Thursday, September 1, 2005
We Know What - But Why?
Human factors is a key to understanding how skilled pilots slip into dangerous situations and finding ways to help them and their crews reverse course.
The Jetranger came in hot and low, 100 kt. at 10 ft. agl. Just before reaching the refueling point, the pilot pulled up the nose and put in hard left cyclic to turn the aircraft on the proverbial dime for a 180-deg. turn before landing to fuel up and go back out.
It was on a movie set in Utah and the pilot was highly experienced, but had never flown for the movies--and this was his chance to show the aerial director and producer that he was just as good at stunt flying as the professional movie pilots from Hollywood.
Unfortunately, he only had about 5 gal. of fuel left in the tank. At the steepest angle of bank, the engine sucked air, flamed out and sent the helicopter crashing into the ground. Technical cause of the accident--fuel starvation. Actual cause--death by stupidity.
Accidents tend to result from a chain of events, with the above weak links being technical aspects brought about by a human link in the chain.
According to Phil Croucher, a British aviation safety consultant, helicopter instructor, chief pilot for a British power line company and author of "Single-Pilot CRM," when it comes to accidents, "it's hard not to focus on the pilot, or other people--that is, the human factor--as the weak link in the chain." About 75-80 percent of helicopter accidents can be attributed to this, he said, "although it's also true that the situations some aircraft are put into make them liable to misfortune as a matter of course, particularly with helicopters."
Croucher noted that the need to study human factors has been recognized since '79 and '80, when a study of some 500 shipping incidents found 55 percent to be human factors-related. And that was in 1879 and '80. In the 1980s and `90s, in-depth analysis of aviation accidents (in all categories--airline and corporate, including helicopters) showed crew interaction to be a major contributing factor. In 75 percent of the accidents, it was the first time the pilots had flown together. In more than half, it was the first leg of a flight sequence in which there was pressure to stay on schedule. In 80 percent, the captain was flying (in an era when junior pilots were loath to question the captain).
Things haven't improved much. A U.S. study in 2000 showed 70 percent of accidents were pilot-related, "based on mistakes that could easily have been avoided," Croucher said. Now the worldwide figure is around 80 percent. "If air traffic continues to grow at the present rate, we will be losing one airliner per week by 2010, and even more GA aircraft." Australian authorities are looking a rate of one helicopter accident a week, he said.
In the United Kingdom, the Civil Aviation Authority requires instructors to be accredited to teach crew resource management (CRM) human factors for multi-crew operations, but not single-pilot, single-engine operations. It is now concentrating on single-pilot, single-engine training in human factors, with upcoming regulations that will require that instructors become accredited no later than early 2007, Croucher said. "Those who are doing single-pilot training now are doing it under grandfather rights."
The whole issue of human factors is being studied in Europe by the Joint Aviation Authorities Human Factors Steering Group, with committees addressing issues such a man-machine interface, initial training for licenses, multi-crew cooperation, cockpit resource management (CRM), flight operations and human factors training.
However, the steering group is made up of volunteers throughout the aviation industry who meet "about three times a year," according to Carey Edwards, a managing director for Surrey, England-based LMQ, a company specializing in pilot instructor training. Edwards chairs the human factors group for the Royal Aeronautical Society. As volunteers, the Steering Group is not doing a lot of work in the field of human factors, although "generally speaking, we tend to address issues on a broad base so that we can advise the JAA where we think they are going wrong." The group has put together a few advisory notices to people who do write legislation, "and we review what is coming out," Edwards said.
One of the biggest problems in Europe is that human factors "still has a bit of bad press," he said. "This is perhaps due to how it was introduced in the early days." When human-factors data and programs were unveiled, pilots were subjected to confusing psycho-babble that left many feeling these initiatives were "touchy-feely" stuff that had no place in the hierarchal, macho world of flying. "Human factors is all straightforward stuff, but we were being told it was not straightforward, it was all sort of magic, so even the most committed ones were saying that they were confused," Edwards said. "No one knew what was really going on, so it was kind of like pushing water up hill to get people motivated toward it."
In the United States, one of the major areas now under FAA study is human factors involved in single-pilot training for emergency medical service operations. While most EMS accidents involve single-pilot operations, the pilots are highly experienced with thousands of hours. So why are they crashing?
Dr. Albert Boquet, a research scientist with the FAA's Civil Aerospace Medical Institute in Oklahoma City, Okla., has been working on that problem for the past year and said the main thing involved in EMS accidents is weather. "There is nothing new about that, but that's where we're seeing accidents that are the most severe. When you look at degraded conditions, whether dark night or instrument conditions, then the frequency of fatalities goes up."
The biggest problem in finding out why experienced pilots are crashing in bad weather is simply getting a handle on their currency level, Boquet said. "When you look at someone with 5,000 hr., there is an assumption that they have some IFR experience." The question is whether they are in fact current in IFR flying skills. Boquet and his colleagues are suggesting to the FAA is that it require that pilots by current in IFR and that their aircraft be equipped for IFR. "It is not enough to just have an IFR pilot. You also have to have the equipment in the aircraft."
Along with making sure pilots are current in IFR operations, they also need to be trained in how to get the appropriate weather, he said. "We aren't sure what these guys are relying on for weather reporting." Local weather forecast are iffy at best. So pilots may be departing a hospital thinking they have a window in which to get to the site of an accident and back. "Then they get to the site and find that the back door has shut down on them and they're in trouble. That's something that we are looking at, but unfortunately, what can be done about it is another story."
The institute is also looking at night-vision goggle training, which is being touted as the great remedy. Boquet questions that. "From what we've found, we don't really see that as being a fix," he said. "There are an inordinate number of accidents at the pick-up site--striking fences, hitting trees, hitting electrical wires--those sorts of things are not going to show up on the NVGs. The NVG is certainly not going to help you in weather."
The institute also is looking at better basic training in rotorcraft operations for the emergency crews on the ground who have called the helicopter in, Boquet said. "These are the people who are going to be guiding them into a landing spot. One of the things we feel is important is that the ground personnel, whether it be sheriff's deputies, state troopers or ground ambulance personnel, be versed in exactly where the helicopters can land. Is the ground too soft? Does the helicopter have enough room to maneuver once it gets in? Will it be able to get out? That is something that can particularly help in preventing helicopter accidents at the accident site."
Boquet noted that from 1990 to 2003, there were 74 accidents identified in the EMS arena, of which nine were controlled flight into terrain, which includes flying into wires, trees, etc. Of those nine, eight involved fatalities, and seven occurred in poor lighting or weather conditions. "When you look at the dispersion of accidents, most of them tended to cluster around the patient pick-up site, either in approach, maneuvering once they were there or climb out."
The industry itself is also focusing on EMS, as well as airborne law enforcement, according to Terry Palmer, manager, rotorcraft special programs for FlightSafety International. She said her company is developing industry-specific programs for human factors training. "We're bringing in EMS crews and having team-type training in air medical resource management," she said. They will also be training based on a new FAA advisory circular on CRM that is expected out this summer or fall, if it has not already come out. Palmer said that the first draft of the AC was written by the late Dr. Michelle North, a noted human factors specialist who was on the HAI safety committee prior to her death last year ("People," September 2004, page 16). The draft AC has already been issued by the FAA. It proposes to establish minimum guidelines for air medical resource management training, and is focused on training "for all helicopter emergency medical service team members." It said the EMS resource management concept was conceived to enhance the safety culture within the air medical community by promoting team cohesiveness and adaptation during change through management of all available resources."
Palmer said that the FlightSafety International training will include a ground school on CRM and human factors specific either to EMS or law enforcement, followed by simulator sessions in which the pilots will be put into actual accident scenarios, "things that actually proved to be disastrous," to see how they respond.
The simulator sessions will be followed by after-action sessions focused on the decision-making process of the pilots during the simulator flight. The program will include pilots flying VFR inadvertently entering instrument meteorological conditions. The ground school will be aircraft specific, but the sims will be generic to ensure that even pilots flying Eurocopter aircraft can get the training.
In developing the new industry specific programs, FlightSafety International will be depending heavily on the businesses and operators "to come to FlightSafety and tell us what they want, what they feel is important," Palmer said. The company is working with Baptist Hospital in Miami and Children's Hospital in Dallas to develop the EMS program. For the law enforcement training, it is turning to the Fort Worth, Texas Police Dept.
In Europe, while there is not a lot of government-sponsored activity on human factors training, operators are "doing extremely good stuff in terms of CRM and human factors training," Edwards said. He said Bristow Helicopters was doing human factors training eight years before they were required to, "particularly in terms of instructor accreditation." It was one of the first operators to start the training, "so they are well ahead of the game and continually looking ahead to ensure that their training is at a continuous high standard." A lot of single-pilot operators are also doing such training "because they realize that it is just as applicable to them as it is to a multi-crew operator," he said.
Decision-making is a key element in the human factors issue, and a key element in decision-making is stress. This is one of the major areas that pilots need to be trained to deal with, particularly in single-pilot operations, Croucher said. "Modern life is very complex. You need the entire body to be working properly in order to make the proper decision. If you're in a continual state of flight, you're all tensed up and all the blood drains from your brain. You have to learn to be calm, to learn relaxation techniques."
For an EMS pilot, the decision on whether to launch in marginal conditions, risking the lives of himself and his crew, or not launch and risk the life of an accident victim, can put additional stress into the equation, impacting on other decisions to be made during the flight.
In other types of helicopter operations, the stress point can be between the authorities and management and/or the customer. "The authorities say, `You're the boss. You're in the cockpit. Fly safe'. The next thing that happens is that the customer or management says you have to fly. When the customer is waiting, safety goes out the window," Croucher said. "So the pilot has a stress point right there--two sets of equally powerful people telling him to do to totally opposite things. He said this is the single most important point a pilot must learn. Young pilots "don't know how to stand up to bullying management, or how to defuse an angry situation." In Canada and the United States, where the customer is always right, pilots are in even a stickier position "because you get no support from the company when the customer threatens to take his business elsewhere." In the U.K., he said customers who pushed a pilot around like that "would be shown the door over here."
"What is the difference between a pilot and a captain, when it takes longer to become a captain than it does to become a pilot? When you have learned to say `no', then you have become a captain," Croucher said.