pptx - Halldale

Report
Beyond Pilot Error:
Aviation Safety and
Training
Kathy H Abbott, PhD, FRAeS
Federal Aviation Administration
Capt. John M. Cox, FRAeS
Safety Operating Systems
27 April 2010
Federal Aviation
Administration
Pilots Are Unique People
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
2
Human Error and Aviation Safety
Old View
• Human error is the
cause of accidents
• Human is the most
unreliable component
• Improve safety by
restricting human
action
New View
• Human error is the effect
of deeper issues
• Human is necessary to
create safety
• Improve safety by
understanding (and
leveraging) human
performance
From Dekker 2002
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
3
Risk Mitigation – Where?
Flexibility/
Adaptability
Design
Engineer
Envelope
Protection
Cat III
Autoland
Designer Error
TCAS/
ACAS
Flight
Director
Pilot
Circling
Approaches
Pilot Error
Overview
• Flight Path Management and Flight Deck
Automation – where can training be
improved?
• WHY do errors occur?
• Looking beyond error at the “sharp end”
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
5
Flight Path Management and Flight Deck
Automation – where can training be
improved?
• Performance-based Operations Aviation
Rulemaking Committee (PARC) and
Commercial Aviation Safety Team (CAST)
PARC/CAST (preliminary results)
• FAA International Rudder Survey
• Recent accidents/incidents
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
6
Flight Deck Automation Working
Group
• Joint under the Performance-based Operations
Aviation Rulemaking Committee (PARC) and
Commercial Aviation Safety Team (CAST)
• Current design, training and use of flight path
management systems in transport airplanes in
“121-like” operations
• Preliminary results from:
– 734 incidents from Aviation Safety Reporting System (ASRS)
within scope
– 46 major incidents and accident reports within scope
– normal ops via Line Operations Safety Audit (LOSA)
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
7
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
8
X X
X X
X
X
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
X
Federal Aviation
Administration
9
Potential Areas for Improved
Pilot Training
• Manual handling
• Flight path management systems
• Unusual attitude avoidance, recognition
and recovery
• Speed and energy management
• Use of rudder
• Managing malfunctions
• Managing distractions
• Crew coordination and communication
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
10
Turkish Airlines Flight TK 1951
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
11
Legal
Regulatory
Organization
Equipment design,
training, procedures
Pilot
Accident
Adapted from Reason
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
12
Legal
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
13
Regulatory
Organization
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
15
Equipment Design Training
Procedures
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
16
Pilot
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
17
Legal
Regulatory
Organization
Equipment design,
training, procedures
Pilot
Data Collection?
Investigations?
Training?
Accident
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
18
Operators, Regulators, Manufacturers,
Training Organizations…
It is about training all the people
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
19
Human Error and Aviation Safety
Old View
• Human error is the
cause of accidents
• Human is the most
unreliable component
• Improve safety by
restricting human
action
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
New View Revised
• Human error is the effect
of deeper issues
• Human is necessary to
create safety
• Get away from blame and
ask “why”?
• Improve safety by
understanding (and
leveraging) human and
organizational
performance
Federal Aviation
Administration
20
Beyond Pilot Error: Aviation Safety and Training
WATS
27 April 2010
Federal Aviation
Administration
21

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