Human Factors Final Exam

What is Flight Operations Quality Assurance (FOQA)?

A data monitoring program that can monitor hundreds of parameters

Where does the data from Flight Operations Quality Assurance come from?

QARs (essentially a FDR)

What is a limitation of Flight Operations Quality Assurance?

You have to go looking for a specific problem and it gives no context on the situations

What is the outcome of Flight Operations Quality Assurance?

A committee reviews the findings and makes recommendations

What is a strength of Flight Operations Quality Assurance?

Actual detailed data, snapshot of real time operations which means inability to hide an event, and you can see the entire operations performance

What is a Line Operations Safety Audit?

Tool used to identify threats to aviation safety, minimize the risk such threats may generate, and implement measures to manage human error in operational contexts

How do Line Operations Safety Audits work?

They enable operators to assess their level of resilience to systemic threats, operational risks, and front-line personnel errors

How is a Line Operations Safety Audit analyzed?

Trained observers are put in the jump seat to see how well crews recover from errors

What are the strengths of Line Operations Safety Audits?

Real time snapshot of line operations, a trained observer who functions under a set criteria is monitoring, and a statistical analysis of the findings is given

What are the weaknesses of Line Operations Safety Audits?

Real time snapshot of operations (only gives info on that time frame), the crew is on “best behavior” when being audited, can take time to prove that suggested changes are effective

Why do we have accident models?

They provide a framework for data gathered, ensuring comprehensiveness of investigation, understanding the relationship of facets, and to help develop causation for better recommendations

What are the 5-M’s in the old concept model?

Man, Machine, Medium, Mission, and Management

In the 5-M model, what does Man mean?

That we need to examine the human component to each accident like human limitations and actions prior to the event

In the 5-M model, what does Machine mean?

Taking a closer look at the design and operations

In the 5-M model, what does Medium mean?

Analyzes the natural and artificial environments

In the 5-M model, what are examples of Mediums artifical environment?

ATC, Airports, Nav Aids, Regs, Procedures, and Charts

In the 5-M model, what does Mission mean?

The purpose of the operation

In the 5-M model, what does Management mean?

Control of allocation of resources and having a specific responsibility to maintain the operations

In the SHEL model, what does S stand for?

Software

What does the Software in the SHEL model do?

It transfers information between the human and the systems

In the SHEL model, what does H stand for?

Hardware

What does the Hardware in the SHEL model do?

Transfers physical and mental interactions between the person and the machine or equipment

In the SHEL model, what does E stand for?

Environment

What does the Environment in the SHEL model mean/do?

The individuals interaction with the environment

In an environment, what are internal factors?

Personal comfort and physical working conditions, temperature, and air quality

In an environment, what are external factors?

Weather conditions, airport surroundings, airport lighting, and icy runways

In the SHEL model, what does the L stand for?

Liveware

In the SHEL model, what does Liveware do?

It monitors the nature of the interactions between humans

What are some examples of Liveware?

Voice communications, phraseology, speech content/rate, language barriers, read and hear backs, crew briefings, crew interactions etc.

What is the Reasons model?

It acknowledges that all elements of the system may have played a role in the mishaps occurrence. Is a “systems approach” to accident investigation

In the Reasons model, what are the two types of failure?

Active and Latent

What is human error?

A normal part of human behavior and is a symptom, NOT a cause of accidents

What is an Active failure?

Typically seen by pilots, controllers, mechanics, etc. and consequences are seen soon after mistake

What are examples of Active failures?

Pilots forgetting to lower landing gear and a mechanic failing to replace O-rings

What are the preconditions of Latent failure?

A high workload, time pressure, acceptance of hazards, and ignorance of the system

What are Latent failure deficiences?

Inadequate procedures, poor scheduling, neglect of hazards, and insufficient training

What are Latent failure decision makers and managers?

Lack of regulation, further removal from the “front lines”, poorly planned government deregulation, and too rapid of an expansion with routes or services

What happens when a Latent error is corrected?

This can result in the elimination of several active errors

What outcome creates an accident?

A combination of Latent and Active failures/errors

What are Inadequate defenses?

Warning systems disabled, absence of monitoring, safety regulations are not enforced, and an over-reliance on automation

What is the “Systems approach” to accident investigation?

New view, HRO, Normal Accident Theory

What are the two ways to view human error?

The “bad apple theory” and that it is a symptom of deeper trouble in a system

What is the bad apple theory?

Complex systems are safe and have to be protected from “unreliable” humans, the oldest and most common approach

What are ways to “fix” the bad apples?

Punish them, fire them, or create more regulations and procedures

Why is the bad apple theory the most common approach?

Because bad person= bad error, it oversimplifies the problem, its a cheap and easy fix, and it shows the public that “we fixed the problem so we care”

Why is the “bad apple theory” not effective?

Because it only places blame, gives an answer as to what happened but not a “why?”, and ignores the local rationality principle

How is human error a symptom of deeper trouble in a system?

It’s not the cause of system failure, not random, is not the conclusion of an investigation, complex systems are not “basically safe”, and safety is never the only goal

What is the local rationality principle?

The idea that people are doing rational and reasonable things given their point of view and focus of attention, knowledge of the situation, and their objectives or the objectives of the organization they work for

What must be understood for local rationality to exist?

An understanding of the crew’s perception of the situation

Many human errors are based on inadequate perception of what?

A situation or an environment

Do crews really understand what was happening to them during an accident?

Most likely no because an accident occurred

Do systems exist to make things more safe?

No, they are intended to make money, products, or render a service

In an accident, what are the identifying events?

Perceptions, decisions, behavior shifts, action or inaction, and changes in process

What is the unfolding mindset?

The thinking at the time of the event, understand why this is different than the retrospective reality

After and accident occurs, what is the suggested protocol?

Collect as much data as possible before any interviews take place. 72 hr. look back information, FOQA/ASAP/FDR/ATC tapes, maintenance, training, and review dispatch paperwork and weather

Local Rationality looks for evidence based off of what?

Human factors concepts like fatigue, workload, perception, and cognition

What is hindsight bias?

Biased because you know the outcome of the decisions made which contaminates your thinking

How does hindsight bias effect human thinking?

It predetermines an outcome making it difficult to sort valid information, you are no longer able to be objective of the event

What are the useless reactions to failure?

Retrospective- ability to look back

Counterfactual- saying what they should have done

Judgmental- they judge individuals, what they did was wrong

Proximal- only focus on the people closest to the terminal event

What happens when you adopt characteristics of useless reactions to failure?

The less you will be able to understand human failure

What is a High Reliability Organization (HRO)?

Hazardous organizations that enjoy a high safety record over long periods of time

What are examples of High Reliability Organizations?

Naval aviation, nuclear power, and can include some power plant operations

How do High Reliability Organizations operate?

They have the mindset that accidents can be prevented through good organizational design and management, safety is the priority, redundancy enhances safety, decentralized decision making is needed to be flexible, trial and error provide for valuable learning, accidents are not inevitable

What is Normal Accident Theory (NAT)?

The idea that in technological systems, accidents are inevitable

What two dimensions is Normal Accident Theory based off of?

Interactive complexity and a tightly coupled system

What is interactive complexity?

The presence of unfamiliar or unplanned and unexpected sequence of events in a system that are either not visible or comprehensible

What is a tightly coupled system?

A system that is highly interdependent, rapid change to one part rapidly affects other parts

What are some characteristics of Normal Accident Theory?

Accidents are inevitable in complex and tightly coupled systems, safety is one of a number of competing objectives, redundancy often causes accidents by increasing interactive complexity and opaqueness, decentralization is needed for complexity, but centralization is needed for tight coupling, organizations cannot train for all operations

What is fatigue?

A complex state causing cognitive impairment as the result of combined effect of sleep/wake history (time awake), circadian phase, and time on task

What happens when you’re fatigued?

Neurobiological effects can begin and can only be returned to baseline with adequate sleep

What are time awake effects?

The cognitive degradation that occurs from continued wakefulness

17 hours of wakefulness is cognitively equivalent to what?

.05% BAC

What is circadian phase?

Time of day modulated core body temperature, sleep propensity, and performance in a sine wave shaped, approximately 24-hours

How does circadian rhythm work?

Set by light exposure and is mediated by the ganglion cells in the retina and the suprachiasmatic nucleus located in the brain

What are the highs and lows of Circadian rhythm?

Lowest: 0600 hrs

Highest: 1800 hrs

What is time on task?

Progressive decrease of performance across the duration of a cognitive task, can be seen within a few minutes of starting the task for both rested and sleep deprived states, more pronounced while sleep deprived, can be reversed with a simple break from the task

What is the one way to prevent fatigue?

Sleep

What is the relationship between fatigue and performance?

Sleep loss degrades performance in all areas from simple reaction times to complex tasks

Who discovered the spin recovery method?

British naval pilot Lt Wilfred Parke in 1912

In the 70s, what was the major cause of aircraft accidents and incidents?

NASA research showed “pilot error”

What are the objectives of communication?

Conveys information, establishes interpersonal/team relationships, establishes predictable behaviors and expectations, maintains attention to task and situational awareness, is a management tool

What is a safety management system?

An organization wide approach to managing safety risk and assuring the effectiveness of safety risk controls

What does Safety Management Systems do?

Provide decision making, management capability, risk controls, safety assurance, knowledge sharing, safety promotion, and safety culture

What are the 4 pillars of safety management systems?

Policy, risk management, assurance, and promotion

What is safety policy?

Establishes senior management’s commitment to continually improve safety

What is safety risk management?

determines the need for, and adequacy of, new or revised risk controls based on the assessment of acceptable risk

What is safety assurance?

Evaluates the continued effectiveness of implemented risk control strategies and supports the identification of new hazards

What is safety promotion?

Includes training, communication, and other actions to create a positive safety culture within all levels of the workforce

What are the 5 steps of Safety Risk Management?

System analysis, identify hazards, analyze safety risk, assess safety risk, and control safety risk