Human Factors Quiz 4

Accident

Boarding to disembarking, aircraft has the intention of flight, results in fatal or serious injury

Fatal Injury

Any injury that results in death within 60 days of the accident

Serious Injury

Any injury that requires hospitalization for more than 48 hours, results in bone fracture, or involves internal organs or burns

Substantial Damage

Damage or failure that adversely affects the structural strength, performance, or flight characteristics of the aircraft and that would normally require major repair or replacement of the affected component

Incident

An occurrence other than an accident associated with the operation of an aircraft that affects or could affect the safety of operations

Major Accident

An accident in which a Part 121 aircraft was destroyed, or there were multiple fatalities, or there was 1 fatality and a Part 121 aircraft was substantially damaged

Serious Accident

An accident in which there was 1 fatality without substantial damage to Part 121 aircraft, or at least 1 serious injury and a Part 121 aircraft was substantially damaged

Injury

A nonfatal accident with at least 1 serious injury without substantial damage to a Part 121 aircraft

Damage

An accident in which no person was killed or seriously injured, but in which an aircraft was substantially damaged

Why do we collect safety data?

To prevent accidents and incidents

How do we do it?

Examine the non-standard events in our operation in an effort to make recommendations and corrections

Two ways of data collection

Self reporting and monitoring systems

What is self reporting?

Where the operator voluntarily reports events, must include certain characteristics such as: trust, independence, ease of reporting, acknowledgment, motivation and promotion, and feedback

Mandatory Self Reporting

company based, tend to catch more technical issues, HF issues usually not reported, hard to define every situation in flight operations

Voluntary Self Reporting

Usually more successful because of confidentiality is a must, especially for HF events

Near Midair Collision Database (NMACS)

Reporting form, FAA must investigate within 90 days of report, ANYONE can submit

NASA Aviation Safety Reporting System

Joint effort between FAA, NASA, Battelle, designed to get information about events to the entire industry for better hazard mitigation

Aviation Safety Action Program (ASAP)

Capture safety data that would not otherwise be captured, agreement between Union, FAA, company to collect, analyze, and correct reportable events, confidential reporting form

Event Review Committee (ERC)

Works well in airline environments, trust is a significant component of these programs, reports can be rejected if they feel that there was an intentional disregard for safety, all members must agree on decisions, Review AC 120-66B

Flight Operations Quality Assurance (FOQA)

data monitoring program, can monitor hundreds of parameters, committee reviews findings and makes recommendations

Line Operations Safety Audit (LOSA)

Tool used to identify threats to aviation safety, minimize the risk of such threats may generate and implement measures to manage human error in operational contexts, places trained observers in the jump seat to see how well crews recover from errors

New View

Human error plays a role in every accident to some degree

Two ways to view human error

Bad apple theory and a symptom of deeper trouble in a system

Bad apple theory

complex systems are basically safe and have to be protected from unreliable humans

Human Error

symptom of a deeper issue in a system, not the cause of system failure, not random, not the conclusion of an investigation

Local Rationality Principle

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

Local Rationality

Identify the events such as perceptions, decisions, behavior shifts, action or inaction, changes in the process

Hindsight Bias

You know the outcome of the decision made which contaminates your thinking

Reactions to Failure

Retrospective- ability to look back

Counterfactual- saying what they should have done

Judgmental- they judge others, what they did was wrong

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

High Reliability Organizations (HROs)

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

Normal Accident Theory

in technological systems, accidents are inevitable