Airline SafetyImprovement potential for US civil aviation | Paramotor Safety
U.S. civil airlines move humans with less risk than any mode ever devised. But there's still room for improvement.
In pursuit of safety we must be careful not to price us out of reach which would lower overall transportation safety by moving travelers to their more dangerous automobiles.
Every airline's pilot training includes some blurb about being the "best in the business." That's good for encouragement and team building and all that but undermines the immutable fact of human frailty.
Great pilots have caused crashes in mundane ways. Usually through simple errors compounded unexpectedly that cause unexpected results—sometimes tragically.
Distraction and complacency may be the two biggest enemies of safety while technology, properly used, its best defense. And it's not great pilot skill that will prevents most accidents, but rather the far more mundane practice of discipline. For example: actually looking at items on a checklist, not accepting substandard performance on an approach, biting the bullet to write up a broken item on that last leg home, etc. These are the things that would prevent most mishaps.
Safety improvements don't happen at the wave of someone's hand—even hands high in the management heap. They happen because someone champions the improvement and convince those in power that the benefit is worth the expense. Don't be fooled into thinking that just because something is safer it will be done. Expense must be weighed. That is why the unpopular analysis of "cost per life saved" is so important—it ranks safety improvements by their efficacy.
Our aviation system has been ingeniously tweaked over the years to overcome many human failings but there is room for improvement. This section is is devoted to that effort.
People Don't Fail, Processes Do
This great article addresses the myths of brushing off accidents as "Pilot Error," a conclusion as useless as saying a death was caused by "gunshot wound." While true, it sure doesn't shed much useful light on what we're really interested in: who done it.
In case the Article link is broken, the content is included below.
Feature The myths of pilot errorBy staff writers - May 1, 2017 Flight Safety Australia (Original Article Here)
Since the legend of Icarus, pilots have copped the blame for not following policies (i.e. don’t fly too close to the sun) and causing aircraft crashes. Over the century of powered flight, innumerable newsreaders, stories and blogs have droned ‘pilot error is suspected’, before moving on to the day’s next story, such as in the case of the recent accident at the Essendon aerodrome.
For anyone involved in aviation, the words ‘pilot error’ are, or should be, immensely aggravating. Pilot error, or controller error or engineer error are facts of life in aviation, because humans are involved in all these jobs. In fact, to blame pilots out-of-hand without evidence is also human error—it is not a useful explanation of why the accident occurred.
This is by no means advocating that aviation should not strive to minimise the errors within one’s performance. The lay-person’s perception that aviation safety may be conceived only in such black and white terms of error and an appropriate punishment is unfortunately the antithesis of the thinking of modern aviation. The well-embedded culture that error is a fact of human existence that needs to be understood, even embraced, rather than denied, is slowly creeping into more and more professions outside of aviation, such as medicine, ground transport and mining. However, even within an industry with insight and awareness, the cognitive processes that aid our thinking can at times lead to faulty conclusions due to over-reliance on heuristics and biases (Tversky & Kahneman, 1974). In fact, we’ll tackle a few in this article that seem to keep coming up in spite of our best efforts.
Myth 1: Good pilots don’t make errors
‘That myth should have been long dispelled,’ says the new CASA human factors fatigue specialist Dr Robert Forsterlee. ‘For example, research on line operations safety audits (LOSA) where pilots observe the performance of their peers during routine flights and log their errors, has shown that firstly, there are always inconsequential errors such as inputting wrong information like weights or altitudes, giving erroneous read-backs, etc. While some errors result from individual performance factors, others may be systemically based. Secondly, although the professionalism of pilots is based on accurate self-assessment, they cannot account for every mistake they make. That’s just human nature, it’s not pilots in particular.’
In his studies of mining and oil drilling, sociologist Andrew Hopkins found, like many others, that human error is universal. ‘Human failure is a fact of life and pilots make errors.’ He cites studies that show airline pilots make between one and five errors per flight sector.
Human factors researcher Matthew Thomas says, ‘Human error is now accepted as a natural part of everyday performance, and can occur both spontaneously or can be precipitated by a variety of environmental and personal factors, such as individual proficiency, workload, fatigue and team-dynamics.’
Myth 2: Error equals incompetence
If you want to make a psychologist snort, ask them about accident proneness—the idea that some people are likely to have accidents because of inherent clumsiness, risk taking or stupidity. As a concept, it is ‘folklore’, according to one review of the evidence. ‘It is not the concept of accident proneness that is being questioned … but rather the unsubstantiated claims that it is an identifiable constellation of personality traits that can be predicted using psychological tests,’ Mark Rodgers and Robert Blanchard write. Studies of accident proneness need to demonstrate large samples, stability of accident proneness over time and to account for the impact of ‘situational and circumstantial variables,’ the unique circumstances of every accident, they say.
In The Limits of Expertise, NASA Ames Research Centre psychologist R. Key Dismukes (with Ben Berman and Loukia Loukopoulos) demolishes the myth that error signals incompetence. ‘Many people assume that if an expert in some domain (aviation, medicine or any other) makes an error, this is evidence of lack of skill, vigilance or conscientiousness. This assumption is both simplistic and wrong,’ the authors write.
‘Skill, vigilance and
conscientiousness are of course essential for safe, effective performance,
but are not sufficient. A particularly problematic misconception about the
nature of skilled human performance is that if experts can normally
perform some task without difficulty then they should always be able to
perform that task correctly. But in fact experts in all domains from time
to time make inadvertent errors in tasks they normally perform without
Myth 3: Errors explain accidents
‘To think in terms of error and blame is itself an error,’ Andrew
Hopkins says. ‘The concept of blame is counterproductive from an
explanatory point of view. We have two paradigms of thinking; the blame
paradigm and the explanatory paradigm and these two things are
incommensurable. They don’t meet in any way.’
Myth 4: I could never make that error
‘With the benefit of hindsight it’s easy to say no way would I have done such a thing,’ Forsterlee says. ‘But you weren’t in that situation, on that day, with that information.’
There are a number of contributors to this mindset such as: optimism bias or the misperception that one is less likely than others to incur a negative consequence; over-estimating skill and under-estimating risk; and the illusion of control phenomenon, which occurs when people trying to obtain a desired outcome that occurred independently of their behaviour tended to believe that they were controlling it.
Understanding that human error, including your own, is inevitable; it's the beginning of improvement, he says. ‘All champions lose games. But they’re champions because they learn from their mistakes, and their losses.’
‘Everybody should be aware of the fallibility of humans. But there are always the personality types who, in the face of all the factual external evidence on the planet, say “I have an alternative explanation that proves I am not wrong.” That’s why highlighting susceptibility to belief in these myths is so important.’
Self-awareness and ability to improve has little to do with age or experience. Professionalism is the continued self-scrutiny to ensure you continue to develop—this is not possible without the ability to accept feedback. Unfortunately, there are people who externalise their lack of achievement and professional growth to circumstances or others rather than their own efforts.
Dismukes and his colleagues found the notion that the crews of doomed aircraft were unusually or grievously deficient does not withstand examination. ‘For the most part, crew performance during these accident flights, to the extent it can be determined from the NTSB reports, seems quite similar to that of the many crew we and others have observed in actual flight observations and in recurrent flight training simulations,’ the authors write.
‘Even the few accidents that involved deviation from explicit guidance or standard operating procedures should be interpreted cautiously; one should consider the actual norms for operating on the line—is the accident crew’s deviation unique or do similar deviations occur occasionally, or even frequently in similar conditions?’
Dismukes also has some sobering thoughts on the role of luck in crashes. ‘I find it ironic that in some windshear accidents the crew was faulted for continuing an approach even though an aircraft landed without mishap one minute ahead of the accident aircraft. Both crews had the same information, both made the same decision, but for one crew luck ran the wrong way.’
Interruption and errors: remembering to do what’s right
On 20 August 2008 a McDonnell Douglas MD-82 airliner lined up to take-off from Barcelona El Prat airport, then returned to the gate to attend to a high-reading engine nacelle sensor. An hour later, it took-off again only to roll right immediately on leaving the ground and crash, killing 154 of the 172 on board. The crew of Spanair flight 5022 had forgotten to extend the flaps for take-off, as the crew of Northwest Airlines flight 255 had done almost exactly 21 years earlier, in another MD-82, on 16 August 1987. Both crews had been interrupted in their take-off preparations and both aircraft had inoperative take-off configuration warnings.
Memory and error was a specialty of Dismukes, who recently retired from NASA after a distinguished career investigating the psychology of mistakes in aviation. The psychologist and former airline transport-rated pilot now has time to enjoy his hobby of gliding. He recently put his academic knowledge into an admirably lucid article for his local gliding club newsletter.
‘Without going into technical detail I will give you a high-level summary of the conclusions we reached, drawing also on the findings of many other research teams.
When we looked at airline accidents in which pilots forget to perform some essential task, we found that most of the things they forgot were routine operational procedural steps, rather than unique actions they were trying to remember to do. These were fairly simple tasks that they had executed thousands of times without difficulty on previous flights, things such as setting flaps, extending the landing gear, turning on hydraulic boost pumps, or reading items on a checklist. What I’m talking about is a relatively new field of cognitive science called prospective memory: remembering to do things we intend to but must defer until a later time.
It quickly became clear that everyone occasionally forgets to do things, no matter how simple the task is, no matter how often they have performed the task previously, no matter how skilful they are at their work, no matter how conscientious they are. So why do we forget and what can we do to prevent these memory lapses?
‘Humans have a vast store of information, almost unlimited, in long-term memory. That’s where everything you know resides. But at any one moment only a tiny sliver of that information is activated and immediately available to conscious manipulation in what is called working memory.
The research shows that to retrieve the deferred intention back into awareness at the right time, we must notice something relevant; some cue must remind us, a cue that is in some way related to the intention.
Priming the memory: error countermeasures
For situations where you have to defer things that need to be done, Dismukes recommends creating reminder cues that will be noticed at the right time. ‘The best reminder cues are distinctive, salient, unusual, and/or block further action, such as putting an empty Styrofoam cup over the throttles of an aeroplane to remind you that there is something you must do before you take-off.’
Reminder cues include:
Dismukes says multitasking, performing a procedural step out of sequence, or substituting an atypical procedural step should be treated as red flags for likely error. ‘Form an implementation plan and create reminder cues,’ he says. ‘Above all, avoid rushing regardless of time pressure,’ Dismukes says. ‘Rushing at best saves a few seconds, and it increases our vulnerability to these and other types of errors enormously.’
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Precious Cargo. Life is an incredible gift, lets work hard to preserve it in our pursuit of motion. Photo by Gary Brown
Â© 2016 Jeff Goin & Tim Kaiser Remember: If there's air there, it should be flown in!