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Could This Happen to You? 1. Yes 2. Maybe 3. No

Definition of Error Chain A series of individual mistakes, any one of which, when considered individually, would not be serious enough to cause an accident; however, when considered together, form the links of a chain of mistakes leading to an accident.

Identifying An Error Chain 11 CLUES 6 OPERATIONAL 5 HUMAN

THE PRESENCE OF JUST ONE INDICATES

Identifying an Error Chain Pilot must maintain control through proper management of actions once links are recognized. The question asked by FAA researchers: If the pilot had been trained to recognize links in the error chain and had been proficient in doing so, were links present which, if found, might have caused a different response and outcome?

In Researching a Number of Accident of Different Types, were Identified in Each Accident FEWEST: 4 AVERAGE: 7

Clues to Identifying Errors Operational Errors Failure to Meet Targets

Failure to Meet Targets Plans Takeoff time Number of passengers or weight of bags Procedures Weather briefing Good preflight Other goals established by/for the pilot SOPs

Clues to Identifying Errors Operational Errors Failure to Meet Targets Use of an Undocumented Procedure

Use of an Undocumented Procedure Use of procedure to deal with emergency or abnormal conditions which is not prescribed in approved manuals or checklists Making it up as you go Results from lack of training Have resources been used to their fullest potential Training facilities Wings program

Clues to Identifying Errors Operational Errors Failure to Meet Targets Use of an Undocumented Procedure Departure from Std. Operating Procedures

Departing from Standard Operating Procedure Intent to depart or inadvertent departure from prescribed SOP Intentional or Inadvertent SOP: Synergistic approach to problem solving with influence of time removed Results in effective means of problem solving without sacrificing time Memory items on an emergency checklist

Clues to Identifying Errors Operational Errors Failure to Meet Targets Use of an Undocumented Procedure Departure from Std. Operating Procedures Violating Minimums or Limitations

Violating Minimums or Limitations Violation of defined minimums or specifications As prescribed by regulations or more restrictive flight operations manuals or directives Includes: weather conditions, operating limitations, rest limitations, system limitations FARs, ADs Instrument approach procedures, ATC clearances Either intentional or unintentional Alcohol

Clues to Identifying Errors Operational Errors Failure to Meet Targets Use of an Undocumented Procedure Departure from Std. Operating Procedures Violating Minimums or Limitations No One Flying the Aircraft

No One Flying the Aircraft Current state of progress of the flight not being monitored Highest priority is staying ahead of the aircraft GPS and glass cockpit displays Situational awareness If not attended to, other important tasks are being overlooked In an emergency, Fly the Aircraft!!!!!!!!

No One Looking out of the Aircraft Easy to be tempted to keep one s head in the cockpit: Focus on electronics Failure to scan Midair collision risk Risk of Spatial Disorientation

Clues to Identifying Errors Human Errors Incomplete Communications

Incomplete Communications Withheld information, ideas, opinions, suggestions, questions Single or two crew operations (CRM) ATC Line crew / CSR Failure to seek resolution of misunderstanding, confusion, disagreement Proper crew or passenger briefing ATC instructions Fueling instructions

Clues to Identifying Errors Human Errors Incomplete Communications Ambiguity

Ambiguity Two or more independent sources of information do not agree Instruments, gauges People Manuals Senses (Vertigo) Controls that do not correspond with associated indicators or control feel Attitude or heading indicators Engine instrument

Clues to Identifying Errors Human Errors Incomplete Communications Ambiguity Unresolved Discrepancies

Unresolved Discrepancies Failure to resolve conflict of: Opinion Between crewmembers Information Between the pilot and ATC Changes in condition Weather Day / Night Mechanical discrepancies MMEL

Clues to Identifying Errors Human Errors Incomplete Communications Ambiguity Unresolved Discrepancies Preoccupation or Distraction

Preoccupation or Distraction Focus attention on any one item Abnormal and emergency conditions Distractions to draw attention away from flight progress Passenger interaction Terrain or weather High workload: demands of flight Single pilot operations Inclement weather

Preoccupation or Distraction Can also be the result of Personal problems Inattention or attention span Complacency Fatigue

Clues to Identifying Errors Human Errors Incomplete Communications Ambiguity Unresolved Discrepancies Preoccupation or Distraction Confusion or Empty Feeling

Confusion or Empty Feeling Sense of uncertainty, anxiety, or bafflement about a particular situation Lack of knowledge or experience Pushed to the limit of one s ability Throbbing temple, headache, stomach discomfort, nervous habit Signals symptomatic of uneasiness and should be trusted as indicators that all may not be right

Failure to Meet Targets Use of an Undocumented Procedure Departure from Std. Operating Procedures Violating Minimums or Limitations No One Flying the Aircraft Incomplete Communications No One Looking out of the Aircraft Ambiguity Unresolved Discrepancies Preoccupation or Distraction Confusion or Empty Feeling

Additional Factors Complacency Health Training 11 Clues Peer Pressure Experience Attitude

ATTITUDE Anti-Authority Impulsivity Invulnerability Macho Resignation

ATTITUDE Anti-Authority Impulsivity Invulnerability Macho Resignation Don t Tell Me!

ATTITUDE Anti-Authority Impulsivity Invulnerability Macho Resignation Don t Tell Me! Do Something Quickly!

ATTITUDE Anti-Authority Impulsivity Invulnerability Macho Resignation Don t Tell Me! Do Something Quickly! It Won t Happen To Me!

ATTITUDE Anti-Authority Impulsivity Invulnerability Macho Resignation Don t Tell Me! Do Something Quickly! It Won t Happen To Me! I Can Do It!

ATTITUDE Anti-Authority Impulsivity Invulnerability Macho Resignation Don t Tell Me! Do Something Quickly! It Won t Happen To Me! I Can Do It! What s The Use!

ATTITUDE Anti-Authority Impulsivity Invulnerability Macho Resignation Don t Tell Me! Do Something Quickly! It Won t Happen To Me! I Can Do It! What s The Use! Follow The Rules!

ATTITUDE Anti-Authority Impulsivity Invulnerability Macho Resignation Don t Tell Me! Do Something Quickly! It Won t Happen To Me! I Can Do It! What s The Use! Follow The Rules! Not So Fast- Think First!

Violation Producing Conditions (VPCs)

Violation Producing Conditions (VPCs) Mission Expectations The perception that the rules must be bent to get the job done. Ego & Power The belief that the violator has the skill and stature to do the job better outside the boundaries. Unlikely Detection The perception that the violation is unlikely to be detected by anyone in authority.

Violation Producing Conditions Poor Planning (VPCs) Lack of adequate planning time or depth resulting in free styling during execution. Leadership Gap Leaders or role models who personally practice or condone procedural noncompliance Unique Event An out of the ordinary situation such as an airshow or special mission

Types of Non-Compliance

Types of Non-Compliance Routine Frequent, known and officially condoned by leadership Situational Just this once due to unforeseen or unplanned for situations Optimizing Workarounds, streamlining, do things better outside the boundaries Rogue Violations Busts rules because I can - ego driven, progressive deviations

Normalization of Deviance (Rationalization)

Normalization of Deviance (Rationalization) Phase One An unexpected event occurs outside the allowable prescribed limits without negative consequences. Phase Two Since nothing bad happened, no action is taken to prevented reoccurrence and the previous limits are informally ignored

Normalization of Deviance Phase Three The deviation continues to occur without consequences, becoming not only expected, but accepted practice. At this point the margin of safety provided by the original prescribed limit is effectively gone. Phase Four Fatal mishap occurs outside the prescribed limits, current management is held accountable for their poor leadership and defends itself by saying it s never happened before and everybody does it.

N.O.D. and Risk Acceptance Each new plateau, when first attained, seems to be the last; but, as we grow accustomed to it, a new horizon beckons. What insulates us from fear as we approach the danger is simply habit, the familiarity of a point we have reached and all the points we ve left behind. Until one steps too far, it s often hard to tell the difference between recklessness and skill.

How to Be a Safe Pilot Existing rules would go a long way to remedy the accident rate. Exhibiting one or more of the five hazardous attitudes or irrational behavior also exposes emotional weaknesses in personality. A pilot should be an emotionally stable person.

How to Be a Safe Pilot An experienced, mature pilot will accept and follow the rules and procedures which will benefit the aviation community. Some pilots break rules simply for the gratification of some emotional need.

Review of Error Chains OPERATIONAL FACTORS 1. Failure to meet targets 2. Undocumented procedure 3. Departure from SOP 4. Violating minimums or limitations 5. No one flying the aircraft 6. No one looking out of the aircraft HUMAN FACTORS 7. Communications 8. Ambiguity 9. Unresolved discrepancies 10. Preoccupation or distraction 11. Confusion or empty feeling ADDITIONAL FACTORS Complacency Training Experience Health Peer pressure 5 HAZARDOUS ATTITUDES Anti-Authority: Don t tell me Impulsivity: Do something quickly Invulnerability: Won t happen to me Macho: I can do it Resignation: What s the use

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