Presented to: Orlando Florida Flying Community By: The FAASTeam - Dr. Karen D. Dunbar Date: December...

Presented to: Orlando Florida Flying Community

By: The FAASTeam - Dr. Karen D. Dunbar

Date: December 7th, 2010

Federal AviationAdministrationFAASTeam FAASTeam

Orlando Florida Orlando Florida PresentationPresentationHuman FactorsHuman Factors

2Federal AviationAdministration

FAASTeam CFI Workshop 8

December 7, 2010

What is a Pilot Deviation?

• A pilot deviation is defined as the actions of a pilot that result in the violation of a Federal Aviation Regulation or a North American Aerospace Defense (Command Air Defense Identification Zone) tolerance. FAA Order 7210.56C.



December 7, 2010



December 7, 2010

A Partial Listing of the Unsafe Acts of Operators

Errors

Decision Errors

“Honest mistakes,” occur when one one does not have appropriate knowledge or made a poor choice, or procedural error.



December 7, 2010

Decision Errors

Improper inflight planning

Improper altitude/clearance

Aborted takeoff/landing decision improper

Weather evaluation inadequate

Improper refueling decisions

Improper remedial action



December 7, 2010


Errors

Skill-based Errors

“Stick and rudder” and other basic flight skills that occur without significant conscious thought. Vulnerable to failures of attention, memory and/or technique.



December 7, 2010

Skill-based Errors

Airspeed not maintained

Aircraft control inadequate

Abrupt vs. excessive vs. not maintained

Stall spin inadvertent

Altitude improper/not maintained

Inadequate visual lookout

Proper glide path not maintained



December 7, 2010


Errors

Perceptual Errors

Errors due to erroneous response to illusions. Occur when sensory imput is degraded.



December 7, 2010

Perceptual Errors

Misjudged distance/Descent

Misjudged altitude

Misjudged maneuver/procedure

Clearance not maintained

Spatial disorientation/vertigo

Visual Illusion



December 7, 2010


Violations

Routine Infractions

“Bending” the rules tolerated by authority. Must look up the supervisory chain to identify those in authority who are not enforcing rules.



December 7, 2010

Routine Infractions

VFR flight into IMC (continued, performed, encountered)

Flight into adverse weather continued

IFR procedure not followed

Procedures/directives not followed

Minimum descent altitude not maintained

Operation with known deficiency in equipment performed



December 7, 2010


Violations

Exceptional Infractions

Isolated deviation from the rules, but not tolerated by management. Difficult to predict, since not indicative of one’s usual behavior.



December 7, 2010

Exceptional Infractions

Low altitude flight/buzzing performed

Operation with known deficiency in equipment intentional

VFR flight into IMC intentional

Flight into adverse weather intentional

Design stress limits of aircraft exceeded

Aircraft weight and balance



December 7, 2010

Preconditions for Unsafe Acts

Substandard Conditions of Operators

Adverse Mental States

Mental conditions that affect performance



December 7, 2010

Adverse Mental States

Impairment – alcohol/drugs (can be OTC meds)

Fatigue – lack of sleep, flight schedule

Excessive workload

Overconfidence in personal abilities

Overconfidence in aircraft capabilities

Complacency

Diverted attention

Circadian dysrhythmia/disruption

Pressure induced by conditions/events



December 7, 2010



Adverse Physiological States

Medical/Physiological conditions that preclude safe operations



December 7, 2010

Adverse Physiological States

Spatial disorientation

Impairment due to illness

Incapacitation/loss of consciousness

Physical impairment

Hypoxia

Motion sickness

Illness



December 7, 2010



Physical/Mental Limitations

Situation exceeds the capabilities of the operator.



December 7, 2010

Physical/Mental Limitations

Lack of recent/total time

Lack of recent/Total instrument time

Visual look out not possible

Physical impairment visual deficiency

Lack of familiarity with geographical area

Lack of familiarity with aircraft



December 7, 2010


Substandard Practices of Operators

Crew Resource Management

Poor communication/coordination among personnel.



December 7, 2010

Classification of CRM failures



December 7, 2010

Crew Resource Management

Preflight planning preparation inadequate

Aircraft preflight inadequate

Crew group coordination inadequate

Poor communication/coordination within and between

aircraft, ATC, etc.

Failure of leadership



December 7, 2010


Substandard Practices of Operators

Personal Readiness

Failure to prepare mentally or physically for duty.



December 7, 2010

Personal Readiness

Failure to adhere to crew rest requirements

Self-medicating

Overexertion while off duty

Poor dietary practices

Failure to adhere to bottle to brief rules



December 7, 2010

Practical Tools to Stop Worker Error

Best Practice Session at the 2009 TapRooT@ summit

Brickey, R., Hubbartt, J., Vallee, C.



December 7, 2010


Situation awareness

Accuracy of a person’s current knowledge and understanding of task at hand and related working conditions compared to actual conditions at a given time



December 7, 2010


Task preview

S ummarize

A nticipate

F orsee

E valuate

R eview



December 7, 2010


Task preview

Job site preview



December 7, 2010


Task preview

Job site preview

Questioning attitude



December 7, 2010


Task preview

Job site preview


Self-checking

S top

T hink

A ct

R eview



December 7, 2010


Task preview

Job site preview


Self-checking

Procedure Use and Adherence



December 7, 2010


Task preview

Job Site preview


Self-checking


Effective Communication



December 7, 2010


Task preview

Job site preview


Self-checking


Effective communication

Phonetic alphabet



December 7, 2010

When is an error/deviation not a pilot error/deviation?

• When it is an ATC operational error or operational deviation.



December 7, 2010

Bottom Line

• Human error is often preventable• Adequate ability, attitude, training, skills,

experience, planning, preparation, decision making, procedure adherence, communication, and self- and situational awareness will avoid most of the errors that lead to unsafe acts by pilots.



December 7, 2010

Presented to: Orlando Florida Flying Community By: The FAASTeam - Dr. Karen D. Dunbar Date: December...

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