Human Factors

Human Factors

By OffRoadPilots 

Human factors and human errors are two separate things but are often used interchangeable in conversations and in the aviation industry. Human errors are attached to a person who could be linked to an occurrence. In addition, the severity of the outcome is a predetermining factor how important it is to assign human error as the root cause after an accident.

Human error root cause analysis has widespread support from the aviation industry. However, with the implementation of the Safety Management System (SMS) regulations, accountability came into play, and it became impossible to justify human error as the root cause.

A healthy SMS looks at the organization and its systems, and the fact that a person overlooked, or missed an item is no longer a root cause, such as a pilot missing a checklist item. Checklists are required and are used for any flight, but there is no evidence a missed checklist item was the root cause of any accidents. At the other end of the spectrum, completing the gear-down checklist item was a contributing factor to a fatal accident in 1972. A descent went undetected when the flight crew became focused on a checklist item.

Human error is a symptom of trouble deeper inside a system or an organization. On the other hand, human error is also a symptom of a successful organization. There are organizations where human errors are integrated with the system and need to be there for the organization to exist and prosper. It is the system itself that is set up for human errors.

Conventional wisdom is that human error is a” bad” thing when using emotions to describe an event. Human error is a sub-category of human factors. Simplified, human factors are how a person react when one or more of the five senses, vision, hearing, smell, taste, and touch are triggered. Human factors are also how external forces, or events, e.g., fatigue, weather, illumination and more, affect performance.

In an organization where there are overwhelming events of human errors, the organization operates within a system that is prone to these errors. An example is Daytona 500, or Reno Air Races, where the systems (race to win) are setting each driver and pilot up for human error, or a crash. Both the Daytona 500 and Reno Air Race organizers have requirements and systems in place to reduce harm to drivers, pilots, or spectators, but these systems are designed for human errors. Imagine how successful Daytona 500 would be if the speed was limited to 50MPH, or if the Reno Air Race required airplanes to fly between gates separated a mile apart.

Civil aviation industry systems are not set up as systems where human errors are desirable, but occurrences still happens because aviation operational systems allow for it. Civil aviation systems are not as obvious as the racing-systems to promote human errors, but they both happens because of human and organizational factors, and to get the job done before closing time.

The aviation industry struggles with the human error concept. This struggle affects their organizational environment, and a trap to fall into is to make pilot, or human errors the root cause. However, the safety management system requires operators to look inward into the organizational systems to repair or replace one or more systems. If a process is stable and undesirable, but not broke, the process should not be fixed. The old saying that “if it ain’t broke don’t fix it” holds true in aviation safety. A stable, or desirable process may from time to tome turn out faulty items and mistakes. Reacting to these mistakes is tampering with the process contributing to an increase in future errors. Tampering with a stable process moves the process closer to a point to become a contributing factor to accidents.

Several years ago, a pilot and three passengers went on a mountain flight with a PA-28-140. The aircraft was full of fuel and above max gross weight at takeoff. As often, when there are no other adverse conditions, the flight departed safely, and slowly climbed into the valley towards the taller mountains.

While the winds were relatively calm at the airport, on this day the winds were extremely strong in the mountains. One pilot had earlier that day refused to take the scenic flight because of the mountain winds, but another pilot accepted.

The pilot banked and turned for the passengers to see the beauty of the mountains. Before the pilot could react, the aircraft stalled and crashed. A close friend found them later the next day in a highly remote area.

Human and organizational factors are often linked together in the text but are two separate factors. Human factors are how human reacts to inputs, while organizational factors are the result, or output, of these reactions. The term organizational factors encompass all elements that influence the way that an organization, and everybody within it, behave. Some of these elements are formal management systems, assurance processes, working practices, whether or not formally documented, risk awareness, how the organization learns from experience, organizational safety culture and more.

A safety policy is directed at human factors. Safety for an airport or airline is to maintain the confidence of the travelling public and safety of the aviation industry is vital to success. Through the introduction of a safety management system, an airport is committing to provide a systemic, explicit, and comprehensive process for managing airside safety risks. By embracing this safety management system, airports establish safety as an integral part of an airport culture where they recognize that safety is paramount.

Human factors is a scientific study that evaluates and comprehend human interactions and human behaviors in relation to other human and elements of a workplace system. The human factors five senses reactive or proactive affect human behavior and performance. These senses are vision, hearing, smell, taste, and touch.

The SHELL model is a model of human factors interactions and includes the software(S), hardware(H), environment(E), liveware, other(L), liveware, self(L).

Software are regulations, standards, policies, job descriptions, expectations, and other intangible items.

Hardware are the physical and tangible items housing intangible items. Hardware are electronic devices, documents, tools, airfield, and other tangible items. The environment has multiple sub-categories. A sub-category of the environment is the designed environment. A design environment is user friendly environment, design and layout, accessibility, tasks-flow, and more. The social environment is about distancing, both physical contact between persons and distancing between equipment and objects, experiences, culture, language and more.

The climate is another sub-category of the environment. Climate environment includes geo location, weather, temperature, and more. Amy these human factors has an affect human behavior in one way or another.

When one or more of the human senses are targeted by inputs, or when interactions between the elements of the SHELL model are incompatible, the effect on human reaction, or process output, are commonly known as human errors, or pilot errors.

Human errors are not errors, but reactions to the operational SHELL model system, and human senses are reactions they are exposed to by the system itself.

OffRoadPilots

Regulatory Conforming Processes

 Regulatory Conforming Processes

By OffRoadPilots

Regulatory conforming processes are processes producing outputs that conform to regulatory requirements. There are three fundamental tasks required when building regulatory performing processes. The first task is the research for input task, the second task is the process design and development task, and the third is the regulatory identification and assignment task. A process must be linked to one regulatory requirement. In a healthy SMS environment, a process is linked to several regulations, or several standards, and to the SMS policy.

The research for input task is a comprehensive research of regulatory requirements for airport or airline operations. In addition to airport or airline regulations, multiple other federal or local regulations may be applicable, such as environment regulation, transportation of the public regulations, and other regulations. However, when researching regulatory requirements for the purpose of building a conforming process, only airport or airline operations regulations are researched for inputs. These are the regulations that an airport or airline operating certificate is tied to and dependant on for its existence. Performance-based regulations are based on a 95% confidence level.

Regulatory research also includes a comprehensive research of standard requirements for airport or airline operations. Standards are also performance- based in the same way as the regulations are. Airport standards has been adapted for use in an operational concept to reflect and support the operational reality of aircraft capabilities and performance specifications. An airport standard establishes a level of service for an airline and its fleet. Rapidly changing technologies in aircraft performance and avionics have a very real potential to impact future aerodrome operations. An increase in the size of critical aircraft or the provision of lower landing, departure or taxi limits will require the aerodrome operator to re-assess the aerodrome facilities and operational procedures to ensure they provide the required standards.

Accuracy requirements for aeronautical data are based upon a 95% confidence level and in that respect, three types of positional data are identified. Positional data are surveyed points e.g. runway threshold, calculated points, e.g. mathematical calculations from the known surveyed points of thresholds for determination of the aerodrome reference point, and declared points, e.g. flight information region boundary points. The confidence level is in the method, or process itself, and is not in a particular confidence interval. If the sampling method was repeated many times, 95% of the intervals constructed would capture the true population mean. As the sample size increases, the range of interval values will narrow, meaning that a larger sample size, or an increased number of data collected, the mean of the sample will generate a much more accurate result if compared with a smaller sample, or fewer tasks completed.

There is a misconception among operators that a 95% confidence level is the same as airports or airlines being 95% safe. Conventional wisdom is that the application of numerical safety levels, such as airline ratings are indications of what level the public are protected from harm when an airline has achieved the maximum 7 of 7 in their rating. An airline rating level takes several other parameters into account, such as staff friendliness, service availability and more to provide a complete travel experience safety level. In the same way as airline ratings apply several parameters in their assessment, airline and airports do the same in their operational assessment oversight. There are therefore no contradictions between a 95% confidence level and a 100% safety rating level, or rated 7/7.

A 95% confidence level is that established safety performance indicators (SPI) and safety performance targets (SPT) will fall within their expectations 95 of 100 times. An airline may establish a confidence level of 95% that their pilots will touch down within the first 1/3 of the runway. For the same airline to establish a 100% confidence level, the airline needs to operate with an expectation that their pilots will touch down anywhere on the full length of the runway 100 of 100 times. A targeted 95% confidence level is therefore safer in operations than a targeted 100% confidence level, which does not provide enough stopping distance for a pilot who used up all of the runway before landing.

The next step is the process design and development task. When designing processes, the objective is to produce an operational sound outcome. At this stage in the design process, regulations, standards, and the SMS policy are considered, but they are not applied to the process design. The reason for considering regulations but not applying regulations, is that an easy trap to fall into is to build a regulatory process. In a regulatory process an airliner captain must fly the regulations when they need to fly the process. E.g. if a regulation, or flight operational quality assurance expectation requires a pilot not to bank an aircraft beyond 25 degrees angle, the wind could push the aircraft into an undesired position, as opposed to flying the process when a pilot would increase the bank angle to maintain aircraft control. A goal when building processes, is for processes be practical to use, and with a task-flow that make sense to users.

Regulations are objective and impartial to a process, while safety is subjective and biased. Regulatory compliance is the priority, while safety is paramount. Maintaining continued regulatory compliance is the foundation and building blocks for the existence of an airport or airline certificate. When safety is paramount, it becomes the highest-ranking order of a system, and regulatory priority is the only tool to maintain safety as the highest-ranking order. Just as an accountable executive is the highest-ranking order of a safety management system, regulatory compliance is the operational priority to maintain that order.

An airport has an obligation to operate with a runway environment that maintains continuous regulatory compliance. This is achieved in multiple ways when each activity or task is linked to a regulatory requirement. One task several airports have adapted, is the daily inspection task. This is not a regulated task, but by using the process daily, they are engaged in activities, or processes, that conforms to regulatory compliance. The key to success is to comprehend what regulatory requirements each activity is linked to.

The last step is the regulatory identification and assignment task, which is to conduct a process analysis to verify what tasks within the process are lined to a regulation. A process compliance analysis is conducted backwards, starting from the end result and output, and move backwards until the beginning. Any broken link in the process must be closed for compliance.

After all broken links are closed, the next step is to analyze the process forward and apply compliance to each step in the process. There will also be steps that are not linked to aviation regulations, such as checking the vehicle before operating airside. Compliance requirements are linked to tasks performed while conducting the inspection. One task may be linked to multiple regulations, and one regulation may be linked to multiple tasks. Comprehensive knowledge of the regulations is required to perform these tasks. The accountable executive is the person who is responsible for compliance with all regulations and is also the person who is the final authority for assigning regulations to tasks.

When regulatory conforming processes are built, implemented, and communicated to workers, compliance becomes simple. Airport or airline workers does not need to change how they work, or how things are done, but are simply completing their processes as expected. Over time as data becomes available, the only task left is to enter data into a statistical process control system for control charts to be produced and analyzed.

The beauty of operating with regulatory linked processes, is that all information is available to airport and airline operators when safety performance is analyzed, and when the regulator conducts inspections.

OffRoadPilots