Top Aircrew Human Factor Errorsin Navy/Marine Corps Aviation:

A Helo Perspective

Top Aircrew Human Factor Errorsin Navy/Marine Corps Aviation:

A Helo Perspective

LCDR Deborah White

Human Factor Analyst

(757) 444-3520 x 7231

(DSN) 564-3520 x 7231

LCDR Deborah White

Human Factor Analyst

(757) 444-3520 x 7231

(DSN) 564-3520 x 7231

22

Stupid People TricksStupid People Tricks

33

Human Error in AviationHuman Error in Aviation

44

BackgroundBackground

Early 1990’s, Shappell and Wiegmann developed the Navy’s Human Factor Analysis and Classification System (HFACS) Classify Human Error in Naval Class A FM Develop data base to follow Human Factor trends

HFACS data base maintained since 1990 Over 400 mishaps analyzed Primarily Fighter/Attack and Helicopter Aircraft

Early 1990’s, Shappell and Wiegmann developed the Navy’s Human Factor Analysis and Classification System (HFACS) Classify Human Error in Naval Class A FM Develop data base to follow Human Factor trends

HFACS data base maintained since 1990 Over 400 mishaps analyzed Primarily Fighter/Attack and Helicopter Aircraft

55

Substandard Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Substandard Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Errors

PerceptualErrors

Skill-BasedErrors

UNSAFEACTS

Errors

DecisionErrors

ExceptionalRoutine

Violations

Adverse Mental States

Physical/MentalLimitations

Adverse Mental StatesAdverse

Physiological StatesPersonal

ReadinessCrew Resource Management

Substandard Practices of Operators

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

ResourceManagement

OrganizationalClimate

OrganizationalProcess

ORGANIZATIONALINFLUENCES

66

ObjectiveObjective

Determine the primary Preconditions that contribute to the Aircrews’ Unsafe Acts

Determine the primary Preconditions that contribute to the Aircrews’ Unsafe Acts

77

MethodsMethods

Analyzed 249 Class A Navy/Marine Corps Aircrew Human Error Mishaps entered in the HFACS database from FY 90 -02Broad HF Errors:

o Classified HF Errors based on HFACS categoriesSpecific HF Errors:

o Descriptions of specific/similar HF Errors determined for each HFACS categories – “Nanocodes”

Number of specific nanocodes for each category calculated and ranked

Analyzed 249 Class A Navy/Marine Corps Aircrew Human Error Mishaps entered in the HFACS database from FY 90 -02Broad HF Errors:

o Classified HF Errors based on HFACS categoriesSpecific HF Errors:

o Descriptions of specific/similar HF Errors determined for each HFACS categories – “Nanocodes”

Number of specific nanocodes for each category calculated and ranked

88

Human Factor Errors (FY90 - 02)Unsafe Acts - Aircrew

Human Factor Errors (FY90 - 02)Unsafe Acts - Aircrew

0

20

40

60

80

100

Skill Based Decision Perceptual Violations(Routine)

Violations(Exceptional)

Helo

TacAir

% o

f M

isha

ps

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

Skill-BasedErrors

SKILL-BASED ERRORS

Failed to recognize extremis (Helo)Improper use of flight controls (Helo)

Breakdown in visual scan (TacAir)Improper use of flight controls (TacAir)

Top nanocodes cited between FY 90 – FY 02

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

DecisionErrors

DECISION ERRORS

Poor Decision (Helo)

Wrong response to emergency (TacAir)Poor Decision (TacAir)

Top nanocodes cited between FY 90 – FY 02

1111

Human Factor Errors (FY90 - 02)Preconditions - Aircrew

Human Factor Errors (FY90 - 02)Preconditions - Aircrew

0

20

40

60

80

100

Crew ResourceManagement

AdverseMental State

AdversePhysio State

Physical/Mental Limit

PersonalReadiness

Helo

TacAir

% o

f M

isha

ps

CREW RESOURCE MANAGEMENT

Failed to Communicate/Coordinate (Helo) Failed to Backup (Helo)

Failed to Communicate/Coordinate (TacAir)

Preconditions for Unsafe Acts

Preconditions for Unsafe Acts

Substandard Practices of

Operator

SubstandardCondition of

Operator

SubstandardCondition of

Operator

Personal Readiness

Crew Resource

Management

Physical/MentalLimitations

Adverse Physiological

States

Adverse Mental States

Substandard Practices of

Operator

Crew Resource

Management

Top nanocodes cited between FY 90 – FY 02

ADVERSE MENTAL STATE

Preconditions for Unsafe Acts

Preconditions for Unsafe Acts

Substandard Practices of

Operator

Personal Readiness

Crew Resource

Management

Physical/MentalLimitations

Adverse Physiological

States

SubstandardCondition of

Operator

SubstandardCondition of

Operator

Adverse Mental States

Channelized Attention/Fixation (Helo)Loss of Situational Awareness (Helo)

Channelized Attention/Fixation (TacAir)

SubstandardCondition of

Operator

SubstandardCondition of

Operator

Adverse Mental States

Top nanocodes cited between FY 90 – FY 02

1414

Human Factor Errors (FY90 - 02)Unsafe Supervision

Human Factor Errors (FY90 - 02)Unsafe Supervision

0

10

20

30

40

InadequateSupervision

Failed toCorrect Problem

PlannedInappropriate

Ops

SupervisoryViolations

Helo

TacAir

% o

f M

isha

ps

UNSAFESUPERVISION

UNSAFESUPERVISION

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

InadequateSupervisionInadequateSupervision

INADEQUATE SUPERVISIONFailed to Provide Adequate Guidance (Helo)

Failed to Provide Adequate Guidance (TacAir)

Top nanocodes cited between FY 90 – FY 02

1616

Human Factor Errors (FY90 - 02)Organizational Influences

Human Factor Errors (FY90 - 02)Organizational Influences

0

10

20

30

40

OrganizationalProcess

ResourceManagement

OrganizationalClimate

Helo

TacAir

% o

f M

isha

ps

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

ORGANIZATIONALINFLUENCES

OperationalProcess

OPERATIONAL PROCESS

Inadequate Documentation (Helo)

Failed to Provide Adequate Guidance (TacAir)

Top nanocodes cited between FY 90 – FY 02

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

ResourceManagement

ResourceManagement

ORGANIZATIONALINFLUENCES

RESOURCE MANAGEMENT

Inadequate Design (Helo)

Inadequate Design (TacAir)

Top nanocodes cited between FY 90 – FY 02

1919

SummarySummary

Predominate Preconditions for Helo Aircrew Unsafe Acts (Skill-based and Decision Errors):Failure to Communicate/CoordinateFailure to BackupChannelized Attention/FixationLoss of Situational Awareness

Predominate Preconditions for Helo Aircrew Unsafe Acts (Skill-based and Decision Errors):Failure to Communicate/CoordinateFailure to BackupChannelized Attention/FixationLoss of Situational Awareness

2020

ConclusionConclusion

To decrease the number of Decision and Skill-based Errors, the importance of good aircrew communication, coordination, and backup must be continually emphasized by Squadron COs and Training Programs.

Aircrew must also recognize the dangers associated with channelized attention and fixation, which can be avoided by utilizing proper scanning techniques and communicating with other personnel (i.e. crewmembers, ATC, other helicopter crews).

To decrease the number of Decision and Skill-based Errors, the importance of good aircrew communication, coordination, and backup must be continually emphasized by Squadron COs and Training Programs.

Aircrew must also recognize the dangers associated with channelized attention and fixation, which can be avoided by utilizing proper scanning techniques and communicating with other personnel (i.e. crewmembers, ATC, other helicopter crews).

2121

What the US Navy is doingWhat the US Navy is doing

Rejuvenating our Crew Resource Management Training:

Rejuvenating our Crew Resource Management Training:

2222

CRM Training Structure for Individual

CRM Training Structure for Individual

Initial CRM Training (Primary Flight Training)Initial CRM Training (Primary Flight Training)Phase 1 (Ground) Academics + Testable (2 day minimum)Phase 1 (Ground) Academics + Testable (2 day minimum)

Phase 2 (Flying) Training with Instructor; Hands on + GradedPhase 2 (Flying) Training with Instructor; Hands on + Graded

Initial CRM Training (Primary Flight Training)Initial CRM Training (Primary Flight Training)Phase 1 (Ground) Academics + Testable (2 day minimum)Phase 1 (Ground) Academics + Testable (2 day minimum)

Phase 2 (Flying) Training with Instructor; Hands on + GradedPhase 2 (Flying) Training with Instructor; Hands on + Graded

Specialized CRM TrainingSpecialized CRM TrainingMission/Platform Specific (Type Model Training)Mission/Platform Specific (Type Model Training)Academics + Scenario Based Event (Hands on):Academics + Scenario Based Event (Hands on):

Graded (1 day minimum)Graded (1 day minimum)

Specialized CRM TrainingSpecialized CRM TrainingMission/Platform Specific (Type Model Training)Mission/Platform Specific (Type Model Training)Academics + Scenario Based Event (Hands on):Academics + Scenario Based Event (Hands on):

Graded (1 day minimum)Graded (1 day minimum)

Training Style:INFODEMOPRACTICEFEEDBACK

*Curriculum emphasis based on career progression.

LeadershipLeadership Training (1 hr)Training (1 hr)

LeadershipLeadership Training (1 hr)Training (1 hr)

Instructor TrainingInstructor TrainingAcademic, Simulator Academic, Simulator and Line IP (4 hr minand Line IP (4 hr min))

Instructor TrainingInstructor TrainingAcademic, Simulator Academic, Simulator and Line IP (4 hr minand Line IP (4 hr min))

Continuation TrainingContinuation TrainingAnnual Academic Course + Annual Academic Course +

Scenario Based Event: Graded (4 hrs min)Scenario Based Event: Graded (4 hrs min)

Continuation TrainingContinuation TrainingAnnual Academic Course + Annual Academic Course +

Scenario Based Event: Graded (4 hrs min)Scenario Based Event: Graded (4 hrs min)

2323

What the US Navy is doingWhat the US Navy is doing

Rejuvenating Crew Resource Management Training

Development of Joint DoD Human Factors Analysis and Classification SystemDocument can be found on Naval Safety Center Web

Page under Aviation, Aeromedicalo http://safetycenter.navy.mil.htm

Rejuvenating Crew Resource Management Training

Development of Joint DoD Human Factors Analysis and Classification SystemDocument can be found on Naval Safety Center Web

Page under Aviation, Aeromedicalo http://safetycenter.navy.mil.htm

2424

Errors

ACTS

Errors

PerceptionErrors

Skill-BasedErrors

Judgment andDecision-Making

Errors

Violations

InadequateSupervision

PlannedInappropriate

Operations

Failed to Correct Known Problem

SupervisoryViolations

SUPERVISION

Resource/AcquisitionManagement

OrganizationalClimate

OrganizationalProcess

ORGANIZATIONALINFLUENCES

Condition of Individuals

Cognitive Factors

Technological Environment

Physical Environment

Self-Imposed

Stress

Coordination/Communication/Planning Factors

Personnel Factors

Psycho-Behavioral

Factors

Environmental Factors

PRECONDITIONS

Perceptual Factors

Physical/Mental

Limitations

Adverse Physiological

States

2525

What the US Navy is doingWhat the US Navy is doing

Rejuvenating Crew Resource Management Training

Development of Joint DoD Human Factors Analysis and Classification System

ORM and Fundamentals of Flying ProgramEmphasize ORM procedures in everything we doTake time during flights to practice basic flying

skills

Rejuvenating Crew Resource Management Training

Development of Joint DoD Human Factors Analysis and Classification System

ORM and Fundamentals of Flying ProgramEmphasize ORM procedures in everything we doTake time during flights to practice basic flying

skills

2626

QuestionsQuestions??