1. Federal Aviation Administration Risk Management for Pilots Human Factors, Decision Making and Risk Management

2. Federal Aviation Administration 2 Risk Management for Pilots

3. Federal Aviation Administration 3 Risk Management for Pilots What does it mean to be “safe?” “free from damage or danger…unharmed” (Webster’s New World Dictionary) Safe is not the equivalent of ‘risk free’ (U.S. Supreme Court – 1972) “Risk Management is more realistic term than safety.” (Jerome Lederer ~1928)

4. Federal Aviation Administration 4 Risk Management for Pilots What’s risk? hazardWhat can hurt us (consequence & hazard)? risklikelihoodWhat’s the likelihood that we’ll get hurt (risk - likelihood)? risk severityHow bad will it hurt if we do (risk - severity)?

5. Federal Aviation Administration 5 Risk Management for Pilots Situation, Hazards, and Risk ? Operation Hazard Environment Consequence

6. Federal Aviation Administration 6 Risk Management for Pilots James Reason Model Organizational Factors Organizational structure Communication Management Structure Goals Policy & Procedure Organizational Factors Organizational structure Communication Management Structure Goals Policy & Procedure Local Factors Physical Environment Operational Environment Task Design Supervision Local Factors Physical Environment Operational Environment Task Design Supervision Active Failures Performance Errors - Perception - Mistakes - Slips - Lapses Violations Active Failures Performance Errors - Perception - Mistakes - Slips - Lapses Violations Organization/ Operation Task/ Environment People/ Team Controls/ Defenses Source: James Reason Outcomes Active Error Path Latent Error Path

7. Federal Aviation Administration 7 Risk Management for Pilots Risk Management and Decision Making Risk management decision- making involves: –Understanding human factors –Understanding the operation –Knowledge of hazards in the operational environment –Making decisions with a disciplined process

8. Federal Aviation Administration 8 Risk Management for Pilots Human Factors

9. Federal Aviation Administration 9 Risk Management for Pilots Situational Awareness Situational Awareness… perception comprehension projection Is the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future. Endsley (1995)

10. Federal Aviation Administration 10 Risk Management for Pilots Human Thought Process Source: Dr. Mica Endsley Mental Model PerceptionComprehensionProjection Stored Patterns

11. Federal Aviation Administration 11 Risk Management for Pilots Crew/Team Situational Awareness Experience Hazard! Environment Consequence Hazard? Environment Consequence Shared Mental Model Experience Risk Perception

12. Federal Aviation Administration 12 Risk Management for Pilots Situation Awareness Errors ASRS data. 169 errors in 113 incidents. –80.2% Level 1 (Perception) errors –16.9% Level 2 (Comprehension) errors – 2.9% Level 3 (Projection) errors

13. Federal Aviation Administration 13 Risk Management for Pilots Factors that Reduce Situational Awareness Insufficient Communication Fatigue/Stress Task Overload Task Underload Group Mindset “Press on Regardless” Philosophy Degraded Operating Conditions

14. Federal Aviation Administration 14 Risk Management for Pilots Cognitive (Mental) Limitations Human working memory (WM) is limited The magic 7 plus or minus 2 (Miller, 1956) Fatigue can reduce this Interruptions can “bump” material in WM Information needed for a typical instrument approach can exceed the capacity available

15. Federal Aviation Administration 15 Risk Management for Pilots Cognitive Workload Combinations of tasks can overload the pilot. e.g. Missed approach –Spatial information (orientation) –Textual information (MA procedure) –Verbal information (communications) Preparation is important. Every IFR approach is a potential missed approach!

16. Federal Aviation Administration 16 Risk Management for Pilots Human Performance Skill-basedSkill-based performance –Mostly automatic –Psychomotor skills –Must be “overlearned” to be automatic Rule-basedRule-based performance –Procedural skill –Understanding, application are important Knowledge-basedKnowledge-based performance –Unique solutions to unique problems –Must start with sound knowledge base –Correlation, application levels of learning

17. Federal Aviation Administration 17 Risk Management for Pilots Human Error Error is ubiquitous - it’s a human thing. Rules and attention to detail are essential in a systematic approach to safety, but... Regulations and exhortations often have limited effectiveness in error prevention. “Be careful” only works so far.

18. Federal Aviation Administration 18 Risk Management for Pilots Human Error Slips/lapses are most often associated with psychomotor or automatic skills. –Skill or “action”-type problems most often responsible for frequent, low-severity events. Mistakes are often associated with cognitive tasks such as decision-making. –Decision-type problems more often responsible for high-severity events (fatal accidents). Many inadvertent rule “violations” are really errors.

19. Federal Aviation Administration 19 Risk Management for Pilots ADM – 5 Hazardous Attitudes Antiauthority (don’t tell me!). Impulsivity (do something quickly!). Invulnerability (it won’t happen to me). Macho (I can do it). Resignation (what’s the use?).

20. Federal Aviation Administration 20 Risk Management for Pilots Attitudes Attitudes develop from: –Personality –Culture (National/ethnic, professional, organizational) –Experience Attitudes affect patterns of behavior Situation may also affect behavior Attitudes may be difficult to change Pilots should recognize aspects of attitudes and be watchful for impacts on cockpit behavior

21. Federal Aviation Administration 21 Risk Management for Pilots Personality (“Big 5”) Openness to experience Conscientiousness Extraversion/Introversion Agreeableness Neuroticism (emotional stability)

22. Federal Aviation Administration 22 Risk Management for Pilots Attitudes Revisited Belanger, 2001

23. Federal Aviation Administration 23 Risk Management for Pilots Risk Management Process

24. Federal Aviation Administration 24 Risk Management for Pilots How do we manage risk? 1Identify the task(s)/functions What am I doing? 1 - Identify the task(s)/functions – What am I doing? 2Describe the environment What are the conditions? 2 - Describe the environment – What are the conditions? –Physical environment (Where, when) –Operational Environment (How, who, with what tools) 3Identify the hazards What can go wrong? 3 - Identify the hazards – What can go wrong? 4Evaluate the risk 4 - Evaluate the risk... –Likelihood of encountering the hazard – How likely am I to run into the hazards?

25. Federal Aviation Administration 25 Risk Management for Pilots Risk Management Process (continued) 4Evaluate the risk 4 - Evaluate the risk … (continued) –Potential severity – How bad will it hurt if I do? 5Identify and evaluate mitigating strategies How can I control my exposure? 5 - Identify and evaluate mitigating strategies – How can I control my exposure? 6Decide on a course of action What am I going to do about it? 6 - Decide on a course of action (alter system behavior) – What am I going to do about it? (Action is required for change) 7 Did my strategy work? 7 - Evaluate effectiveness of controls – Did my strategy work?

26. Federal Aviation Administration 26 Risk Management for Pilots Using Accident Data Study the flight and other mission tasks. Look at the flight environment. Find the areas where most problems occur. Determine the severity of problems. Determine how often they occur. Determine what I need to do to avoid them.

27. Federal Aviation Administration 27 Risk Management for Pilots Task Analysis ( Phases of Flight) Predeparture - ground Takeoff Climb Cruise Descent/holding Approach Landing Postarrival

28. Federal Aviation Administration 28 Risk Management for Pilots All/Fatal by Phase of Flight 9

29. Federal Aviation Administration 29 Risk Management for Pilots Risk Comparisons – Likelihood vs. Severity Frequency (Likelihood): –Takeoff & Landing –Lots of accidents (High Likelihood) –Relatively few fatal accidents (Low Severity) Severity –Climb, Cruise, Maneuvering –Fewer accidents (Lower Likelihood) –More fatal accidents (Higher Severity)

30. Federal Aviation Administration 30 Risk Management for Pilots Risk Mitigation Eliminate the Hazard Avoid the Hazard Reduce the Risk Severity –Lower the Severity Likelihood –Lower the Likelihood – Work on the risk factors Beware of “Substitution Risk” ( “Built in” latent failures Decisions about risk trades –Situation with lowest severity –Work on the likelihood

31. Federal Aviation Administration 31 Risk Management for Pilots Risk management Training

32. Federal Aviation Administration 32 Risk Management for Pilots Can Risk Management be Trained? Absolutely! “Judgment” is not a matter of the “right stuff.” Risk management is an active skill Like instrument skills, principles can be learned and taught to others. Pilots should be trained RM as a part of all training.

33. Federal Aviation Administration 33 Risk Management for Pilots Training Risk Management tasksDetermine the tasks – flight and mission tasks environmentAnalyze the typical environment pilotConsider the pilot(s) involved Review typical maneuvers and procedures hazardsAnalyze potential problems (hazards) riskEvaluate risk planDevelop a plan to teach the tasks considering the hazards EvaluateEvaluate the training

34. Federal Aviation Administration 34 Risk Management for Pilots Incorporating RM in Procedures and Training The best way to manage risk is to build it in to: –Operational Procedures (e.g. checklists, flight planning) –Company, club, school procedures –Training The best risk management is not something extra that you do – it’s the way you do what you have to do anyway. Most accidents are not due to emergencies or malfunctions – they are due to poor management of normal situations (the “pilot created emergency”)

35. Federal Aviation Administration 35 Risk Management for Pilots Pilot Training and Qualification System Knowledge Procedural Knowledge/Skill Maneuver Skills Flight Proficiency Flights: (Integrated Knowledge & Skill) Theoretical Knowledge SVPVMV LOE/SBT Theory Skills Basic Skills (KB) (KB/RB)(SB/RB) (SA) Source: Advanced Qualification Program Cognitive Cognitive/ Behavioral Cognitive, Behavioral, Constructive

36. Federal Aviation Administration 36 Risk Management for Pilots Training Scenarios Put it all together in typical flights Integrate Knowledge and Skill Stress Situational Awareness and its impacts on equipment modes and logic Teach the trainee how to manage workload Teach the trainee how to simplify situations Include scenarios with full and degraded automation

37. Federal Aviation Administration 37 Risk Management for Pilots Summary – Risk Recap 1.What am I doing? 2.What are the conditions? 3.What can go wrong? 4.How likely am I to run into the hazards? 5.How bad will it hurt if I do? 6.How can I control my exposure? 7.What am I going to do about it? 8.Did my strategy work?

38. Federal Aviation Administration 38 Risk Management for Pilots “Carelessness and overconfidence are more dangerous than deliberately accepted risk” “Carelessness and overconfidence are more dangerous than deliberately accepted risk” - Wilbur Wright, 1901 Wilbur Wright gliding, 1901 Photographs: Library of Congress