Click to Do Good Pilots Make edit Master

Click to. Do Good Pilots Make edit Master title style Why Errors That Sometimes Lead • Click to edit Master text styles to Accidents? • • Second level Third level Key Dismukes, Ph. D. Fourth level Fifth level Annual MMOPA Convention 28 October 2010 3/18/2018 1

Most Accidents Are Attributed to Pilot Error Click to edit Master title style • How should we think of this? • Click to edit Master text styles • Why do experienced pilots make • mistakes performing routine tasks? Second level - Lack level • Third of skill? Carelessness? Bad attitudes? Some other, more subtle answer? • Fourth level • Are errors inevitable? • Fifth level can we do about them? - If so, what - What is the relationship between errors and accidents? • How we answer these questions is crucial to aviation safety 3/18/2018 2

Research on Pilot Performance Click to edit Master title style • Has focused mostly on airline operations - Extensive data - Limited funding for GA safety • Click to edit Master text styles Extracted findings • • Second level relevant to your type of flying - Will not discuss errors made by novices • Third level can be more challenging than airlines’ - GA operations • • Fourth discuss Darwin award accidents level Will not • Fifth level • Focus on challenges faced by experienced, conscientious pilots 3/18/2018 3

Overview of Talk Click to edit Master title style • Research community’s perspective on why all skilled operators (not just pilots) are vulnerable to error • • Click to edit Master textinstyles vulnerability to Describe specific situations which error is high • Second level Practical countermeasures pilots can take to reduce • • Third level vulnerability and to manage consequences of error • Fourth level • Fifth level 3/18/2018 4

Consensus from Decades of Human Factors Research Click to edit Master title style • Simply naming human error as “cause” is simplistic • -Clicklittle to further to edit Master text Does styles understanding and • Second level prevent future accidents • Third level • Must avoid hindsight bias • Fourth level • • Absent willful misconduct, “Blame and punish Fifth level mentality blocks path to improving safety • Path to accidents driven by interactions among multiple factors 3/18/2018 5

Equipment and interface design Social/organizational Factors: Click to edit Master title style • community norms • regulations/enforcement • passenger expectations • Click to edit Master text styles Skilled • Second level performance • Third level (both effective and ineffective) • Fourth level Individual Factors: • goals • • technical & level Fifth interpersonal skills • experience and currency • physiological state • attitudes 3/18/2018 Inherent characteristics and limitations of human perception and cognition Task Demands Conditions (e. g. , weather) Events 6

Confluence of Factors in a CFIT Accident (Bradley, 1995) Click to edit Master title style Approach controller failed to update altimeter setting Weather conditions Non-precision approach ≥ 250 foot Rapid change in terrain clearance Strong crosswind barometric pressure Training & Standardization issues? • Click to edit Master text styles Tower window PF used Altitude Hold Autopilot would broke • Secondhold to capture MDA not level PM used non-standard Are most pilots Tower closed callouts to alert PF PF selected aware of this? • Third level Heading Select Altimeter update Altitude Hold not available may allow altitude Additional workload • Fourth level sag 130 feet in Airline’s use of turbulence ? QFE altimetry • Fifth. Increased vulnerability level to error ? Crew error (70 feet) in altimeter setting 3/18/2018 170 foot error in altimeter reading Aircraft struck trees 310 feet below MDA 7

How Can We Prevent Multiple Factors from Converging to Cause Accidents? Click to edit Master title style • • • Click to edit Master Must styles recurring patterns text look for underlying themes and Second level • Must develop tools to help Third level individuals and organizations recognize nature of Fourth level vulnerability Fifth level 3/18/2018 8

Some Major Themes and Recurring Patterns (not an exhaustive list) Click to edit Master title style • Plan continuation bias • • Snowballing workload text styles Click to edit Master • • “Multitasking”: Concurrent task demands and Second level prospective memory failures • Third level • Ambiguous situations without sufficient information to • determine best course of action Fourth level • • Procedural drift Fifth level • Situations requiring very rapid response • Organizational issues 3/18/2018 9

Some Major Themes and Recurring Patterns (not an exhaustive list) Click to edit Master title style • Plan continuation bias • • Snowballing workload text styles Click to edit Master • • “Multitasking”: Concurrent task demands and Second level prospective memory failures • Third level • Ambiguous situations without sufficient information to • determine best course of action Fourth level • • Procedural drift Fifth level • Situations requiring very rapid response • Organizational issues 3/18/2018 10

Major themes/patterns Plan Continuation Bias Click to edit Master title style • Tendency to continue original or habitual plan of action even when conditions change • Click to edit Master text styles • Not just “Get-there-itis” • Second level • • Third level Operates sub-consciously • • Fourth level back and Pilot fails to step re-assess situation • Fifth level and revise plan 3/18/2018 11

Plan continuation bias Example: Flight 1420 DFW to Little Rock Click to edit Master title style • 2240: Departed DFW over two hours late • 2254: Dispatch: Master text styles right but LIT Click to edit Thunderstorms left and • • clear; suggest expedite approach Second level Third level • • Crew concluded (from radar) cells were about 15 • miles fromlevel they had time to land Fourth LIT and Fifth level • • Typical airline practice to weave around cells -Hold or divert if necessary but usually land • Crews are expected to use best judgment with only general guidance 3/18/2018 12

Flight 1420 (continued) Plan continuation bias Click to(landing): Master title style edit Crew received series of wind • 2234 to 2350 reports – Wind edit Master varied, with worsening trend • Click to strength/direction text styles – Crew discussed whether legal to land (tactical issue), but not level • Secondwhether to continue the approach (strategic issue) • • 2339: 32: Controller reported wind shift: now 330/11 Third level • Fourth level • 2339: 45: Controller reported wind-shear alert: • Centerlevel 340 at 10; North boundary: 330 at 25; Fifth field Northwest boundary: 010 at 15 – Alert contained 9 separate chunks of information – Average human working memory limit is 7 chunks 3/18/2018 13

Flight 1420 (continued) Plan continuation bias Click to edit Master title style • Crew requested runway change from 22 L to 4 R for better alignment with new wind. --Flight vectored • Click to edit around for new visual approach to 4 R Master text styles • Vectoring turned aircraft radar antenna away from airport • Second level – Crew could not observe airport on radar for 7 minutes • Third level • Crew’s response to wind reports was to try to expedite • Fourth level visual approach to beat the storm • Fifth level • 2344: Crew lost visual contact and requested vectors for ILS 4 R – Vectors took aircraft deeper into storm – Crew requested tight approach, increasing time pressure 3/18/2018 14

Flight 1420 (continued) Plan continuation bias Click towas extremely busy, tired at the end of edit Master title style • By now crew long duty day, and in a difficult, stressful situation • Click to edit Master text styles • 2347: New weather report: RVR 3000; wind 350 at • Second level 30 G 45 - FO level • Third read back incorrectly as 030 at 45 (which would • Fourth level have been within crosswind limits) • Fifth level failed to catch - Controller incorrect readback (hearback often fails) 3/18/2018 15

Flight 1420 (continued) Plan continuation bias Click 10 to edit Master title style - Sixth of items on Before Landing checklist • 2347: 44: Captain: “Landing gear down” - FO lowers landing gear • Distracted, FO forgot to arm ground spoilers and other • Click to edit Master text styles remaining checklist items • Second level notice omission - Captain failed to • Crew waslevel busy for 2 & ½ minutes from lowering gear Third extremely • • to touchdown Fourth level • Fatigue: level 16 hours and on dark side of clock • Fifth Awake • Stress, normal response to threat, but: - Narrows attention, preempts working memory • Combination of overload, fatigue, and stress impairs crew performance drastically 3/18/2018 16

Flight 1420 (continued) Plan continuation bias Click to edit Master title style • Overloaded, captain forgot to call for final flaps but was reminded by FO • Lost sight of runway and reacquired just above DH; unstabilized • in alignment and sink rate text styles Click to edit Master - Company had not established explicit policy requiring go-around - Either landing or go-around would be in middle of thunderstorm • Second level • 2350: 20: level touched down right of centerline • Third Aircraft - Veered right and left up to 16 degrees before departing runway • Fourth level • Unarmed spoilers did not deploy • Fifth level • Captain used normal reverse thrust— 1. 6 EPR - Limited to 1. 3 EPR on wet runways to limit rudder blanking • 2350: 44: Crashed into structure at departure end of runway - Aircraft destroyed; 10 killed, many injured 3/18/2018 17

Flight 1420 (conclusion) Plan continuation bias Click to edit Master title style • Many factors and many striking features (much detail omitted) • Click to edit Masteras they happened, trying to text styles • Crew responded to events manage, but: • Second level - Never discussed abandoning the approach • Third level of plan continuation bias - Striking example • Fourth level • Experts in all domains are vulnerable to plan continuation bias • Fifth level • What causes this vulnerability? - Still under research; multiple factors probably contribute 3/18/2018 18

Plan Continuation Bias--Likely (Unconscious) Factors Click to edit Master title style • Habitual plan has always worked in past (e. g. , threading around storm cells) - MIT study: T-Storm penetration common on approach - Leads to inaccurate mental model of level of risk • Click to edit Master text styles Information often • • Second levelincomplete or ambiguous and arrives piecemeal - Difficult to integrate • Third level under high workload, time pressure, stress, or fatigue Many situations are • • Fourth level not clear-cut; rather, gradual deterioration Expectation bias • • Fifth level makes us less sensitive to subtle cues that situation has changed • Competing goals: Safety versus mission success, passenger satisfaction • Framing bias influences how we respond to choices 3/18/2018 19

Snowballing Workload Click to edit Master title style • • • Under high workload our cognitive resources are fully occupied with immediate demands Click to edit Master text styles No resources left over to ask critical questions Second to shed some tasks, individuals often become level Forced reactive rather than proactive Third level new event rather than thinking ahead strategically - React to each Fourth level As situation deteriorates, we experience stress: - Compounds situation by narrowing attention and pre-empting working Fifth level memory Catch-22: High workload makes it more difficult to manage workload - By default, continue original plan, further increasing workload - When we most need to be strategic we are least able to be strategic 3/18/2018 20

Prospective Memory Lapses Click to edit Master title style • PM: The cognitive processes involved in remembering (and sometimes forgetting) to do things we intend to do later • In 5 of 27 major U. S. airline accidents attributed to crew error, • inadvertentto edit Master text styles a central role: Click omission of procedural step played • Second level Third level • • GA pilots often report inadvertent omissions to ASRS • Fourth level • Insurance for GA retractable-gear 40% higher than fixed gear • • Fifth level experienced pilots, controllers, mechanics and Why would highly - Forgetting to set flaps/slats, to set hydraulic boost pumps to high, to turn on pitot heat before takeoff, to arm spoilers before landing other operators forget to perform simple, routine tasks? • Another NASA study: The Multitasking Myth: Handling Complexity in Real-World Operations 3/18/2018 21

Six Prototypical Situations for Forgetting Tasks Click to edit Master title style 1) Interruptions—forgetting to resume task after interruption over 2) Removal of normal cue to trigger habitual task, e. g. : - “Monitor my frequency, • Click to edit Landinggo to tower at styles Master text FAF” - Consequence: without clearance • 3)Secondtask performed out of normal sequence. e. g. : Habitual level - Deferring landing • Third level gear until later in the approach Habit capture—atypical action substituted for • 4)Fourth level standard instrument departure habitual action - Example: Modified • 5)Fifth leveltask that must be deferred Non-habitual - “Report passing through 10, 000 feet” 6) Attention switching among multiple concurrent tasks - Examples: Glitch in GPS data entry; cell phone use while driving 3/18/2018 22

Glass Cockpits Help in Some Ways But Not Others Click to edit Master title style • Enhance situation awareness & planning (e. g. nav displays) • Off-load workload once programmed, but: Increase workload if used • - Click to editclearance unwisely (e. g. , reprogramming Masterduring approach) text styles revised landing Increase level • - Secondmonitoring demands (humans are poor monitors) • Pilots are vulnerable to automation complacency • - Third level & logic are not transparent to pilot Automation actions • Fourth level • Pilot-automation interfaces are improving, but: - Programming & data entry impose substantial memory load • Fifth level • Currency & proficiency are critically important - Readily maintained by full-time pilots, not so easy for less frequent flyers 3/18/2018 23

Checklists Are a Major Defense (not a panacea) Click to edit Master title style • Vulnerable to same sorts of errors previously discussed • Click to checklist use by airline pilots • NASA study ofedit Master text styles - Two findings especially relevant to GA • Second level • Third level • Checklist items sometimes inadvertently skipped - When interrupted, distracted, or multitasking • • Fourth level “Looking without seeing” (item is mis-set) • Fifth level bias - Expectation - Running on automatic (visual gaze on item too brief) 3/18/2018 24

Carelessness? ? ? Click to edit Master title style • Research: Expert human operators in every domain are vulnerable to these types of errors • Click to edit Master text styles - (Even after eliminating Darwin award winners) • • • Second level Human brains Third level not wired to be completely reliable in these prototypical situations Fourth level - Cannot completely eliminate error Fifth news: We can reduce vulnerability through level Good countermeasures (threat & error management) - Ways to reduce number of errors - Ways to catch errors to prevent consequences 3/18/2018 25

Countermeasures Systematic Risk Assessment Click to edit Master title style • Must identify risks in order to manage them • • • - Create strategies in advance for addressing threats - Causes “priming” (faster retrieval from memory) Click to edit Master text styles Two types of risk: generic and specific to today’s flight Second level Go beyond standard flight planning: Third level - Identify our assumptions (e. g. , 15 kt headwind) - Ask “What if my assumptions are wrong? Fourth level to subtle cues in flight) (sensitizes us Fifth level continuation bias Counteract plan - “Is this panning out the way I planned? ” - “How will I know it may not work out? Will I know in time? ” - Identify bottom lines in advance (e. g. bingo fuel) - Have a back door 3/18/2018 26

Countermeasures Workload Management Click to edit Master title style • Be on guard for effects of snowballing workload - Recognize symptoms: rushing, anxiety, becoming reactive Click to edit Master text • • Proactively manage workload: styles - Buy time (e. g. , • Second levelholding, vectors) - Shed lower priority tasks - Use available • Third level resources (e. g. , autopilot, ATC, passengers) • • Do not allow yourself to rush Fourth levelfew seconds, increases errors enormously - Rushing saves • Fifth level • Force yourself to take time for strategic assessment • Recognize vulnerability to forgetting critical tasks - Always present, no matter how experienced in aircraft - Increases under workload, stress, interruptions, distractions 3/18/2018 27

Countermeasures Preventing Prospective Memory Lapses Click to edit Master title style • Identify where and when you will complete deferred tasks - Also interrupted tasks and tasks out of normal sequence Clickitto edit Master text styles - Say out loud - Ask person in right seat to help you remember • • Second level • • Pause to level when transitioning between flight phases Third review - For example: Before taking runway, at top of descent - Have level • Fourth. I forgotten anything? - What do I need to remember coming up? • Fifth level • Create reminder cues. Best if: - Visually distinctive, unusual and/or physically impede next action - For example, put suspended checklist in throttle quadrant 3/18/2018 28

Countermeasures Protect Checklist Performance Click to edit Master title style • Recognize vulnerability to skipping items, misperceiving items - No matter how experienced in aircraft • Click to edit Master text styles • Slow down, be deliberate • Second level • Point to or touch each item checked • Third level • Annunciate checklist responses out loud - Wait until after • Fourth level pointing to/touching item checked • Fifth level • Deliberate approach requires discipline - Goes against the natural grain of fast, fluid response - Substantially reduces errors 3/18/2018 29

Countermeasures Passenger Briefing Click to edit Master title style • My experience: Most vulnerable to error with passenger I have not flown with before: Click to edit Master me at stylesmoments - Passenger may interrupt text crucial - I divert my attention explaining operations • • Second level • • With good briefing passenger can be a useful resource Third level • • Start with standard briefing: Fourth level - Airplane features, emergency egress, event sequence, etc • Fifth level • Go beyond standard briefing: - Sterile cockpit, watch for traffic, manage charts, prospective memory aid, etc 3/18/2018 30

Countermeasures The BFR is Not Enough! Click to edit Master title style • Insurance companies often require more frequent recurrent training for advanced aircraft Click to edit Master text styles • • Must go beyond normal and emergency procedures Second level • • Need opportunity to practice judgment and decision-making in diverse challenging situations • Third level • Debriefing for lessons learned is essential - Instructors should • Fourth level facilitate pilot self-analysis (self debriefing) • Fifthcan debrief ourselves after every actual flight - We level • Thoughtful review of accident reports can help - What led the accident pilot into that trap? - How would I manage that situation? 3/18/2018 31

Countermeasures Practice Judgment & Decision-Making Click to edit Master title style • NTSB cites problematic judgment & decision-making in most GA accidents Click to edit Master text styles • • We must be prepared for a wide range of situations we hope never to encounter • Second level of co-pilot or dispatch - Without assistance Third level • • Military and airline pilots undergo frequent realistic simulator training for diverse challenging situations • Fourth level • GA pilots could benefit by using desktop simulation in a • similar way Fifth level - Need the elements of surprise and dynamically unfolding situations - Desktop IFR simulators could be enhanced • 3/18/2018 mental rehearsal alone is beneficial Even 32

A Pithy Summary Click to edit Master title style Chief of USMC Aviation Safety: • • • Click to edit Master text styles Fly Smart, Stay Half-Scared, and Always Have Second level a Way Out Third level Fourth level Fifth level 3/18/2018 33

More Information Click to edit Master title style • Click to edit Master text styles § Dismukes, Berman, & Loukopoulos (2007). The Limits of Expertise: • Second level Rethinking Pilot Error and the Causes of Airline Accidents (Ashgate Publishing) • Third level § Loukopoulos, Dismukes, & Barshi (2009). The Myth of Multitasking: Managing Complexity in Real-World Operations (Ashgate Publishing) • Fourth level § Berman, B. A. & Dismukes, R. K. (2006). Pressing the Approach: A NASA • Fifth level Study of 19 Recent Accidents Yields a New Perspective on Pilot Error. Aviation Safety World, 28 -33. § Can download papers from: http: //human-factors. arc. nasa. gov/ihs/flightcognition/ § This research was funded by the NASA Aviation Safety Program and the FAA 3/18/2018 34