EATS, Berlin, October 2019 Lex Rock Heemstra Human Factors ... · FlyDubai 981 19-Mar-16B737-800...
Transcript of EATS, Berlin, October 2019 Lex Rock Heemstra Human Factors ... · FlyDubai 981 19-Mar-16B737-800...
EATS, Berlin, October 2019
Lex Rock Heemstra – Human Factors Specialist
PROBLEM STATEMENT
“The modern airplane is the product of a program of research, development and refinement in detail that no other structure or mechanism has ever matched. The results have been so remarkable that there is always danger of forgetting that these extraordinary craft still have to be operated by men, and that the most important test they have to meet is still that of being operable without imposing unreasonable demands or
unnecessary strains on the flight personnel.”Edward P. Warner , 1946
President ICAO : 1947-1957 “History repeats itself ….because nobody listens”
John Lennon
27 FATAL AIRLINE ACCIDENTS 2009-20192366 FATALITIES
Loss of Control 6
On Approach 10
Go Around (LOC) 6
LL Circuit (CFIT) 1
Engine Failure 1
Wrong Eng Shut 1
Ran out of Fuel 1
Unknown 1
Source: Boeing Statsum 2009-2018 & Civil Aviation Final & Preliminary Accident Reports
Total Flight Hours
Type of AccidentAircraft Designation Date Aircraft Type PIC FO
Air France 447 01-Jun-09A330-203 6547 2936 LOC
Ethiopean 409 25-Jan-10B737-800 10233 673 LOC
AeroUnion 302 13-Apr-10A300-203 16754 3114 Approach
Afriqiyah 771 12-May-10A330-202 17016 4216 Approach
Air India 812 22-May-10B737-800 10215 3620 Go Around
Air Blue 202 28-Jul-10A321-231 25497 1837 LL Circuit
Aires 8250 16-Aug-10B737NG 7643 1900 Go Around
Henan 8387 24-Aug-10EMB-190 ? ? Approach
UPS 6 03-Sep-10B747-400 11200 5549 Cargo Fire
Iran Air 277 09-Jan-11B727- 286 ? ? Go Around
Hewa Bora 08-Jul-11B727- 286 ? ? Approach
First Air 6560 20-Aug-11B737-200 12900 4848 Approach
Bhoja 213 20-Apr-12B737-236 10158 2832 Approach
Dana 992 03-Jun-12MD 83 18166 1143 Eng's Fail
Air Bagan 11 25-Dec-12Fokker 28 5937 849 Approach
Asiana 214 06-Jul-13B777-200 9793 12387 Approach
UPS 1354 14-Aug-13A300F 6406 4721 Approach
Tatarstan 363 17-Nov-13B737-500 2784 2093 Go Around
Malaysian 370 08-Mar-14B777-200ER 18365 2813 ?
Air Algiere 5017 20-Jul-14MD 83 12988 7016 LOC
AirAsia 8501 28-Dec-14A320-216 20537 2247 LOC
Transasia 235 04-Feb-15ATR 72-600 4914 6922 Shut down Wrong Engine
FlyDubai 981 19-Mar-16B737-800 5961 5767 Go Around
Emirates 521 03-Aug-16B777-31H 7457 7957 Go Around
LaMia 2933 28-Nov-16Avro RJ85 6692 6923 Fuel Starve
Turkish 6491 16-Jan-17B747-412F 10808 5894 Approach
Lion Air 610 29-Oct-18B737 Max 6028 5174 LOC
Ethiopean 302 10-Mar-19B737 Max 8122 361 LOC
Total Flight Hours
Captains < 8000 37%
FO’s < 4000 48%FO’s < 2000 22%
Monitoring &
Intervention
Resilience
Training
Startle EffectJet Upset
Recovery
REQUIRED CRM/HF TRAINING
▪ EXISTING
▪ Communication
▪ Leadership & Teamwork
▪ Situational Awareness
▪ Workload Management
▪ Problem Solving & Decision Making
▪ 5 of the 9 EBT Competencies
▪ ADDITIONAL
▪ Monitoring & Intervention
▪ Resilience Training
▪ Startle Effect & Management
▪ Jet Upset Recovery
Classroom
Theory
Simulators
Practise
During
Flight
Execution
RECURRENT CRM DELIVERY
On own, i.e.
Pilots only,
CC only,
ATC only
33%
First on own
and then
Combined
14%
Combined
Only
53%
WORLDEUROPE21 Operators
14 International Airlines
EASA - GM3 ORO.FC.115 (March 2019): (i) combined CRM training: 6 training hours over a period of 3 years;
On own,
i.e. Pilots
only, CC
only, ATC
only
33%
First on
own and
then
Combined
30%
Combined
Only
37%
SOURCE OF PROCEDURES
+
-
TOP 10% - MOVERS & SHAKERS
BOTTOM 10% - “TROUBLE MAKERS”
80% MAJORITY – GOOD, SOLID, RELIABLE
SOLUTION
“DELIBERATE MISTAKES”
HONEST MISTAKES
SPEND 80%
OF THEIR
TIME
FIXING
INDUSTRY CONCERN REGARDING MONITORING
▪ 2010 – NASA “Checklists and Monitoring in the Cockpit: Why Critical Defenses sometimes fail”. Dismukes, R.K. & Berman, B.
▪ 2013: RAeS Flight Operations Group – Aircraft Commander in the 21st
Century: “Pilot Monitoring – Cultivating a Healthy Unease”
▪ 2013: UKCAA Paper 2013/02: “Monitoring Matters - Guidance on the Development of Pilot Monitoring Skills”
▪ 2014: FSF: “A practical Guide for Improving Flight Path Monitoring”
▪ 2016: IATA: “Guidance material for improving Flight Crew Monitoring” 1st
edition
▪ 2017: FAA: AC 120-71B “Standard Operating Procedures and Pilot Monitoring Duties for Flight Deck Crewmembers”
PILOT MONITORING (PM)MAJORITY OF AIRLINES
The general PM phase of flight responsibilities are:
▪ Checklist reading
▪ Communications
▪ Tasks asked for by the PF
▪ Monitoring taxiing, flight path, airspeed, airplane configuration, and navigation.
▪ The general PF phase of flight responsibilities are:
▪ taxiing
▪ flight path and airspeed control
▪ airplane configuration
▪ navigation.
GORILLA VIDEO EXERCISES
• Count the number of passes by the white team
• Video over: • If Gorilla not spotted: 14 X passes
• If Gorilla spotted: 11-16 X passes
• Assign pairs – one PF and the other PM.
• The novelty of the situation draws in both PF and PM to the detail
• Who then monitors the big picture?
• When assigned PF – Detail & PM – Big Picture • Gorilla spotted and 14 passes as a team.
• Are we training monitoring correctly?
EFFECTIVE MONITORING
0
10
20
30
40
50
60
70
80
90
100
Never Hardly Ever Sometimes Often Very Often
"I have observed the other pilot make errors due to a lack of knowledge /understanding of the automation"
FO's Captains Instructors
Source: Multicultural Airline Automation Questionnaire 2010; N= 306 (Heemstra:2010)
FO’sCaptains
Instructors
Source: Automation & Monitoring Questionnaire, 2013; N = 326 Pilots (156 Captains & 170 FO’s)
0
10
20
30
40
50
60
70
80
90
100
0-2000 2000-4000 4000-6000 6000-8000 8000-10000 10000-12000 12000-14000 14000 Plus
“I have observed the other pilot make errors due to the lack of knowledge/understanding of the automation”
First Officer N=170 Based on Total Flight Hours
Never Hardly Ever Sometimes Often Very Often
EFFECTIVE MONITORING – FIRST OFFICERS
Beginning
of Effective
Monitoring
Source: Automation & Monitoring Questionnaire, 2013; N = 326 Pilots (156 Captains & 170 FO’s)
EFFECTIVE MONITORING – CAPTAINS
0
10
20
30
40
50
60
70
80
90
100
8000-10000 10000-12000 12000-14000 14000-16000 16000-18000 18000-20000 20000 Plus
“I have observed the other pilot make errors due to the lack of knowledge/understanding of the automation”Captains N = 156 Based on Total Flight Hours
Never Hardly Ever Sometimes Often Very Often
Source: Automation & Monitoring Questionnaire, 2013; N = 326 Pilots (156 Captains & 170 FO’s)
THE MONITORING COMPONENT – A HUMAN
▪Human Factors – Cognitive Limitations:
▪The human brain has difficulty with sustained vigilance
▪The human brain has quite limited ability to multitask ▪ (Task Switching – Yes, Multitasking – No)
▪Humans are vulnerable to interruptions and distractions
▪Humans are vulnerable to cognitive limitations that affect what they notice and do not notice
Flight Safety Foundation: Practical Guide to Flight Path Monitoring - November 2014
AUTOMATION CONFIDENCE
0
10
20
30
40
50
60
70
Not Confident With Difficulty Minor Deviations Fly it Accurately As accurately as
Automation
“I would be able to fly a SID out of Home base and meet all target speeds and altitudes without Autopilot, Auto-throttle and Flight
Director, i.e. totally manually”N= 306, FO:161; Capt:110; TRI/TRE:35
FO's Capts TRI
Source: Multicultural Airline Automation Questionnaire 2010; N= 306 (Heemstra; 2010)
Comfort
Zone
Automation
AUTOMATION INDUCED STARTLE
Inputs or Workload
Pe
rfo
rma
nce
Knowledge,
Skills & Experience
Automation Ability
Automation
Failure –Sudden
No Trend
Overall Research Feedback – Do nothing for up to 30 seconds it situation allows
PERCEPTION OF STRESS BY MULTINATIONAL PILOTS
0 10 20 30 40 50 60 70 80 90 100
Random drug/alcohol test
Holding pattern at destination
Departure delay after boarding
Shortage of meals, etc
Long wait for gate on arrival
Filing an ASR report
Encountering thunderstorms
Unpleasant exchange ground crew
Difficulty understanding ATC
Complex rerouting/flight plan change
Passenger requires medical care
Turbulence all levels
Wait for room at hotel
Unpleasant exchange Cabin Crew
Don’t get along with other pilot Flight crew becomes ill
Go around after unstable
Line check
Divert to alternate (weather)
Hard landing
Return due to mechanical failure
Unpleasant exchange Flight Crew
Security Emergency in flight
Emergency Landing
High speed rejected takeoff
Source: Multinational Airline Stress Questionnaire Jan/Feb 2011: N= 154, Captains = 81, FOs = 73
Stress Components
The amount of perceived
CONTROL over the
situation, and
The ability to PREDICT the
short term future.
PERCEPTION OF STRESS BY MULTINATIONAL PILOTS
0
20
40
60
80
100
120
140
160
180
200
Age
Perceived Stress by Age
Perceived Stress 10 per. Mov. Avg. (Perceived Stress)
Source: Multinational Airline Stress Questionnaire Jan/Feb 2011: N= 154, Captains = 81, FOs = 73
PERCEPTION OF STRESS BY MULTINATIONAL PILOTS
0
20
40
60
80
100
120
140
160
180
200
Flight Hours
Perceived Stress by Hours (Experience)
Perceived Stress 10 per. Mov. Avg. (Perceived Stress)
Source: Multinational Airline Stress Questionnaire Jan/Feb 2011: N= 154, Captains = 81, FOs = 73
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Self Control Adaptibility Optimism Self Sufficiency Persistence
Le
ve
l o
f R
es
ilie
nc
e (
Pe
rce
nta
ge
)
Components of Resilience
Elements of ResiliencePersonal Situation vs Work Situation N=413
Personal Work
Source: Podzigun, I - Resilience Study based on “GRIT” – (A.L. Duckworth) - 2016
Acting or
Reacting
Improvise &
creative
Trust in own
talents &
solutions
Maintaining
a Positive
Outlook
Stick-to-it
attitude
5
8
11
14
17
20
1 2 3 4 5 6 7 8 9 10 11
Le
ve
l O
f R
esil
ien
ce
Years in Company
Resilience based on Years in CompanyPersonal Situation vs Work Situation N=413
Personal Work Linear (Personal) Linear (Work)
Source: Podzigun, I - Resilience Study based on “GRIT” – (A.L. Duckworth) - 2016
COGNITIVE PROCESSING – SYSTEM I & II THINKING
▪ System I : Fast, Automatic, Frequent, Emotional, Stereotypic & Subconscious
▪ Procedural Memory & Everyday thinking
▪ System II: Slow, Effortful, Infrequent, Logical, Calculating & Conscious
▪ Analytical & required for Problem Solving & Decision Making
SO WHAT NOW?
▪ Several monitoring functions automated
▪ Effective Monitoring grows with deliberate practise & qualitative experience
▪ Stress reaction does NOT improve with age or flight hours
▪ Resilience - fairly stable over a lifetime – you have got what you have got
▪ Startle – General consensus – do nothing for 30 seconds
▪ Overall the human is not designed to conduct sustained vigilance
▪ Complex automation failures require enhanced pattern recognition to rectify which increases with knowledge, skills & experience
▪ Existing PF & PM roles appear to create 1 + 1 = 1, especially during novel abnormal situations
▪ We need 1 + 1 =/ > 2
ABNORMAL/EMERGENCY EVENTS
▪Memory Item – conduct as trained.
▪All other: ▪ FO – Pilot Flying:
▪ max automation as available
▪ Intuitive (System I) – mainly procedural memory
▪ Detail Orientated
▪ Capt – Pilot Managing: (use of knowledge & experience)▪ Slide seat back – enhances big picture
▪ Engage System II – logical, calculating, conscious
▪ Big Picture Orientated
▪ Problem Solving & Decision Making
▪ Once new plan assessed and briefed – conduct flight/landing as per company procedure
CONSIDERATION▪Pilot Flying:
▪ Physically flies the aircraft – manual or automated
▪ Corrects as instructed by PM
▪ Responsible for correct & intended flight path
▪ Detail orientated – System I Thinking
▪Pilot Managing: ▪ Manages the flight path and operation of the aircraft
▪ Responsible for the safe and efficient operation of the aircraft
▪ When managing – it is his/her sector
▪ Takes ownership of responsibility – increased monitoring
▪ Big Picture Orientated – System II Thinking
BACK TO THE FUTURE CAPTAIN?
THANK YOU