Aviation Human Factors Protecting Us from Ourselves

Jason Quisling Aviation Compliance Evaluator EC145/EC135 Air Methods Corporation jquisling@airmethods.com IHST/USHST – Training Work Group and SMS Work Group

Protecting Us from Ourselves

Weather report: Vertical visibility zero.

Pilot: �Is that in feet or meters?�

Please don’t try this in your helicopter!!!

Ground Rules •  The purpose here is to develop awareness

and educate.

•  We are here to learn from others very costly mistakes.

•  Comments and ideas presented here are mine personally and do not necessarily reflect the opinions of my employer.

House of Pain Est. circa 1939

•  Fuel Mismanagement •  LTE •  Vortex Ring State •  Dynamic Rollover •  Autorotation •  IIMC/ Flight in DVE

•  Loss of SA •  Miscommunication •  Overconfidence •  Lack of Planning •  Lack of Proficiency •  Violating regulation

or SOP

A Little About The Numbers

– www.ihst.org or www.ushst.org

1

Unacceptable

rise: Average of 181 annual

accidents during this period.

IHST begins Average of 148 annual accidents.

Average of fatal accidents down from 31 to 25 annually.

Source: NTSB data as of 8/01/2012

Analysis of US Accidents: 2000, 2001, 2006 by US Joint Helicopter Safety Analysis Team

Loss of Control

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Per

form

ance

Man

agem

ent

Dyn

amic

Rol

love

r

Exc

eedi

ngO

pera

ting

Lim

its

Em

erge

ncy

Proc

edur

es

Loss

of T

/RE

ffect

iven

ess

Inte

rfere

nce

with

Con

trols

Gro

und

Res

onan

ce

Tie-

dow

ns/h

oses

Set

tling

w/

pow

er

% o

f Tot

al A

ccid

ents

Figure 9. Loss of Control – Occurrence Category

Note: Categories are a percentage of the total of 523 accidents

Accidents by Phase of Flight

Phase of Flight was determined as the flight profile the aircraft was in when the accident sequence was initiated. Hover includes In Ground Effect (IGE) and Out of Ground Effect (OGE) operations. For identification purposes Maneuvering was considered a Phase of Flight which was NOT classified as Landing, Enroute, Hover, Take-off, Approach, Standing and Taxi. In general, Maneuvering is considered to be a change of direction whether in low speed or high speed flight. Figure 10 identifies Enroute as the Phase of Flight where the majority of fatal accidents occurred. These fatalities can be attributed to potentially higher velocity speeds at impact.

Phase of Flight

2

4

3

11

28

34

4

2

18

32

63

78

72

68

104

0 20 40 60 80 100 120

Taxi

Standing

Approach

Take-off

Hover

Maneuvering

Enroute

Landing

Accidents

Note: 86 Fatal Accidents in Red, 437 Non-Fatal Accidents in Yellow

Figure 10. Phase of Flight (523 Accidents)

Note: 86 Fatal Accidents in Red, 437 Non-Fatal Accidents in Yellow

9 US JHSAT 2011 Compendium Report Volume I

IIMC in Alaska •  Lack of FRAT •  Inadequate SOP’s

•  Punitive Culture •  Flight Data Monitoring

Hubris Helicopter pilots are inherently teenagers…

They will consistently tend to overestimate their abilities and underestimate the risks in a

particular operation.

This is your greatest threat to maintaining SA!!

Helicopter Operation

Over the three years of analysis the accidents have been grouped by mission (CY2000) or by operation (CY2001, CY2006). Because of the differences in categorization of the operations by NTSB and the missions/operations identified by JHSAT between years, a single categorization was needed to analyze the dataset. Each accident was reviewed and placed in a consistent grouping. This new grouping was referred to as Industry Segment and has changed the “labeling” of a small percentage of the accidents, but allowed a consistent comparison across the years.

The versatility of helicopters is reflected in the variety of Industry Segments in which they operate; from personal and commercial flying to emergency medical transport, logging, and law enforcement. Figure 6 shows that the highest number of helicopter accidents occurred during Personal/Private flight (18.5%), Instructional/Training (17.9%) and Aerial Application (10.9%). The number of aircraft flying in each of these different Industry Segments varies widely. It should be noted flight hour exposure rates are not available for each of these Industry Segments due to insufficient data available. Since exposure rates were unknown for this analysis, comparison of these statistics alone should not be used to rank the relative safety record between different segments. If Industry segment flight hour models were available in the future, analyses may allow for those comparisons to be made.

Accidents by Industry (523 Total Accidents)

33

756

33

5710

47

19

6

7885

5030

3229

282216

1712

10148

0 10 20 30 40 50 60 70 80 90 100 11

Electronic News Gathering

Utilities Patrol/Construction

External Load

Logging

Firefighting

Offshore

Aerial Observation

Business

Air Tour / Sightseeing

Law Enforcement

Commercial

Emergency Medical Services

Aerial Application

Instructional/Training

Personal/Private

Total Accidents

Note: 86 Fatal Accidents in Red, 437 Non-Fatal Accidents in Yellow

0

Figure 6. Accidents by Industry (523 Total Accidents) Note: 86 Fatal Accidents in Red, 437 Non-Fatal Accidents in Yellow

Accidents by Activity

During the analysis, the team also grouped the data by “Activity”. This additional category describes what specific activity the helicopter was completing on the specific flight

6

US JHSAT 2011 Compendium Report Volume I

1.  Distraction -Talking/ Wx/ Listening/ Workload/

Warning light/ Etc. 2.  Time – involved in a task there is always

too much or too little. 3.  Illusion/Misinterpretation -You can talk yourself into some pretty

dumb things, when you �know� you are right.

3 Basic Elements of Disorientation

Night – Degraded Visual Environments

•  Lack of visual cues = IIMC in visual conditions

•  Technology to the rescue? •  New emergencies??

Night Vision Goggles/Image Intensifier Set AN/AVS-9 (F4949 Series)

Engineered for life

For more than 45 years, ITT Night Vision has provided the military with premier vision-enhancing solutions. As the world's leading manufacturer of Generation 3 (Gen 3) image intensification technology, ITT continues to work hand-in-hand with customers to expand night vision and vision-enhancing capabilities, technologies, and resources. ITT also provides technical support, service, training, and maintenance for our products to maximize customer benefits and usability.

ITT Night Vision offers the AN/AVS-9 (ITT F4949 Series) Night Vision Goggle/Image Intensifier Set with various objective lens filter options and various flight helmet-mount configurations – all designed to meet individual customer requirements.

Features and Benefits

● Gen 3 tube performance offering high resolution, high gain, photoresponse to near infrared, and exceptional reliability.

● Class A, B, C, and UK 645 minus-blue filters for objective lens available to suit all types of cockpit lighting, including color displays and fighter HUDs.

● Helmet mount configurations designed for fixed-wing and rotary-wing applications, adapting to most aviator helmets (U.S. HGU-55/P, HGU-56/P, HGU-84/P, SPH-4AF, SPH-4B, SPH-5; British Alpha 202 and Mk4; French OS and CGF). Other mounts available upon request.

● 25-mm eye-relief eyepieces easily accommodate eyeglasses.

● Low-profile battery pack improves aviator head mobility and increases battery life.

● Other features include flip-up/flip-down capability, simple binocular attachment, individual interpupillary adjustment, tilt, vertical and fore-aft adjustments to fit all aviators.

Standard Accessories● Carrying case tailored to system● Lens caps● Lens paper● Operator's Manual● Helmet attachment instructions● Neck cord (rotary-wing versions)● Low-profile battery pack (rotary wing versions)

Optional Accessories● Battery pack adapter (fixed-wing versions)● Low-profile battery pack (fixed-wing versions)

● Clip-on power source

Approved for unlimited distribution per 07-S-2340.

Unlimited Distribution

Video by Dave Duncan

Safety Management Systems - SMS

! Organizational Cultures and Safety

! Leadership and Teamwork

! Metrics – Recording, Reporting, Evaluating and Fixing

! Data driven decision making will show where to spend the dollars.

Safety Policy Risk Management

Safety Assurance

Safety Promotion

Culture is Key Reporting Culture + Just Culture + Flexible Culture + Learning Culture =

Informed Culture which equates to “Safety Culture”

It’s Power is derived from not forgetting to be afraid.

Role of Aviation Human Factors

•  Asking and understanding the ‘Why’…

•  Provides a means of understanding the individual, as well as the organizational, institutional, and other social factors that are vital to error management and increased safety.

•  Human Error accidents, which most are, can then be controlled cost-effectively.

Error Management 101 1.  ALL HUMAN BEINGS MAKE

MISTAKES. 2.  Maintain Situational Awareness 3.  Miscommunication is a reoccurring problem. 4.  You do not know what you don’t know!!! 5.  Technology and training cannot prevent ALL errors. 6.  Human decision-making failures begin at the top of an organization. 7.  Accidents will result from NOT breaking the Error Chain.

Fuel Exhaustion •  Plan Continuation Bias •  AS350 US •  EC135 UK

LOW FUEL light(s) = “LAND THE DAMN HELICOPTER!!!” - Matt Zucarro

Safety

�Reliability is invisible in the sense that reliable outcomes are constant, which means there is nothing to pay attention to. Operators see nothing, and seeing nothing presume that nothing is happening.�

-Karl Weick

Wire Strike Protection System

All systems have limitations – including those designed to protect us.

Swiss Cheese Theory

•  Every defense we put up is littered with holes. •  Multiple defenses may prevent accidents for

awhile. •  Over time drift occurs…

–  we can find the right combination that lines up all the holes in our defenses.

•  This results in an accident.

EC135 EMS Crash

Obstacles are always closer than you think. Wires are present near any road or structure. Communication frequently results in misidentifying a known obstacle.

Known Hazards are often Forgotten or Overlooked

Sometimes People Do Stupid Things

While it’s true that you can’t fix stupid…

Sometimes ..it Just Happens!!

Unintended Actions Dr. James Reason

Slips – Error of Commission

Lapses – Error of Omission

Intended Acts “Watch This…”

Mistakes or Violations

Hazardous Attitude?

Along for the ride… Enroute IFR - on top at 7000MSL: •  In descent at about 6400MSL - IMC for about 3 minutes. •  Needed to add power to maintain A/S – IN THE DESCENT.

•  Vy and Max Continuous Power with ROD above 1200fpm.

•  Just below 3000msl (~1200AGL) descent was arrested and aircraft is VMC between layers.

Every accident, no matter how minor, is a failure of the organization.

Flight Safety Foundation reports that for every single accident, there are on average 360 previous incidents, that if corrected,

may have prevented the accident.

Bell 407 Icing Encounter

•  Surface observations MVFR

•  AIRMET for Icing in effect

It is Important to Have a Little…

It may not be sexy…but we still bend metal through:

•  Vortex Ring State – Settling with Power

•  Dynamic Rollover

•  Loss of Tailrotor Effectiveness

•  Flight in Degraded Visual Environments

It can happen to you

•  Video of Mil 17 VRS crash

S-92 MGB Loss of Oil Pressure

•  Training is only as good as the info going in.

•  Know your aircraft systems, but remember,

•  You never know what you don’t know

CRM – SRM – AMRM – Etc.

•  System for maintaining highest operating efficiency, during periods of greatest STRESS.

F-16 Birdstrike

CRM for Dummies – “What�s Our Plan?”

Maintenance and Preflight

BREAKING NEWS: Captain America Training New Pilots

Be A Professional Aviator Excerpts on professionalism by Tony Kern:

A mere pilot logs hours, a professional aviator logs lessons. Experience does not automatically equate to wisdom, skill or judgment. Debrief every flight for its inherent lessons, even if it’s just to yourself.

A mere pilot meets minimum standards; a professional aviator redefines them upward.

Measure yourself against your God-given potential, not some arbitrary regulatory minimum.

A mere pilot shows up; a professional aviator shows up ready. Readiness is far more than showing up on time; it is preparing for

optimum performance against the day where you have to be at your very best just to survive.

Situational Awareness …or lack thereof.

Fly Smart!! And You Think You Have Stress?