearnCRMtasksandskills
DesignandSystemFactors
• Usedwrongswitch,leverorcontrol• Misreadormisinterpretedinstrumentreading• Couldnotreachorseecontrol• Couldnotseeorreadinstrumentorindicator• Failedtorespondtowarningsignalorwrongresponse
• Modeconfusion• AutomaGoncomplacencyorfascinaGon
CondiGonsthatcontributetodesign‐inducederrors1. PoorprimaryaircraXcontrolsordisplayarrangement2. Inadequateprimarydatadisplayordataformat3. Hardtoreadinstrumentdata(Textsize,font,color,glare,
lighGng)4. IncompaGblecockpitcontroldisplayacGvaGonorresponse5. Inadequatehazardadvisoryorwarningdisplay6. Poorcockpitdesignlayout(vision,reach)7. Poorhumancomputerdisplayinterface/usability(error‐
pronedesign)8. PoorsystemsinstrucGon9. InadequateaviaGonsystemssupportorfaciliGes(navaids,
airport,airtrafficcontrol)10. Non‐standardcockpitlayout11. InappropriatetypeorlevelofautomaGon,orexcess
operaGonalmodecomplexity
DesignandSystemsFactorsRiskManagement
• TrainandtestaircraXsystemsknowledge• Flybythebook• IdenGfyaircraXlimitsandtolerances• IdenGfyfaultycockpitlayout,controlanddisplaydesigns
• PublishhazardreportsandrecommenddesignchangesFlightOps
• ConsiderAirports,ATC,Manufacturers(AircraX,Engines,Avionics…),Contractors
SupervisoryFactors• Inadequatescheduleorcrewassignment• Failedtomonitorcrewrest/duty• Failedtoestablishadequatestandards• Failedtomonitorcompliancetostandards• FailedtomonitorcrewqualificaGon/training• Failedtoscreen/removehighriskaviators• Failedtoestablish/monitorqualitystandards• IntenGonallyviolatedordirectedotherstovioatestandards,ruleor
regulaGon• Commandfailedtomonitor,perceiveandassessactualmission
risks,withrespectto:– EnvironmentalhazardsandoperaGngcondiGons– Missiontaskingandaircrewskilllevel– Aircrew,andsystemlimitaGons(AircraX,maintenance,Airports,ATC,
Dispatch,flightops
• CondiGonscontribuGngtosupervisoryfailures1. Excessopstempo,organizaGonalworkload(imposedby
commandorsystem)2. Poorcommandsafetyclimate/culture,laxsafetysupervision3. Inadequatestandardsand/orlowperformanceexpectaGons4. Commanddidnotprovideadequateresourcestosupportsafe
missionaccomplishment5. Commanddidnotadequatelytrainthemishappilotorcrew6. Commandersdidnotsetagoodexample,orsetabadexample7. Supervisorsdidnotprovideadequatecommitmentoremphasis
onsafeoperaGons8. CommandhaspoorcommunicaGonsup/downcommandchain9. Commandhasnosystemoweaksystemformanagementof
highriskaviator10. CommandhasweakprocessforoperaGonalriskmanagement11. Commanddidnotprovideadequateaeromedicalofhuman
factorstraining12. Commanddidnotenforceaeromedicalstandards
SupervisoryFactorRiskManagement
• EstablishposiGvecommandclimate• Setthesafetyexample• IncludesafetyadvocacyasorganizaGonalgoal• Setclearperformancestandards• MonitorcompliancetoSOPs• Knowyourselfandyourteam• Keepanopendoorandopenmind• Correctpoorperformanceandnon‐compliance• Rewardsafebehavior• Embedriskmanagement
OrganizaGonalFactors
• ProducGon• “RiskManagement”
RegulatoryFactors
• ProducGon• ProtecGon• ProbableCauseparadigm
References
• HumanFactorsChecklist:AnAircraXAccidentInvesGgaGonTool,AppendixB:CrewResourceManagement
(NavalPostgraduateSchool,SchoolofAviaGonSafety,Ciavarelli&Sather,2002)
hdps://www.netc.navy.mil/nascweb/sas/files/hfchklst.pdf
ThankyouforyourdedicaGontotheconGnuousimprovementofaerospacesafety
KentLewis
(817)692‐1971
