AVN 3300 Human Factors Final

What is an accident?

An occurrence associated with the operation of an aircraft that takes place between the time a person boards to the time all have disembarked and someone suffers a fatal or serios injury or aircraft receives substantial damage.

- Something happens between boarding and disembarking where someone breaks bone or dies or aircraft is messed up.

3 components of an accident

1. From boarding to disembarking

2. Aircraft has the intention of flight

3. Results in fatal or serious injury

Alright chat what's a fatal injury?

Any injury that results in death within 30 days of the accident

Computah tell me what a serious injury is

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

And substantial damage is what???

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

- Aircraft needs maintenance

2 types of data collection

1. It comes to you (self reporting)

2. You go looking for it (monitoring systems)

FAA reporting program

Near-Midair Collision Database (NMACS)

Reporting form

FAA must investigate within 90 days

Anyone can submit

NTSB database

Records back its inception in 1967

Searchable format

NTSB.GOV

NASA ASRS

NASA Aviation Safety Reporting System

- Joint effort between FAA-NASA-Battelle

- Created because of TWA B727 accident in IAD (1974)

- Started in 1976 and designed to get information about events to the entire industry for better hazard mitigation

NASA ARS program protection

Limited immunity from FAA if:

- The incident was inadvertent

- Not criminal, or result in an accident of lack of qualification

- Reporter cannot have dealt with enforcement action within previous 10 years

- Must be reported within 10 days

Alert Bulletins (AB)

Early warning reports issued by NASA to inform the FAA, the NTSB, and industry of air, equipment, ground, or any other safety hazards

- Everyone gets warning for everything

For Your Information (FYI) Notices:

Notices issued by NASA that inform the FAA and aviation industry of conditions that may be sufficient for hazards or indicate an adverse safety or security trends

- Almost everyone gets warning for almost everything

Aviation Safety Action Program (ASAP)

Agreement between Union-FAA-Company to collect, analyze, and correct reportable events

Confidential

Non-punitive reporting

- Bruh what the hecky just another reporting program

Event Review Committee (ERC)

Typically works very well in most airline environments

Some airlines have lost their programs because for trust related issues

Reports can be rejected if it seems there was an intentional disregard for safety

All ERC members must agree on decisions

- Program to review reports at airline level, programs can be lost for lack of trust, reports can be denied

Flight Operations Quality Assurance program (FOQA)

Data monitoring program

Data comes from QARs (essentially a FDR [Flight Data Recorder])

Can monitor hundreds of parameters

Committee reviews the findings and makes recommendations

- Committee sees data from FDR and then assures flight quality

Line Operations Safety Audit (LOSA)

Tool used to identify threats to aviation safety, minimize the risks such threats may generate and implement measures to manage human error in operational contexts. LOSA enables operators to assess their level of resilience to systemic threats, operational risks and front-line personnel errors, thus providing a principled, data-driven approach to prioritize and implement actions to enhance safety.

- Tool used by operators to identify threats, their own strengths and weaknesses and creates a data-driven plan to better safety

Line Operations Safety Audit

Places trained observers in the jumpseat to see how well crews recover from errors

Proper analysis will show an organizational how well their systems resilience is working

Must be repeated to be effective

Summary for LOSA, ASAP, and FOQA

Takes all 3 programs to adequately monitor and assess the safety of an organization

The Bad Apple Theory 😛

The oldest and most common approach

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

Human error is a symptom of deeper trouble in a system

- Human is bad, system is good

She Ate

She = Onika

Ate = Burger

Ways to fix "bad apples"

Punish them (does not change erroneous behavior)

Fire them (does not change the work environment)

Create more regulations or procedures (usually widens the procedures-practice gap)

- All bad

"Fixing" the bad apples is popular cuz...

Cheap and easy

Quick

Oversimplifies problem

"Fixing" bad apples is faulty cuz...

Only assess blame

Answers what happened but not why

Ignores the local rationality principle

Local Rationality Principle

People are doing rational and reasonable things given their:

Point of view and focus of attention

Knowledge of the situation

Their objectives and/or the objective of the larger organization they work for

Local Rationality pt.1

Understanding the crews perception of their situation is paramount

Many human errors are based on an inadequate perception of a situation or environment

Systems do not exist to be safe but rather to make money, products or render a service

- Humans can be unsafe due to their inadequate perceptions, safety systems are only for profit (???)

Local Rationality pt.2

Identify the EVENTS

- Perceptions, Decisions, Behavior shifts, Action or Inaction, Changes in the process

Determine and describe the "unfolding mindset" at each event

Understand if/why the "unfolding mindset" was different than the retrospective "reality"

- Anyway, this is how you inspect or whatever

Suggested Protocol???

Collect all of the data you can before any interviews

- 72 hr look back data

- FOQA/ASAP/FDR/ATC tapes (as available & appropriate)

- Maintenance

- Training

- Review dispatch paperwork and WX

Determine as many events as you can from the "objective" data

Local Rationality pt.3

Look for evidence of HF concepts

- Fatigue, Workload, Perception, Cognition

Determine the defenses that appear to have been breached

Hindsight Bias

You are biased because you know the outcome of the decision(s) made - which contaminates your thinking

- People overestimate what their ability would have been to detect or prevent the problem when they know the outcome

- People think that a bad outcome must have been preceded by an equally bad process to get there

-You are no longer able to object about the event. You can never quite get it completely back

-- You can never know your true response to a situation once it has passed cuz you are biased from the known outcome

Reactions to Failure

Useless reactions to failure share the following features

- Retrospective - ability to look back

- Counterfactual - saying what they should have done

- Judgmental - they judge people, what they did was wrong

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

The more you react like this, the less you will be able to understand human failure

High Rationality Organization (HRO)

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

- Dangerous but safe

- Ex. Naval aviation, nuclear power, some power plant operations

Characteristics of an HRO

Accidents prevented through organization

Safety is priority

Redundancy = increased safety

Decentralized decision making = flexibility = good

Trial and error and accident good for learning

Let's talk 🫣

There are a lot of lists in this Quizlet that I need you to forgive me for

And in response I will forgive you for not helping me with my Quizlet

Normal Accident Theory (NAT)

Perrow says that in technological systems, accidents are inevitable

This is based on two interrelates dimensions

- Interactive Complexity

- Tightly Coupled system

There are several characteristics of NAT

NAT major points

Accidents are inevitable

Interactive and complex systems should not be built

Redundancy serves to add complexity (true) and therefore should be avoided (really?)

- More components mean more to go wrong

Sit down kiddos and let mama tell you about smth called fatigue

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

- When you're tired 👁️👄👁️

Time awake effects

The cognitive degradation that occurs from continued wakefulness

17 hours of wakefulness is cognitively equivalent to .05% BAC

Neurobiological effects can only be returned to base line with adequate sleep

Strict restriction degrade performance in dose dependent manner

- Sleepy = drunk

Circadian phase

Circadian rhythm is set by the light exposure and is mediated by the ganglion cells in the retina and the suprachiasmatic nucleus located in the brain

Sleep propensity follows core body temperature

Lowest performance is around 0600hrs and highest is 1800hrs

Time of day (circadian) effects are reversed by passing into different phase

- Circadian rhythm is set by light. Day - wake up. Sleep goodness goes off body temp so like idk chilly with a blanket makes me sleepy personally