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UNIT 9 Aviation Safety Human Factor 181

Unit 9 Notes
__________________
__________________
Aviation Safety Human Factor __________________
__________________
__________________
__________________

Objectives __________________
__________________
After reading this unit, you will be able to:
__________________
y Understand brief about Flight Safety
__________________
y Understand various Human-Factors
y Understand various Psychological Problems
y Know abotu various Physiological Issues
y Understand ongoing HF Training for all Personnel

OBJECTIVE
Flight safety is the major objective of the International Civil
Aviation Organization. Considerable progress has been made,
but additional improvements are needed and can be achieved.
It has long been known that some three out of four accidents
result from less than optimum human performance,
indicating that any advance in this field can be expected to
have a significant impact on the improvement of flight safety.

A study was conducted by Department of Transport and

Regional Development Bureau of Air Safety Investigation,
USA to analyze Human Factors in Fatal Aircraft Accidents
on the 75 fatal aeroplane accidents which occurred in USA
in the period 1 January 1988-31 December 1990. They found
that most accidents had more than one contributing factor,
and out of that over 70% of the accidents involved pilot
factors.

Accordingly among the broad accident factors, 72% of the

accidents were judged to involve pilot factors (see figure).
Weather was a factor in 17% of the accidents. Other
personnel contributed to 12% of the accidents. (Other
personnel refers to people other than the pilot of the aircraft,
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Notes and includes air traffic controllers, other flight crew and
__________________ maintenance workers.)
__________________
Fatal accidents to fixed wing aircraft - broad accident
__________________
factors
__________________
__________________
__________________
__________________
__________________
__________________
__________________

This was recognized by the ICAO Assembly, which in 1986

formulated the following objective for the task:

"To improve safety in aviation by making States more aware

and responsive to the importance of human factors in civil
aviation operations through the provision of practical human
factors material and measures developed on the basis of
experience in States."

Human behaviour and performance are cited as causal factors

in the majority of aircraft accidents. If the accident rate is to
be decreased, Human Factors must be better understood and
the knowledge more broadly applied. The expansion of
Human Factors awareness presents the international
aviation community with the single most significant
opportunity to make aviation both safer and more efficient.

So much so that even a specific terminology known as

'ergonomics' meaning the 'Human Engineering' is being used
to denote the field of Human Factor. Ergonomics is commonly
thought of as how companies design tasks and work areas to
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UNIT 9 Aviation Safety Human Factor 183
maximize the efficiency and quality of their employees' work. Notes
However, ergonomics comes into everything which involves __________________
people, like sports and leisure, health and safety should all __________________
embody ergonomics principles if well designed. __________________

As already mentioned, some three out of four accidents have __________________

resulted from less than optimum human performance. This __________________

has commonly been classified as "pilot error". The term "pilot __________________
error" is of no help in accident prevention. In fact, it is often __________________
counterproductive because, although this term may indicate __________________
WHERE in the system a breakdown occurs, it provides no __________________
guidance as to WHY it occurs.
__________________
An error attributed to humans in the system may have been
design-induced or stimulated by inadequate training, badly
designed procedures or the poor concept or layout of
checklists or manuals. Further, the term "pilot error" allows
concealment of the underlying factors which must be brought
to the fore if accidents are to be prevented.

Most often it is thought that human factors are related to

flight crews only. However, now it has been established that
human factors problems affect on the performance of
maintenance people, and other ground staff also.

SAFETY.
The best way to illustrate the effect on safety of a lack of
proper application of Human Factors is through the example
of accidents. A few accidents in which aspects of Human
Factors are relevant are described here as examples.

a) In December 1972 - an L1011 crashed in the Florida

Everglades and a B-737 crashed at Midway Airport in
Chicago. In the first case, duties were not properly
allocated and the whole flight crew became preoccupied
with a landing gear indicator light bulb. In the second
case, the captain - as a leader - did not properly manage
the resources which were available to him.

b) In 1974, a B-707 crashed during approach at Pago-Pago

in Samoa, with a loss of 96 lives. A visual illusion related
to the black-hole phenomenon was a cause factor.
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Notes c) In 1974, a DC-10 crashed after take-off because a cargo

__________________ door failed (it opened and blew out). The force applied
__________________ by a cargo handler to close the cargo door, the door
__________________ design and an incomplete application of a service bulletin
__________________ were cited as factors.
__________________ d) In 1974, a B-727 approaching Dulles Airport in
__________________ Washington crashed into Mount Weather, with a loss of
__________________ 92 lives. Lack of clarity and inadequacies in air traffic
__________________ control procedures and regulations led to the accident.
__________________
The absence of timely action of the regulatory body to
resolve a known problem in air traffic terminology was
__________________
also listed as a factor.

e) In 1977, two B-747s collided while on the runway at

Tenerife, with a loss of 583 lives. A breakdown in normal
communication procedures and misinterpretation of
verbal messages were considered factors (ICAO Circular
153-AN/98).

f) In 1977, a DC-8 crashed after take-off in Alaska. The

influence of alcohol on pilot performance was cited as a
factor.

g) In 1979, a DC-10 crashed into Mount Erebus in Antartica.

Information transfer and data entry errors played a role
in the accident.

h) In 1982, a B-737 crashed after take-off in icing conditions

in Washington. Erroneous engine thrust readings
(higher than actual), and the co-pilot's lack of
assertiveness in communicating his concern and
comments about aircraft performance during the take-
off run were among the factors cited. .

i) The report of a 1983 A300 accident in Kuala Lumpur

suggests that variations in panel layout amongst the
aircraft in the fleet had adversely affected crew
performance. (The aircraft was on a dry lease.).

j) In 1984, a DC-10 overran the runway at John F. Kennedy

Airport in New York. Excessive reliance on automation
was noted in the accident report.
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UNIT 9 Aviation Safety Human Factor 185
k) Excessive reliance on automation was also listed as a Notes
factor in a loss of control incident in 1985, in which a B- __________________
747 lost 20,000 feet in less than two minutes and __________________
sustained structural damage. __________________

l) In 1987 an MD-80 crashed on take-off in Detroit. The __________________

pilots had not set the flaps, thus violating standard __________________
operating procedures. Also, the take-off configuration __________________
warning did not sound, for undetermined reasons. __________________
__________________
CASE HISTORY __________________
(Ref: National Transportation Safety Board NTSB, USA __________________
Aircraft Accident Report No. & Date NTSB-AAR-79-7, June
7, 1979)

About 1815 Pacific Standard Time on December 28, 1978,

United Airlines, Inc., DC-8-61 aircraft, operating Flight 173
crashed into a wooded, populated area of suburban Portland,
Oregon, during an approach to the Portland International
Airport. The aircraft had been holding southeast of the
airport at a low altitude for about one hour while the flight-
crew coped with a landing gear malfunction and prepared
the passengers for the possibility of a landing gear failure
upon landing.

The plane crashed about 6 nautical miles southeast of the

airport. The aircraft was destroyed; there was no fire. Of
the 181 passengers and 8 crewmembers aboard, 8 passengers,
the flight engineer, and a flight attendant were killed and
21 passengers and 2 crewmembers were injured seriously.

During investigation it was determined that, as a result of a

relatively minor landing gear problem, the aircraft was in a
holding pattern while awaiting landing at Portland, Oregon.
Although the first officer knew the aircraft was low on fuel,
he failed to express his concerns convincingly to the captain.
The plane ran out of fuel and crashed, killing 10.

The National Transportation Safety Board summarized that

the probable cause of the accident was the failure of the
captain to monitor properly the aircraft's fuel state and to
properly respond to the low fuel state and the crewmember's
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Notes advisories regarding fuel state. This resulted in fuel

__________________ exhaustion to all engines. His inattention resulted from
__________________ preoccupation with a landing gear malfunction and
__________________ preparations for a possible landing emergency.
__________________ Contributing to the accident was the failure of the other two
__________________ flight crewmembers either to fully comprehend the criticality
__________________ of the fuel state or to successfully communicate their concern
__________________ to the captain.
__________________
__________________
TYPES OF HUMAN FACTORS
__________________ Indeed, Human Factors problems can negatively impact the
performance of all personnel, whether they are on ground or
in the air, from senior personnel to the individual staff.

Human Factors can be classified into four primary categories:

aero-medical, physiological, performance, and design. There
may be others, but these four have traditionally proven to be
the most common human factors noted in mishap
investigation reports. In each case, the causes, indicators,
and approaches to resolving the problems will be discussed.

l AEROMEDICAL

Medical Health

Psychological State

l PHYSIOLOGICAL

Limits & Capabilities

l PERFORMANCE

Limits & Capabilities

l SYSTEMS DESIGN

AEROMEDICAL PROBLEMS
Medical Health Problems:
- FATIGUE

- INADEQUATE NUTRITION
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UNIT 9 Aviation Safety Human Factor 187
- FLYING WHEN SICK Notes
__________________
- SELF-MEDICATION
__________________
Flying, maintaining, or handling an aircraft whilst fatigued __________________
is a sure way to increase the probability of a mishap. The __________________
ability to perceive, understand, and respond to even the most
__________________
mundane tasks can be greatly impaired when in a state of
__________________
physical and/or mental fatigue. One would expect fatigue to
__________________
become most evident during sustained operations, but it is
likewise observed during normal operations. __________________
__________________
CAUSES
__________________
- COMPETITIVENESS

- DESIRE TO COMPLETE MISSION

- DENIAL

- INADEQUATE REST

- NOISE/VIBRATION STRESS

- CIRCADIAN (24-Hrs rhythmic biological

Cycle) DISTURBANCES

- EXCESSIVE PHYSICAL STRESS

- EMOTIONAL STRESSORS

Many of us are guilty of rushing to work without having had

a good breakfast, or lunching on fast food items, or some
make shift breakfast. Clearly, inadequate nutrition can
degrade physical strength as well as mental acuity; both of
which are critical to maintaining a safe aviation environment.

The last two categories are ties together. There are a number
of folks who will go to work even when they are quite ill. In
some jobs, this may not affect performance. In aviation,
however, being in good health is critical to optimizing
performance. Still, there are those who, as we shall see, feel
that being ill is not a sufficient reason to go temporarily 'hard
down'. These folks tend to try to suppress symptoms of their
illness by self-medication; an option clearly forbidden to
aviators. Sadly, there are still instances where crews are
found to betaking medications while in flying status.
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Notes The question remains: why do these problems occur?

__________________
These are some of the causes for the onset of aero medical
__________________
problems. It is interesting to note here that by definition,
__________________
people in aviation tend to be highly competitive, zealous
__________________ individuals. These attributes are reinforced throughout the
__________________ person's career and are often manifested outside of the
__________________ workplace. Anything that may disturb the inertia toward peak
__________________ performance is to be avoided or, when that is not possible,
__________________ denied. The remainder of the causes listed reflect both
__________________
physiological and emotional factors which are manifested as
medical problems.
__________________
Here we see some of the indicators which provide evidence
for medical problems. Many of these again are discussed in
subsequent categories (physiological and performance-based
human factors). It is this commonality of behavioural
indicators which precludes one from being able to
consistently diagnosis the etiology of the human factors
problem on such evidence.

INDICATORS
- DISINTEGRATION OF SKILLED
PERFORMANCE

- TASK FIXATION

- COMMUNICATION PROBLEMS

- PERCEPTUAL DISTORTION

- SLOWED REACTION TIME

- DECREASED ATTENTION SPAN

- CONFUSION

- INCREASED RISK TAKING

- COMPLACENCY (A feeling of reduced

awareness of danger ahead.)

CURES
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UNIT 9 Aviation Safety Human Factor 189
Administration Notes
__________________
Ensure that crew health is monitored regularly &
__________________
sick crews are not scheduled.
__________________
Conduct aero medical training re: health issues, __________________
human limitations, etc __________________

Crew __________________
__________________
If they are ill or fatigued, they should seek medical
__________________
attention & should not fly.
__________________
How can one minimize mishaps where aero medical factors __________________
were found to be involved? Responsible, proactive
intervention at all levels of the command chain is a must.

Psychological Problems:
- DISRUPTION OF PSYCHO-SOCIAL
INTERACTIONS

- CRIMINAL BEHAVIOR

- ONSET OF PSYCHOPATHOLOGY

- SUICIDE

Psychological problems may not always be as evident as

biomedical problems. The hidden complexities of
psychodynamic processes may or may not manifest as overt
indicators. As a community, those in aviation are as prone
to experiencing the same societal, financial, and familial
stresses as those in other professional communities. Thus,
when psychological problems occur, and are not dealt with
in a timely, effective manner, the result can result not only
affects the individuals involved, but may in turn impact an
organization's mission. This becomes most evident in the last
of the factors on this list: suicide.

Here are some common causes for the onset of psychological

problems. They affect us all, but it is when their results
become chronic or pronounced that the following indicators
become evident.
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Notes CAUSES
__________________
- ENGAGEMENT/WEDDING/ SEPARATION/
__________________
DIVORCE
__________________
__________________ - LONG SEPARATION FROM FAMILY
__________________
- BREAKDOWN IN COPING SKILLS/
__________________ COMPARTMENTALIZATION
__________________
- FALSE SELF-IMAGE
__________________
__________________ - CHANGE OF JOB STATUS
__________________
- ILLNESS

- DEATH OF FRIEND, FAMILY

- FINANCIAL PROBLEMS

Again, we must stress that all of us may experience one or

more of these indicators from time to time. It is only when
these indicators are chronically observed, especially to the
point where they degrade performance, which they may point
to some form of psychological problem.

INDICATORS
CHRONIC PERIODS OF

- APATHY (Lack of interest in things)/ EUPHORIA

(An exaggerated or false feeling of happiness)

- ANXIETY

- IRRITABILITY/NEGATIVITY

- WITHDRAWN

- SLEEP LOSS/MENTAL FATIGUE

- ILLNESS

- PERFORMANCE DECREMENTS

- INCREASED RISK TAKING

- MOOD SWINGS

- SUICIDAL IDEATIONS/ATTEMPTS
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UNIT 9 Aviation Safety Human Factor 191
Many of us are taught to take our problems and place them Notes
aside; to compartmentalize them until such time as we can __________________
allow ourselves to better deal with them. On first glance, __________________
this can be a noble approach and an effective way of coping. __________________
However, a problem occurs when we start to stockpile our __________________
problems in this way, essentially compounding them by failing
__________________
to resolving them. When this occurs, the indicators described
__________________
earlier start to appear; that is, compartmentalization fails
__________________
and performance is affected. It is imperative, therefore, to
recognize that there are limits to compartmentalization, and __________________

that not everyone is as 'skilled' at this ability as others. __________________

__________________
COMPARTMENTALIZATION (To separate into
distinct parts)

A HEALTHY COPING MECHANISM

TOTAL COMPARTMENTALIZATION

NOT POSSIBLE!

STRESSORS DECREASE ABILITY TO

COMPARTMENTALIZE

INDICATORS APPEAR WHEN

MECHANISM IS "MAXED OUT" (Exhausted)

As with our approach to medical problems discussed earlier,

one must be proactive in the prevention of mishaps as a
function of psychological problems. One may not be able to
prevent the problem, but one can keep the affected individual
out of the air, or away from the aircraft.

CURES
Administration

Conduct periodic Human Factors Councils and

Boards when necessary.
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Notes Provide training to heighten aircrew awareness.

__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
Remove individual from flight schedules.
Conduct aero medical training re: psychological
health issues, human limitations, etc.
Monitor crew mental health closely.
Crews
They should co-operate and should not hide any
problem.
In case of any problem they should themselves offer
for not flying.

PHYSIOLOGICAL ISSUES
There are a number of physiological issues which are
addressed under the umbrella term of 'human factors'. Many
of them fall under one of the four general categories are listed
here.

l PHYSIOLOGICAL FUNCTIONING IN THE

AEROSPACE ENVIRONMENT

l SURVIVAL AND SAFETY

l AEROSPACE PHYSIOLOGY TRAINING

l PROTECTIVE EQUIPMENT AND SYSTEMS

Aircrew performance has been shown to be affected by the

nature and scope of these factors.

PHYSIOLOGICAL FUNCTIONING IN THE

AEROSPACE ENVIRONMENT

- FLIGHT OPERATIONS

- ACCELERATION

- VIBRATIONS

- NOISE/ HEARING

- VISUAL SYSTEM/ VISION ENHANCERS

(NVDS)
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UNIT 9 Aviation Safety Human Factor 193
- THERMAL ENVIRONMENT Notes
__________________
- PHYSICAL FITNESS
__________________
SURVIVAL AND SAFETY __________________
__________________
GENERAL SURVIVAL SKILLS
__________________
SAFETY IN CARRIER OPS __________________

Physiologists are concerned with performance in all of these __________________

environments. Training in each of these areas is critical if __________________
safety is to be maintained and survival ensured. __________________
__________________
AEROSPACE PHYSIOLOGY TRAINING

ALTITUDE

EGRESS (A place to Exit or escape)

VISUAL PROBLEMS

SURVIVAL

HUMAN FACTORS

The effects of altitude on performance become clearest during

physiology training. The effects of pressure changes and lack
of oxygen are demonstrated in controlled altitude chamber
'Simulated flights'.

The physiologist is also the expert in protective equipment

and systems; the 'gear' which is designed to ensure safety
and survival.

PROTECTIVE EQUIPMENT & SYSTEMS

It is the responsibility of administration to ensure that flight

crew are thoroughly versed in the physiological aspects of
human factors. This is best accomplished through careful
monitoring of personnel records for currency, and providing
for physiological training if and when required.

Administration:

l ENSURE PERSONNEL HAVE RECEIVED/

AREPROVIDED WITH NECESSARY
PHYSIO.TRAINING.
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Notes l ENSURE CURRENCY AND PROVIDE FOR

__________________ REFRESHERS IF NECESSARY.
__________________
Up to this point, we've examined how the medical,
__________________
psychological, and physiological aspects of human factors will
__________________ affect performance. We will now turn to a more 'cognitive'
__________________ approach to performance by examining an individual's
__________________ behavioural capabilities and limits, and how they are
__________________ manifested. Capabilities will vary with the individual; what
__________________ we all have in common is that we make errors. It is, however,
__________________
possible to enhance our capabilities whilst minimizing error
(or the effects of error).
__________________
PERFORMANCE ISSUES

- HUMAN LIMITS/ERROR

- SITUATION AWARENESS

- INFORMATION PROCESSING

- WORKLOADS

- SYCHO-MOTOR ISSUES (or pertaining to

movement produced by action of the mind or will.)

- AIRCREW & GROUNDCREW COORDINATION

Performance problems are manifested as breakdowns in

flight behaviour(s). Some originate at a perceptual level
whilst others combine perceptual and cognitive anomalies.
Both result in degraded performance.

PROBLEMS:

LOSS OF AIRCRAFT CONTROL

INABILITY TO COMPLETE MANEUVER/MISSION

BREAKDOWN IN DISCIPLINE

POOR HEADWORK

LOSS OF SITUATION AWARENESS

SPATIAL DISORIENTATION
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UNIT 9 Aviation Safety Human Factor 195
These are some of the primary causes of degraded flight Notes
performance most often noted in mishap analyses. __________________
__________________
CAUSES:
__________________
AEROMEDICAL/INTERPERSONAL PROBLEMS __________________

WORKLOAD-CAPABILITIES MISMATCH __________________

__________________
COGNITIVE - TASK INCOMPATIBILITY (Cognitive-
__________________
an information processing view of an individual's
__________________
psychological functions.)
__________________
INADEQUATE MISSION PREPARATION __________________

LACK OF TRAINING/EXPERIENCE

FAULTY OR INADEQUATE MENTAL MODEL OF

SYSTEM/TASK

Some of the more prominent behavioural indicators are listed

here.

PERFORMANCE ISSUES

POOR HEADWORK

ERRORS OF OMISSION

CHANNELIZED OR LACK OF ATTENTION

POOR/INADEQUATE CREW COORDINATION

DEGRADED AIRCRAFT CONTROL

SLOPPY PROCEDURES/NATOPS VIOLATIONS

HOW CAN WE MINIMIZE/PREVENT IT?

Will we ever be able to totally eliminate human error, and

the other factors leading to degraded performance? Probably
not, but one can continue to strive for that goal. How can the
person in the cockpit, on the flight deck, or in the hangar
minimize his/her making an error? Some of the more 'classic'
recommendations are listed here. However, there is a better
way to tackle the types of human factors problems discussed
to this point.
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Notes SOLUTIONS
__________________
RECOGNIZE PERSONAL LIMITS
__________________
__________________ MINIMIZE DISTRACTIONS
__________________
PRIORITIZE
__________________
__________________ NEVER ASSUME ANYTHING!
__________________ PRE-PLAN
__________________
STAY AHEAD OF AIRCRAFT
__________________
__________________ CREW COORDINATION TRAINING

SYSTEM DESIGN

COCKPIT DESIGN

AVIONICS AND DISPLAYS

EGRESS SYSTEMS

CONTROLS

LIGHTING

DESIGN FOR MAINTAINENACE PERSONNEL

EASY ACCESS

HANDLING FEATURES

SPECIAL GEAR/TOOLS

FOOLPROOFING

Each organization should create and maintain and ongoing,

dynamic human factors program. This can be best
accomplished under the umbrella of operational risk
management. It is also critical to revise existing safety
programs to include a strong emphasis on human factors.
Human factors councils and boards must be carried out as
per instruction. The way to best prevent the onset of human
factors problems is to maintain a highly visible HF training
program.
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UNIT 9 Aviation Safety Human Factor 197
KEY ELEMENTS OF A HUMAN FACTORS PROGRAM Notes
__________________
- AN EFFECTIVE OPERATIONAL RISK
__________________
ASSESSMENT PROCESS
__________________
- INCORPORATE HF INTO SAFETY PROGRAM __________________

- HF COUNCIL/BOARD __________________
__________________
- ONGOING HF TRAINING FOR ALL
__________________
PERSONNEL
__________________
- AN EFFECTIVE OPERATIONAL RISK __________________
ASSESSMENTPROCESS __________________

INCORPORATE HF INTO SAFETY PROGRAM

Another way to ensure that Human Factors programs can

be promulgated is by incorporating one into an organization's
Safety program. This does not require any added
administrative processes. Rather, incorporation of a Human
Factors necessitates an ongoing program of training and
awareness.

ONGOING HF TRAINING FOR ALL PERSONNEL

Again, the best way to promote Human Factors awareness

is by training. This brief is but one resource in this process.
There are a host of other HF briefs and resources available
from military and civilian safety and aviation agencies.

References
1. The Human Factor in Naval Aviation Safety, Cdr Andy
Bellenkes Force Aviation Human Factors Safety Officer,
Comnavairlant Code N452, USA

2. Document No. CAP 719, Fundamental Human Factors

Concepts, -A publication of Civil Aviation Authority,
U.K.

3. Document No. CAP 716, Aviation Management Human

Factors, -A publication of Civil Aviation Authority, U.K.

4. ICAO as Circular number 216-AN/131. Human Factors,

Digest No. 1 "Fundamental Human Factors Concepts".
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Notes 5. Department of Transport and Regional Development,

__________________ USA, Bureau of Air Safety Investigation-Human Factors
__________________ in Fatal Aircraft Accidents.
__________________
__________________
Questions
__________________ General Questions.
__________________
1. What are the primary categories of human factors that
__________________
may adversely affect the performance of aircraft
__________________
personnel, and may result into an aircraft accident or
__________________
incident?
__________________
2. Taking example of the case history an aircraft accident
caused due to involvement of some extent of human
factor, please give the causes of the accident with
possible methods of prevention and your views on
avoiding such accidents.

3. Describe briefly the various categories of human factors.

Objective Type of questions

a. As per statistical records, maximum number of aircraft
accidents are caused due to -----

b. Human Factors can be classified into four primary

categories: aero-medical, ------, performance, and design.

Answers to Objective Type of questions

a. Human Factors.

b. Physiological.