DRAFT

AVIATION HUMAN FACTORS

RISK MANAGEMENT GUIDE

Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect.”

Table of Contents

  • Background and Purpose
  • Information
  • Techniques and Procedures
  • Appendix A: Human Factors in Flight Safety”
  • Appendix B: Life Stresses”
  • Appendix C: Pilot Error and Marginal Aviator Seminar”
  • Appendix D: Human Error Model”
  • Appendix E: USMC Field Flight Performance Board”

Background

Human error continues to be a leading cause of aviation mishaps. A search for common factors in these mishaps reveals three major themes.

  • Individuals did not display the knowledge, skill, or air discipline necessary for the tasks assigned or forced on them by events.
  • Personnel were often under serious stress from personal and professional problems. These problems can result in fatigue, distraction, and deterioration of performance.
  • Supervisors made decisions that would have been different had they known all the information.

In almost every case, some of the individualdeficiencies or problems were known to various supervisors and peers, but only as isolated pieces of the whole picture that were not assembled until after the mishap. Unfortunately, sometimes it takes a tragedy to direct and motivate individuals to fully dedicate their efforts to prevent mishaps from reoccurring. When it is too late and the damage is done, a question that can often haunt us is: id we do everything possible to prevent this mishap and save his life?”

The human factors risk management process builds on the leadership principle of knowing your people.”

Purpose

The purpose of this guide is two fold. First to give members of squadron human factors councils and boards a detailed outline and set of procedures to manage the risks associated with human factors. Too often, council/board members begin their jobs with little guidance or experience, and must stumble through the process to gain skill in managing human factors risks.

Second, this guide will give all squadron members an appreciation for the human factors council/board. There is potential for speculation and myth among junior personnel about what the board is doing. Human factors management requires active and willing participation by all members of the command.

This is a guide only. There is no intent to prescribe specific procedures or to modify existing policy and regulations. Comments and recommendations are encouraged and should be sent directly to the HQMC Safety Division:

Commandant of the Marine Corps (SD)

Headquarters, U. S. Marine Corps

Washington, DC 20380-1775

Commercial phone: (703) 614-2423/1202/1077Commercial FAX: (703) 695-3231

DSN phone: 224-2423/1202/1077DSN FAX: 225-3231

Information

General. Human factors risk management is no different from any other risk management activity. It uses the same process of:

  • Hazard identification
  • Risk assessment to evaluate severity, probability and exposure
  • Risk control
  • Eliminate the hazard
  • Reduce exposure to the hazard
  • Reduce severity of the hazard
  • Risk acceptance and control implementation
  • Supervision and follow-up

It is very different, in that it deals with sensitive personal and professional matters. Additionally, it can be difficult to apply objective methods to human factors hazards and risks.

Categories. Human factors risk falls into three broad classes:

  • Aeromedical
  • Aeronautical adaptation. This is a psychological factor the flight surgeon evaluates during flight physicals, along with the physical factors of balance, hearing, sight, general fitness, etc.
  • Illness, disease, injury.
  • Physical factors. Fatigue, rest, physical activity, mental work load, environment factors.
  • Aviation physiology. Water/land survival, hypobaric exposure, ejection seat/egress training, G tolerance, visual illusions, task management, etc.
  • Personal/social. This area includes emotional stress, marital or family discord, financial problems, personality disorders, etc.
  • Performance. There are two categories of performance:
  • Flight. Ability to learn or complete a maneuver, discipline, skill progression, proficiency, currency, qualifications, aircrew coordination, headwork/judgment, planning, knowledge.
  • Ground. Timeliness and quality of work, interaction with superiors, subordinates and peers, leadership, basic military skills.

Command environment. In order for human factors risk management to work properly, a positive, open atmosphere needs to be established. This fosters an environment where aircrew can report on themselves without fear of retribution, and assurance that assistance is available. It also allows individuals to ”Keep an eye on each other” without degrading into ”battling” or spying. This assists the human factors council/board in identifying risks and taking corrective action.

Corrective action should be applied and explained as rapidly as possible. Very sensitive personal information must be safeguarded in order to promote confidence in the system. Additionally, human factors councils/boards must be careful about managing perceptions of individuals that are subject to board discussions and action. The council/board should maintain an atmosphere of constructive feedback and positive corrective action.

Human factors engineering. A major part of human factors management is dealing with the cognitive challenges that result from human - machine interaction. Although the squadron level council/board has little direct impact on cockpit/aircraft designs, they should periodically review these factors for impact on aircrew performance. Especially critical is differing aircraft configurations and the training aircrew receive to deal with changing aircraft models. The council/board can recommend engineering changes and formulate training to manage risk. The board should also be an active participant in the Systems Safety Working Group and Operational Advisory Group process. Communication through aviation hazard reports, NATOPS change recommendations and mission needs statements is essential.

Techniques and Procedures

General. Human factors risk management begins with leadership. As discussed above the command should have an open environment that promotes professional communication and teamwork.

Accountability and responsibility are the key components. The command must clearly identify expectations and standards, and demand adherence to those standards. In addition the command needs to disassociate punitive action for violations/infractions from corrective action for simple human mistakes, slips and lapses. Intentional violations of rules and regulations cannot be tolerated. Simple human error is difficult to eliminate entirely and cannot be eliminated merely by saying so…..?????

Finally, the command must ensure that safety privilege, as defined in the Naval Aviation Safety Program (OPNAVINST 3750.6_), is protected and maintained. Any association or inference of association of safety personnel--DSS, ASO, AMSO, Flight Surgeon, members of aircraft mishaps boards--with administrative/punitive action could seriously damage hazard identification efforts.

Organization. There many ways to organize the human factors effort. This guide is not intended to dictate exact procedures and policy. It is intended to provide a basic structure for commands to adapt to their particular needs. Each aircraft community and squadron has itparticular requirements and unique circumstances that must be accounted for. Additionally, command prerogative is acknowledged.

The Naval Aviation Safety Program (OPNAVINST 3750.6_) recommends the following structure for managing human factors issues.

Human Factors Review. Two human factors review processes should be available to squadrons; a proactive informal review of the performance, physical and psychological status, and attitudes and motivation of all officer and enlisted aircrew, to be conducted on a regular basis; and a formal review to be conducted when deemed necessary by the commanding officer. In the absence of wing, group or TYCOM guidance, squadrons shall establish their own human factors review processes as outlined below:

(1) Informal reviews will be conducted by a Human Factors Council (HFC) that includes, at a minimum, either the commanding or executive officer, the Aviation Safety Officer, the operations officer, the training officer, the NATOPS Officer, and the Flight Surgeon. The information generated is for the commanding officeruse only for the enhancement of safety. It shall be kept in confidence and shall not be used for disciplinary or administrative action. No official record or report is required, however, personal notes may be produced and retained by the commanding officer.

(2) Human Factors Boards (HFB) will conduct a formal review of any area of an aircrew memberperformance, training, health, attitude or motivation felt by the commanding officer to be relevant. The Human Factors Board should include, as a minimum, the Aviation Safety Officer, Flight Surgeon, and any additional officers of the commanding officerchoosing. The Human Factors Board should be proactive. It is to be convened early on, once a significant problem is discovered. Its goal is to identify the specific problem(s) and provide a course of action for resolution. A formal report with conclusions and recommendations should be produced and forwarded to the commanding officer for determination of final action.

Councils, Boards and Meetings. To summarize the above, the HFC always meets on a regular basis. The HFB is essentially an on-call meeting for a specific occurrence. For example, the HFB could be a signal of difficulty board, a progress review board, a special qualification board, or in the extreme case a board to consider FFPB action. There is nothing to stop a HFC from recommending and taking specific corrective action without first convening a HFB.

Human factors management meetings can range the spectrum from the operations officer and commanding discussing a pilot informally, to a formally convened FFPB.

Link to other committees/boards. One of the keys to success in managing aviation safety is open communication. It is helpful for the HFC/HFB to have input from the enlisted safety council, the aviation safety council and the standardization board.

One technique that is especially helpful is conducting human factors review during periodic standardization/qualification boards. As each aircrew is recommended for a qualification or workup for a qualification the board can review that individuals progress, attitude, motivation, etc. Any identified problems and deficiencies should be brought up at that time.

Reviews. The HFC/HFB should have at its disposal a summary of each aircrewqualifications, flight time, and other flight activity (frequency of flights, date last flown, landings, approaches, etc.).

One technique is to take one name at a time from the squadron roster and discuss the above information and discuss anecdotal information from recent flights and other daily activity. This includes an open discussion of the members present. Members of the council/board should possess the maturity to discuss themselves. If needed or desired the CO or XO can convene a subset of the council/board.

Another technique to discuss only those individuals who have been identified as having problems. This can be successful if the squadron enjoys an open atmosphere and effective communication of human factors hazards. Members of the council/board need to be careful of the possibility for not having all relevant information.

Corrective Action. Corrective action can take many forms and generally fall into the following spectrum from minor to more serious. These corrections can be implemented either singly or in combination.

In very serious cases, such as death of family member, divorce, birth, serious flight deviation, etc., the individual should be immediately grounded and evaluated for risk. In these cases the CO should make a decision to allow the individual to fly vice a decision to ground.

  • Surveillance. Continue to monitor for performance and behavior. Criteria for evaluation should be very specific. Any serious degradation of either should be immediately reported to members of the board.
  • Counseling. This can be done by the entire board, a few members of the board or by the CO. Counseling can run the spectrum from an interview to collaborative to directive.
  • Selective flight scheduling. The individual can be assigned to fly with selected personnel or can be scheduled to fly less demanding flights.
  • Tailored training program. Extra events in aircraft and/or simulator, resetting training to a more basic level to gain experience, return to FRS for additional training, change in instructors, additional academic study, etc.
  • Assistance with ground job/collateral duties. Reduction of duties or a change of jobs to reduce work load.
  • Leave. Time to deal with problems or distracters.
  • Grounding. Temporary removal from flight status to reduce pressure and allow time to deal with problems.
  • Referral for evaluation and professional counseling. This includes medical, psychological, or pastoral.
  • Referral to field flight performance board (FFPB).

FFPB. The FFPB is an administrative body to determine flight status of an individual aircrew. The purpose of the FFPB is to uphold established standards of flight performance, maturity and discipline and to prevent those aircrew-caused mishaps that can be anticipated through early identification of substandard performers. The ultimate purpose is to maintain a safe and effective aeronautical force. Appendix E contains specific information and procedures for the FFPB.

Appendix A

Human Factors in Flight Safety

This outline is based on pioneering work in flight crew personality and performance conducted by CAPT Roger Reinhardt, USN (Naval Aerospace Medical Institute) and Dr. Robert Alkov (Naval Safety Center). Their data was adapted for operational use by CAPT Frank Dully, USN and later LTCOL Joyce Teters, USAF. The current outline is tailored specifically for Naval Aviators.

THE PROBLEM: More than 70% of all Naval Aviation mishaps can, in part, be attributed to flightcrew-related problems - HUMAN FACTORS.

THREE CLASSES OF HUMAN FACTORS: Aeromedical, personal/social, and performance-related.

AEROMEDICAL

Problems: self-medication, flying when ill, fatigue.

Causes: competitiveness, desire to complete mission, denial, inadequate rest, disturbed or displaced biological (circadian) rhythms, excess physical activity, high mental workload, physical or emotional stress, and environmental factors (noise, motion, temperature, lighting)

Indicators: Disintegration of skilled performance leading to loss in overall management of complex tasks, overlooked peripheral activities, task fixation, breakdown in learned skills, communication/coordination breakdown, disrupted sense of timing, perceptual distortion, reaction and decision-making times slow, attention span decrease, irritability, confusion

Solution: Supervisors - ensure that squadron flight surgeon monitors flightcrew health. Flightcrews - if ill or fatigued, do not jeopardize mission, crew and aircraft. Report to flight surgeon - DO NOT FLY UNTIL RECOVERED!

PERSONAL/SOCIAL

Problems: emotional stress, marital/family discord, inability to cope, financial problems, personality disorders.

Causes: engagement, wedding, separation, divorce, long separations from family, lack of coping skills, false self-image, change in jobs, loss of crew/squadron member, death, family illness, inability to “Compartmentalize” problem.

Indicators: apathy, anxiety, irritability, mental fatigue, short-tempered, defensive, argumentative, acting-out, overly sensitive to criticism, withdrawn, sleep loss, preoccupied, projection of blame, changed eating habits, more prone to making perceptual, cognitive and response errors in flight, noticeable decrement in all-around performance, expresses negative attitudes, illness.

Solution: Supervisors - conduct periodic human factors review to identify individuals with problems, provide awareness through training, ensure that problems are dealt with quickly, efficiently, and effectively before allowing the individual to fly. Be concerned and show it! Promote a e thy brotherkeeper” attitude. Flightcrews - if a squadron member has a problem, offer your support, lend a shoulder, become involved. If you have a problem, do not deny or hide it, seek help without delay. DO NOT FLY!

NOTE: Some aeromedical specialists feel that compartmentalization of personal problems (that is, consciously suppressing them until they can be dealt with at a later time) is necessary for mission safety. They note that mishaps can occur when compartmentalization is less than optimal. Others feel that complete compartmentalization is not possible and (whether we admit it or not) will influence our performance. These specialists suggest temporarily removing the aviator from flight status prior to dealing with the problem. In this case, the individual should not be returned to flight status until the problem has been resolved. Supervisors - remember that total compartmentalization of problems may not be possible. Donrisk lives based on that assumption!

PERFORMANCE

Problems: degradation in flight performance, loss of aircraft control, inability to complete mission or maneuver.

Causes: medical or personal/social problems, exceeding limits of personal or aircraft capabilities, inadequate preparation for mission, lack of training or experience.

Indicators: poor headwork, errors of omission, channelized or lack of adequate attention, poor or inadequate aircrew coordination, degraded aircraft control, sloppy procedures, deviation from briefed flight, chronically behind the aircraft.

Solutions: Recognize personal limits and capabilities, minimize ambient distractions, avoid distractions, prioritize tasks, never assume anything, pre-plan for any and all problems, stay ahead of the aircraft, remain vigilant, be alert for errors whether made by yourself or others, donlet an error get by, maintain appropriate scan-do not fixate, accept nothing less than your best, avoid boredom and complacency, communicate effectively, maintain proficiency, know NATOPS procedures thoroughly.

Appendix B

Life Stressors

Specific life events create stress that if not managed properly will increase the probability of making errors. The following life events and associated stress have been contributing factors in many mishaps attributed to human error. Life stressors are cumulative and thus will carry greater value than other predictors. The following values can be assigned to the associated specific life events:

Life EventValue

Death of a spouse100

Divorce73

Marital separation/difficulties65

Death of a family member/close friend63

Personal injury or illness53

Marriage50