Safety Stand Down 2013 Building a Safety Community

1. Safety Stand Down 2013Building a Safety Community

2. Agenda 0745 – 0845 Breakfast 0845 - 0950 Welcome and Introductions 0950 - 1000 Break 1000 – 1050 Human Factors Dr. Karen D. Dunbar 1050 – 1100 Break 1100 – 1200 Loss of Control Dennis H. Whitley 1200 – 1245 Lunch 1245 – 1300 Tribute To Flight Attendants 1300 – 1445 Miracle on the Hudson Doreen Welsh 1445 – Closing remarks - Adjourn

3. Welcome • Exits • Restrooms • Emergency Evacuation • Breaks • Sponsor Acknowledgment • Other information

4. Sponsors Altra Medical DJ Public Relations Inc. ExecuJet Charter Service Federal Aviation Administration Federal Aviation Administration Safety Team Hillsborough County Aviation Authority JETEX Flight Support

5. Sponsors NBAA OSI Restaurant Partners LLC Rockwell Collins St. Petersburg - Clearwater Int. Airport Standard Aero Signature Flight Support

6. Sponsors Landmark Aviation Tampa Air Traffic Controllers Tampa International Airport Fire Department Tampa Jet Center West Star Aviation WINSLOW Life Raft World Fuel

7. Tampa FSDO Personnel • Amanda Cromie – FSDO Manager • Jose Figueroa • Front Line Manager • Patrick Seggerman • Front Line Manager • James Minary • FAASTeam Program Manager

8. Florida FSDO Borders Alabama FSDO SO09 North Florida FSDO SO15 & SO35 South Florida FSDO SO19

9. Florida FSDO Borders Orlando FSDO SO15 North Florida FSDO SO35 Tampa FSDO SO35

10. FSDO Information • CFI and DPE Oversight • Flight Schools • Charter Companies • Film Production • Accidents & Incidents • Complaints • Repair Stations • Mechanic Schools • IA Mechanics • Special Flight Permits • Field Approvals

11. Contact us • http://faa.gov • Field & Regional Offices • Flight Standards District Offices (FSDO) • Select State • Select Office

12. Wings Credits • 3 Knowledge Credits for this Stand Down • Preregistered? • Initial roster • Not Preregistered? • Sign in with legible faasafety.gov email • No Account? • See a Rep today

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14. The Safety Stand Down • Military Origins • Response to Safety Issue • Temporary Operations Halt • Devote time to Safety

15. The Safety Stand Down • Human Factors • Investigates interaction between humans and systems • Evaluates fit between user, equipment and environment • Considers capabilities and limitations • Focus on task, demands, equipment and information • Loss of Control • Number 1 Factor in fatal accidents • Appch. & Ldg. LOC Workgroup • Findings & Recommendations • Technology • Human Factors

16. LOC Workgroup Findings • Lack of single – pilot CRM skills • Unstabilized approaches • Flight after extended periods of not flying • Inappropriate go-around procedures • Insufficient transition training • Over reliance on automation • Flight after use of drugs • Lack of Aeronautical Decision Making Skills

17. FAA Information Session • Presented by: • FAA Southern Region • Tampa Florida FAASTeam

18. Introduction to Human Error • Presented by: Dr. Karen D. Dunbar FAA Safety Team Representative

19. Human Error Making Sense of Accident Reports Presented to: FAASTeam 2013 Safety Stand Down 19

20. Overview • Error Fundamentals • System aspects of error • Application of Error Fundamentals • Gold Seal Key Concepts SSD 2013

21. To Err is: • Human • Universal • Inevitable • A bad thing

22. Certificate of Agreement Safety Stand Down 2013 In so far as I am able, I agree to suspend thoughts of judgment and retribution with respect to the characters in the stories I am about to hear or relate; and to the presenter of this seminar. I will seek to understand why events occur rather than to identify and punish those who were responsible for those occurrences. I understand that this agreement has no legal effect whatever and, in any case, applies only during this seminar unless I choose to continue with this way of thinking in the future. SSD 2013

23. The 5 Ws Who What When Where Why

24. The 6th W Who What When Where Why What’s to be done about it?

25. Four questions are easy Who What When Where Why What’s to be done about it?

26. The Accident Report Who What When Where Probable Cause Safety Recommendation

27. The Accident Report Who What When Where Moose on Field Moose proof fence

28. Hindsight Bias Bad Judgment Breakdown Hindsight Outside Lost the Bubble Violation Error Failure Incident Evolution Time (Sidney Dekker 2006)

29. Hindsight Bias Inside -Common Sense -Better -Best Option -Quick -Prod- uctive -Flexible -Good Idea -Judgment -Experience -Skill -Creative -Perfect -Easy -Profitable -Loyalty SSD 2013 Incident Evolution Time (Sidney Dekker 2006)

30. Ever have one of those days? • Take a wrong turn on a familiar route • Set out for work when you intended to go to the store • Lock keys in car or house • Can’t find the keys to lock in car or house

31. People cannot easily avoid those actions they did not intend to commit SSD 2013 James Reason & Alan Hobbs (2003)

32. People cannot easily avoid those actions they did not intend to commit Blaming people for their errors is emotionally satisfying but remedially useless. We’re still accountable for our mistakes though. James Reason & Alan Hobbs (2003)

33. Mikey’s story • Late night with interrupted sleep • Altered routine • Preoccupation with work • How big an error? • Consequence was huge • Error was common

34. People cannot easily avoid those actions they did not intend to commit We all operate within systems Sometimes without knowing it SSD 2013

35. Vehicular Child Fatalities Passenger Side Airbags vs Hyperthermia Deaths

36. Vehicular Child Fatalities Passenger Side Airbags vs Hyperthermia Deaths

37. Vehicular Child Fatalities Passenger Side Airbags vs Hyperthermia Deaths 38

38. Accident Chain of Events

39. Accident Chain of Events

40. Accident Chain Cultural Influences Preconditions Unsafe Acts

41. Unsafe Acts Cultural Influences Preconditions Leaving Mikey in car

42. Pre-conditions Cultural Influences Pax side airbag Sleeping Child Preoccupation Leaving Mikey in car Fatigue Warm Weather

43. Cultural Influences Child care responsibility Work ethic Pax side airbag Sleeping Child Preoccupation Leaving Mikey in car Fatigue Warm Weather

44. Safety significant errors can occur at all levels of the system Child care responsibility Work ethic Pax side airbag Sleeping Child Preoccupation Leaving Mikey in car Fatigue Warm Weather

45. The Swamp Cultural Influences Preconditions Unsafe Acts Adapted from Reason (1990)

46. Coming Soon Bayou Junction Housing Development Cultural Influences Preconditions Unsafe Acts Adapted from Reason (1990)

47. The General Aviation System Tasks Technology People Structure/Organization

48. 60 U.S. General Aviation Source NTSB 50 40 Accidents/100,000 flight hours 30 20 Accidents=Approximately 7/100,000hrs Fatal Accidents=Approximately 2/100,000hrs 10 0 1950 1970 1990 1960 1980 2000

49. Human Error is Both Universal and Inevitable SSD 2013 It is the Downside of Having a Brain James Reason & Alan Hobbs (2003)

50. Filter (Attention) Hands, Feet, etc. Senses Conscious Workspace Input Functions Output Functions Long-term memory (Knowledge base) Feedback Loops A Simplified “Blueprint” of Mental Functioning James Reason & Alan Hobbs (2003)