1. Basic concepts.pdf

2024-02-13 Human Performance and Limitation Asist. dr. A. Radzevičienė History of human performance 1487 Leonardo DaVinci The Vitruvian Man Anthropometry Wings for human...

2024-02-13 Human Performance and Limitation Asist. dr. A. Radzevičienė History of human performance 1487 Leonardo DaVinci The Vitruvian Man Anthropometry Wings for human 1  2024-02-13 History of human performance 1783 hot air baloon 1852 Henry Griffard History of human performance 1848 first powered aeroplane by 1903 Orville Wright 12 sec flight John Stringfellow 2  2024-02-13 The Relevance of Human Performance in Aviation Human Performance (Human Factors) is relevant wherever and whenever the human being is involved in aviation. It promotes: Safety and efficiency. Health, fitness and well-being. Operating skills. Awareness of the common areas of human error. Judgement and decision making. Leadership qualities. Crew coordination. The Relevance of Human Performance in Aviation Efficient design of: Aircraft, cockpit, instrument and control layouts. Operating procedures. Checklists. Safety and efficiency of Charts. the operation Training procedures. and Well-being of the Efficient and comfortable working environments. individual Efficient personnel selection. Efficient communications. 3  2024-02-13 Human factor 1900 Frank and Lillian Gilbreth 1949 British psychologist Trying reduce human error in Hywel Murrell medicine Multidisciplinarity: Challenge-response system Hywel Murrell psychology, 1799-1882 1910 Wright brothers engineering, first apply human factors industrial design, statistics, human performance, operations research anthropometry Human factor World War I – World War II The Cold War aeronautical laboratories Military research laboratories 1930s human limitations and Laboratories at universities human capabilities 1951 Fitts Report about Human 1947 Fitts and Jones analyzed the Factor issues in aviation most effective configuration of 1957 Human Factors Society in US controls and dials in the aircraft Primary research areas control panel fatigue and disorientation Analyzed pilots errorrs during WW II aircraft 4  2024-02-13 Human factor 1960-1970 1980 Boeing 727, 737 and 747 Increase automation New technologies Human factor and the age of pilots Accidents due to human factor error Experience could interfere Flight management computer (FMC) and the flight management system (FMS) Dependance on automation Flight envelope protection For reducing human error Lack of standardization The problem with humans is that we tend to be extraordinarily creative when it comes to finding new ways in which to commit errors. The Dirty Dozen 12 human factors that degrade human performance 1. Lack of communication Failure to transmit, receive, or provide enough information to complete a task. Only about 30% of verbal information is received and understood by either side in a conversation. Remembering the beginning and the end. Improve communication: Say the most important things in the begining Repeat at the end Use checklists 5  2024-02-13 The Dirty Dozen 12 human factors that degrade human performance 2. Complacency Overconfidence from repeated experience performing a task Avoid predict the results: Expect to find errors Don‘t sign it if you didn‘t do it Use checklist Learn from mistakes of others The Dirty Dozen 12 human factors that degrade human performance 3. Lack of knowledge Shortage of the training, information, and/or ability to succesfully perform Don‘t guess, know! Use current manual Ask when you don’t know Participate in training 6  2024-02-13 The Dirty Dozen 12 human factors that degrade human performance 4. Distractions Anything that draws you attention away from the task at hand. Distractions are the first cause of forgetting things, including what has or has not been done in a maintenance task Causes about 15% of all maintenance errors Get back in the groove after a distraction Use checklists Go back 3 steps when restarting the work The Dirty Dozen 12 human factors that degrade human performance 5. Lack of teamwork Failure to work together to complete a shared goal Personality conflicts Poor communication Lack of coordination Lack of consensus Build a solid teamwork Discuss how a task should be done Make sure everyone understands and agrees Trust you teammates 7  2024-02-13 The Dirty Dozen 12 human factors that degrade human performance 6. Fatigue Physical or mental exhaustion threatening work performance Cause problems with: Alertness Decision-making Reaction time Strength Cognitive ability Judgement Situational awarenes Eliminate fatigue-related performance issues Watch for symptoms of fatigue in yourself and others Have others check your work The Dirty Dozen 12 human factors that degrade human performance 7. Lack of resources Not having enough people, equipment, documentation, time, parts, etc. to complete a task. Improve supply and support Order parts before they are required Have a plan for pooling or loaning parts 8  2024-02-13 The Dirty Dozen 12 human factors that degrade human performance 8. Pressure Real or perceived forces demanding high-level job performance Reduce the burden of physical or mental distress Communicate concerns Ask for extra help Put safety first The Dirty Dozen 12 human factors that degrade human performance 9. Lack of assertiveness Failure to speak up or document concerns about instructions, orders, or the action of others Express your feelings, opinions, beliefs, and needs in a positive, productive manner Express concerns but offer positive solutions Resolve one issue before addressing another 9  2024-02-13 The Dirty Dozen 12 human factors that degrade human performance 10. Stress A physical, chemical, or emotional factor that causes physical or mental tension Manage stress before it affects your work Take a rational approach to problem solving Take a short break when needed Discuss the problem with someone who can help The Dirty Dozen 12 human factors that degrade human performance 11. Lack of awareness Failure to recognize a situation, understand what it is, and predict the possible results See the whole picture Make sure there are no conflicts with an existing repair or modifications Fully understand the procedures needed to complete the task 10  2024-02-13 The Dirty Dozen 12 human factors that degrade human performance 12. Norms Expected, yet unwritten, rules of behaviour Help maintain a positive environment with your good attitude and work habits Existing norms don’t make procedures right Follow good safety procedures Identify and eliminate negative norms Human factor 1990 Threat and Error Management (TEM) a safety management initiative pilots will make mistakes – the goal is to find them three components: 1. threats, 2. errors 3. undesired aircraft states (UAS) 11  2024-02-13 Operational threats Environmental threats Organizational threats Weather: thunderstorms, turbulence, icing, Operational pressure: delays, late arrivals, wind shear, cross/tailwind, very low/high equipment changes. temperatures. Aircraft: aircraft malfunction, automation ATC: traffic congestion, TCAS RA/TA, ATC event/anomaly, MEL/CDL. command, ATC error, ATC language difficulty, ATC non-standard phraseology, Cabin: flight attendant error, cabin event ATC runway change, ATIS communication, distraction, interruption, cabin door units of measurement (QFE/meters). security. Airport: contaminated/short runway; Maintenance: maintenance event/error. contaminated taxiway, lack Ground: ground handling event, de-icing, of/confusing/faded signage/markings, ground crew error. birds, aids U/S, complex surface navigation procedures, airport constructions. Dispatch: dispatch paperwork event/error. Terrain: High ground, slope, lack of Documentation: manual error, chart error. references, “black hole”. Other: crew scheduling event Other: similar call-signs. Occur spontaneously or could be planed Latent Errors actions or inactions by the flight crew that lead to deviations from organizational or flight crew intentions or expectations. Errors can be spontaneous (i.e., without direct linkage to specific, obvious threats), linked to threats, or part of an error chain 12  2024-02-13 Errors Detection and response – the core of the TEM model Errors: Handling Procedural Examples of errors Aircraft handling errors Manual handling/flight controls: vertical/lateral and/or speed deviations, incorrect flaps/speed brakes. Automation: incorrect altitude, speed, heading, auto throttle settings, incorrect mode executed Systems/radio instruments: incorrect packs, incorrect anti-icing, incorrect altimeter Ground navigation: attempting to turn down wrong taxiway/runway, taxi too fast Procedural errors SOPs: failure to cross-verify automation inputs Checklists: wrong challenge and response, items missed, checklist performed late Callouts: omitted/incorrect callouts Briefings: omitted briefings, items missed Documentation: wrong weight and balance, fuel information, ATIS or clearance information Communication errors Crew to external: missed calls, misinterpretations of instructions, incorrect read-back, wrong clearance Pilot-to-pilot: within crew miscommunication or misinterpretation 13  2024-02-13 Undesired Aircraft States flight crew-induced aircraft position or speed deviations, misapplication of flight controls, or incorrect systems configuration, associated with a reduction in margins of safety. Undesired Aircraft States Examples Aircraft control (attitude). Vertical, lateral or speed deviations. Unnecessary weather penetration. Unauthorized airspace penetration. Aircraft handling Operation outside aircraft limitations. Unstable approach. Continued landing after unstable approach. Long, floated, firm or off-centreline landing. Proceeding towards wrong taxiway/runway. Ground navigation Wrong taxiway, ramp, gate or hold spot Incorrect systems configuration. Incorrect flight controls configuration. Incorrect aircraft Incorrect automation configuration. configurations Incorrect engine configuration. Incorrect weight and balance configuration 14  2024-02-13 Countermeasures (1) Planning Countermeasures - Concise, not rushed, and met SOP The required briefing was interactive SOP BRIEFING requirements - Bottom lines were and operationally thorough established Operational plans and decisions - Shared understanding about plans PLANS STATED were communicated and - “Everybody on the same page” acknowledged Roles and responsibilities were WORKLOAD - Workload assignments were defined for normal and non-normal ASSIGNMENT communicated and acknowledged situations Crew members developed effective - Threats and their consequences CONTINGENCY MANAGEMENT strategies to manage threats to were anticipated - Used all available safety resources to manage threats Countermeasures (2) Execution Countermeasures Crew members actively monitored MONITOR / - Aircraft position, settings, and and cross-checked systems and CROSS-CHECK crew actions were verified other crew members Operational tasks were prioritized WORKLOAD - Avoided task fixation - Did not and properly managed to handle MANAGEMENT allow work overload primary flight duties - Automation setup was briefed Automation was properly AUTOMATION to other members - Effective managed to balance situational MANAGEMENT recovery techniques from and/or workload requirements automation anomalies 15  2024-02-13 Countermeasures (3) Review Countermeasures - Crew decisions and actions EVALUATION/ Existing plans were reviewed were openly analyzed to MODIFICATION OF PLANS and modified when necessary make sure the existing plan was the best plan - Crew members not afraid to Crew members asked questions express a lack of knowledge - INQUIRY to investigate and/or clarify “Nothing taken for granted” current plans of action attitude Crew members stated critical - Crew members spoke up ASSERTIVENESS information and/or solutions without hesitation with appropriate persistence Human factor 2000 Categorizing accidents caused by groups or individual acts. 16  2024-02-13 The SHEL Model How are errors made? How and why do accidents happen? Interrelationship between human factors and the aviation enviroment 17  2024-02-13 The SHEL Model L = Liveware H = Hardware At the centre of the model is pilot. Design of Flight Decks Man – the most valuable and flexible The physical structure of the aircraft component of the system. The second Presentation of instruments L represents other humans whather inside or outside the aircraft Positioning and operating sense of controls S = Software E = Enviroment Procedures The conditions both inside and outside Manual the cockpit Checklist layouts Symbology Computer programmes Maps and charts SHELL model interfaces Software – Liveware Interactions are those between the human operator and the non-physical supporting systems that exist within the workplace. Hardware – Liveware Interactions between the human operator and the machine, better known as the Human-machine Interface or HMI Environment – Liveware Interaction that occurs between the human operator and the internal and external environments Liveware – Liveware Interaction between the central human operator and any other person in the aviation system during the performance of associated tasks 18  2024-02-13 Liveware – Liveware Interactions can influence behavior and performance: positively negatively L-L interface is largely concerned with: Interpersonal relations Leadership Crew cooperation, coordination and communication Dynamics of social interactions Teamwork Cultural interactions Personality and attitude interactions Liveware – Liveware L-L interface have contributed to the development of cockpit/crew resource management (CRM) programs in an attempt to reduce error at the interface between aviation professionals. Examples of mismatches: Communication errors due to misleading, ambiguous, inappropriate or poorly constructed communication between individuals Reduced performance and error from an imbalanced authority relationship between aircraft captain and first officer Poor structure of shared authority, i.e., who is responsible for specific actions and when those actions will be performed 19  2024-02-13 The Competent Pilot A high sense of responsibility Ability (academic and flight handling) Motivation A good communicator Flexibility Physical fitness Reliability A balanced personality A team player Calmness under stress An eye for detail Competency in Risk Assessment Competency in the skills of Stress and Crew Managements The Competent Pilot Training methods and techniques : Courses should designed to be: Flight Simulator, Relevant Crew Resource Management (CRM), Regular Line Oriented Flying Training (LOFT), Clear and concise Self-development, Time-efficient Leadership, Participational Flight Safety, Include course reading and revision Survival and Correspondence material courses Self-training 20  2024-02-13 Human factor 2000 a greater emphasis was placed on considering groups rather than individuals, and categorizing accidents into those caused by individuals and those caused by organizational action or inaction Aircraft Accident Statistics 21  2024-02-13 Aircraft Accident Statistics 22  2024-02-13 Transport Safety Performance in the EU Fatality rate : By plane 0,003 By rail 0,27 By car 2,57 The aviation fatal accident rate over the last 10 years is approximately 1 per 1.2 million flights Statistically, you have more chances of being killed riding a bicycle or even by lightning than traveling by plane. Source: https://www.icao.int/safety/Do cuments/ICAO%20Safety%20Re port%202021%20Edition.pdf 23  2024-02-13 Source: https://www.icao.int/safety/Do cuments/ICAO%20Safety%20Re port%202021%20Edition.pdf Causes of accidents 24  2024-02-13 Accidents in aviation Human factor Accidents, percent Technical reason Now Time Causes of Accidents 5 most common specific causes of pilot-induced accidents Loss of directional control Poor judgement Airspeed not maintained Poor preflight planning and preflight decision making Not maintaining ground clearance 25  2024-02-13 Safety culture The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management Safety culture It refers to the extent to which individuals and groups will commit to personal responsibility for safety and to: act to preserve enhance and communicate safety concerns strive to actively learn adapt and modify (both individual and organizational) behaviour based on lessons learned from mistakes strive to be honoured in association with these values 26  2024-02-13 Safety culture Open Culture Where all levels of an organization play an active part in the improvement of the safety culture. Closed Culture Where an organization is reluctant to release information on threats, errors or undesired aircraft states to other agencies. National Culture Both government and ethnic factors influence attitudes towards safety culture. Factors that Promote a Good Safety Culture Leadership Commitment Good example Organizational culture characteristics and safety perceptions among members interacting within a particular entity Organizational culture has the potential to affect the following: Interactions between senior and junior members of a group; Interactions between industry and regulatory authority personnel; the degree to which information is shared internally and with the regulatory authorities the prevalence of teamwork in the regulatory authority or industry organization; reactions of personnel under demanding operational conditions; acceptance and utilization of particular technologies; and the tendency to take punitive measures in reaction to operational errors within a product or service provider or by the regulatory authorities 27  2024-02-13 Organizational culture Is affected by such factors: business policies and procedures; supervisory behavior and practices; safety improvement goals as well as minimum tolerance levels; management attitude toward quality or safety issues; employee training and motivation; the relationship between the regulatory authorities and product and service providers and work life balance policies. Just Culture a culture in which front line operators and others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. A non-punitive culture is a work environment in which staff are encouraged to deliver their best work possible in every situation.... the individual is held accountable for his or her actions. 28  2024-02-13 Safety culture Elements by James Reason 1. An informed culture the organization collects and analyses relevant data, and actively disseminates safety information 2. A reporting culture cultivating an atmosphere where people have confidence to report safety concerns without fear of blame 3. A learning culture an organization is able to learn from its mistakes and make changes 4. A just culture errors and unsafe acts will not be punished if the error was unintentional 5. A flexible culture the organization and the people in it are capable of adapting effectively to changing demands Reason’s Swiss Cheese Model 29  2024-02-13 Safety first? Safety first - but not at any cost 30