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Federal AviationAdministrationBeyond Pilot Error:
Aviation Safety and Training
Kathy H Abbott, PhD, FRAeSFederal Aviation Administration
Capt. John M. Cox, FRAeSSafety Operating Systems
27 April 2010
2Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Pilots Are Unique People
3Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Old View New View• Human error is the
cause of accidents• Human is the most
unreliable component• Improve safety by
restricting human action
• 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
Human Error and Aviation Safety
Federal AviationAdministration
Risk Mitigation – Where?
Designer Error
PilotDesign Engineer
Envelope Protection
TCAS/ACAS
Flight Director
Pilot Error
Flexibility/Adaptability
Cat IIIAutoland
Circling Approaches
5Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Overview
• Flight Path Management and Flight Deck Automation – where can training be improved?
• WHY do errors occur? • Looking beyond error at the “sharp end”
6Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
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
7Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
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)
8Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
9Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
X X XXX
X X
10Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Potential Areas for ImprovedPilot 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
11Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Turkish Airlines Flight TK 1951
12Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Pilot
Equipment design, training, procedures
OrganizationRegulatory
Accident
Legal
Adapted from Reason
13Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Legal
Federal AviationAdministration
Regulatory
15Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Organization
16Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Equipment Design Training Procedures
17Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Pilot
18Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Pilot
Equipment design, training, procedures
OrganizationRegulatory
Accident
Legal
Data Collection?Investigations?Training?
19Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Operators, Regulators, Manufacturers, Training Organizations…
It is about training all the people
20Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Old View New View Revised• Human error is the
cause of accidents• Human is the most
unreliable component• Improve safety by
restricting human action
• 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
Human Error and Aviation Safety
21Federal AviationAdministration
Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010
Thank You
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