1. Top Aircrew Human Factor Errors in Navy/Marine Corps Aviation: A Helo Perspective LCDR Deborah White Human Factor Analyst (757) 444-3520 x 7231 (DSN) 564-3520 x 7231 LCDR Deborah White Human Factor Analyst (757) 444-3520 x 7231 (DSN) 564-3520 x 7231

2. 2 Stupid People Tricks

3. 3 Human Error in Aviation

4. 4 Background  Early 1990’s, Shappell and Wiegmann developed the Navy’s Human Factor Analysis and Classification System (HFACS)  Classify Human Error in Naval Class A FM  Develop data base to follow Human Factor trends  HFACS data base maintained since 1990  Over 400 mishaps analyzed  Primarily Fighter/Attack and Helicopter Aircraft  Early 1990’s, Shappell and Wiegmann developed the Navy’s Human Factor Analysis and Classification System (HFACS)  Classify Human Error in Naval Class A FM  Develop data base to follow Human Factor trends  HFACS data base maintained since 1990  Over 400 mishaps analyzed  Primarily Fighter/Attack and Helicopter Aircraft

5. Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Errors Perceptual Errors Skill-Based Errors UNSAFE ACTS Errors Decision Errors Exceptional Routine Violations Adverse Mental States Physical/Mental Limitations Adverse Mental States Adverse Physiological States Personal Readiness Crew Resource Management Substandard Practices of Operators Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION Resource Management Organizational Climate Organizational Process ORGANIZATIONAL INFLUENCES

6. 6 Objective Determine the primary Preconditions that contribute to the Aircrews’ Unsafe Acts

7. 7 Methods  Analyzed 249 Class A Navy/Marine Corps Aircrew Human Error Mishaps entered in the HFACS database from FY 90 -02  Broad HF Errors: oClassified HF Errors based on HFACS categories  Specific HF Errors: oDescriptions of specific/similar HF Errors determined for each HFACS categories – “Nanocodes”  Number of specific nanocodes for each category calculated and ranked  Analyzed 249 Class A Navy/Marine Corps Aircrew Human Error Mishaps entered in the HFACS database from FY 90 -02  Broad HF Errors: oClassified HF Errors based on HFACS categories  Specific HF Errors: oDescriptions of specific/similar HF Errors determined for each HFACS categories – “Nanocodes”  Number of specific nanocodes for each category calculated and ranked

8. 8 Human Factor Errors (FY90 - 02) Unsafe Acts - Aircrew Skill BasedDecisionPerceptualViolations (Routine) Violations (Exceptional) Helo TacAir % of Mishaps

9. Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors UNSAFE ACTS UNSAFE ACTS Errors Skill-Based Errors SKILL-BASED ERRORS  Failed to recognize extremis (Helo)  Improper use of flight controls (Helo)  Breakdown in visual scan (TacAir)  Improper use of flight controls (TacAir) Top nanocodes cited between FY 90 – FY 02

10. Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors UNSAFE ACTS UNSAFE ACTS Errors Decision Errors DECISION ERRORS  Poor Decision (Helo)  Wrong response to emergency (TacAir)  Poor Decision (TacAir) Top nanocodes cited between FY 90 – FY 02

11. 11 Human Factor Errors (FY90 - 02) Preconditions - Aircrew Crew Resource Management Adverse Mental State Adverse Physio State Physical/ Mental Limit Personal Readiness Helo TacAir % of Mishaps

12. CREW RESOURCE MANAGEMENT  Failed to Communicate/Coordinate (Helo)  Failed to Backup (Helo)  Failed to Communicate/Coordinate (TacAir) Preconditions for Unsafe Acts Preconditions for Unsafe Acts Substandard Practices of Operator Substandard Condition of Operator Substandard Condition of Operator Personal Readiness Crew Resource Management Physical/Mental Limitations Adverse Physiological States Adverse Mental States Substandard Practices of Operator Crew Resource Management Top nanocodes cited between FY 90 – FY 02

13. ADVERSE MENTAL STATE Preconditions for Unsafe Acts Preconditions for Unsafe Acts Substandard Practices of Operator Personal Readiness Crew Resource Management Physical/Mental Limitations Adverse Physiological States Substandard Condition of Operator Substandard Condition of Operator Adverse Mental States  Channelized Attention/Fixation (Helo)  Loss of Situational Awareness (Helo)  Channelized Attention/Fixation (TacAir) Substandard Condition of Operator Substandard Condition of Operator Adverse Mental States Top nanocodes cited between FY 90 – FY 02

14. 14 Human Factor Errors (FY90 - 02) Unsafe Supervision Inadequate Supervision Failed to Correct Problem Planned Inappropriate Ops Supervisory Violations Helo TacAir % of Mishaps

15. UNSAFE SUPERVISION UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Inadequate Supervision Inadequate Supervision INADEQUATE SUPERVISION  Failed to Provide Adequate Guidance (Helo)  Failed to Provide Adequate Guidance (TacAir) Top nanocodes cited between FY 90 – FY 02

16. 16 Human Factor Errors (FY90 - 02) Organizational Influences Organizational Process Resource Management Organizational Climate Helo TacAir % of Mishaps

17. Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES ORGANIZATIONAL INFLUENCES Operational Process OPERATIONAL PROCESS  Inadequate Documentation (Helo)  Failed to Provide Adequate Guidance (TacAir) Top nanocodes cited between FY 90 – FY 02

18. Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES Resource Management Resource Management ORGANIZATIONAL INFLUENCES RESOURCE MANAGEMENT  Inadequate Design (Helo)  Inadequate Design (TacAir) Top nanocodes cited between FY 90 – FY 02

19. 19 Summary  Predominate Preconditions for Helo Aircrew Unsafe Acts (Skill-based and Decision Errors):  Failure to Communicate/Coordinate  Failure to Backup  Channelized Attention/Fixation  Loss of Situational Awareness  Predominate Preconditions for Helo Aircrew Unsafe Acts (Skill-based and Decision Errors):  Failure to Communicate/Coordinate  Failure to Backup  Channelized Attention/Fixation  Loss of Situational Awareness

20. 20 Conclusion  To decrease the number of Decision and Skill-based Errors, the importance of good aircrew communication, coordination, and backup must be continually emphasized by Squadron COs and Training Programs.  Aircrew must also recognize the dangers associated with channelized attention and fixation, which can be avoided by utilizing proper scanning techniques and communicating with other personnel (i.e. crewmembers, ATC, other helicopter crews).  To decrease the number of Decision and Skill-based Errors, the importance of good aircrew communication, coordination, and backup must be continually emphasized by Squadron COs and Training Programs.  Aircrew must also recognize the dangers associated with channelized attention and fixation, which can be avoided by utilizing proper scanning techniques and communicating with other personnel (i.e. crewmembers, ATC, other helicopter crews).

21. 21 What the US Navy is doing  Rejuvenating our Crew Resource Management Training:

22. 22 CRM Training Structure for Individual Initial CRM Training (Primary Flight Training) Phase 1 (Ground) Academics + Testable (2 day minimum) Phase 2 (Flying) Training with Instructor; Hands on + Graded Initial CRM Training (Primary Flight Training) Phase 1 (Ground) Academics + Testable (2 day minimum) Phase 2 (Flying) Training with Instructor; Hands on + Graded Specialized CRM Training Mission/Platform Specific (Type Model Training) Academics + Scenario Based Event (Hands on): Graded (1 day minimum) Specialized CRM Training Mission/Platform Specific (Type Model Training) Academics + Scenario Based Event (Hands on): Graded (1 day minimum) Training Style: INFO DEMO PRACTICE FEEDBACK *Curriculum emphasis based on career progression. Leadership Training (1 hr) Training (1 hr)Leadership Instructor Training Academic, Simulator and Line IP (4 hr min) Instructor Training Academic, Simulator and Line IP (4 hr min) Continuation Training Annual Academic Course + Scenario Based Event: Graded (4 hrs min) Continuation Training Annual Academic Course + Scenario Based Event: Graded (4 hrs min)

23. 23 What the US Navy is doing  Rejuvenating Crew Resource Management Training  Development of Joint DoD Human Factors Analysis and Classification System  Document can be found on Naval Safety Center Web Page under Aviation, Aeromedical ohttp://safetycenter.navy.mil.htm  Rejuvenating Crew Resource Management Training  Development of Joint DoD Human Factors Analysis and Classification System  Document can be found on Naval Safety Center Web Page under Aviation, Aeromedical ohttp://safetycenter.navy.mil.htm

24. 24 Errors ACTS Errors Perception Errors Skill-Based Errors Judgment and Decision-Making Errors Violations Inadequate Supervision Planned Inappropriate Operations Failed to Correct Known Problem Supervisory Violations SUPERVISION Resource/Acquisition Management Organizational Climate Organizational Process ORGANIZATIONAL INFLUENCES Condition of Individuals Cognitive Factors Technological Environment Physical Environment Self- Imposed Stress Coordination/ Communication/ Planning Factors Personnel Factors Psycho- Behavioral Factors Environmental Factors PRECONDITIONS Perceptual Factors Physical/ Mental Limitations Adverse Physiological States

25. 25 What the US Navy is doing  Rejuvenating Crew Resource Management Training  Development of Joint DoD Human Factors Analysis and Classification System  ORM and Fundamentals of Flying Program  Emphasize ORM procedures in everything we do  Take time during flights to practice basic flying skills  Rejuvenating Crew Resource Management Training  Development of Joint DoD Human Factors Analysis and Classification System  ORM and Fundamentals of Flying Program  Emphasize ORM procedures in everything we do  Take time during flights to practice basic flying skills

26. 26 Questions?