Sunday, March 1, 2009
Human Factors: The Evolution of Human Factors
Human factors is the science of understanding the relationships of people, machines and technology. It recognizes the possibility of human error, and allows us the opportunity to identify this threat and resolve it before it becomes an incident or an accident.
I recall my first cockpit resource management (CRM) course as a HH65A U.S. Coast Guard Dolphin pilot during the 1980s. The airlines had discovered CRM played a significant part in most accidents and incidents. It was evident the airlines were not alone as CRM plays a major role in accidents and incidents in helicopters. Not knowing what to expect, some of the seasoned pilots surmised it would probably consist of a "bunch of touchy-feely nonsense".
My first brush with human factors and their affect on accidents occurred during a college course in the late 1970s. I was assigned an NTSB accident report of a Boeing 727 that crashed due to the crew missing a checklist item and not activating the pitot heat prior to takeoff. Of course, back then it was simply categorized as "pilot error". Many accidents and incidents can be prevented and are attributed to a series or "chain of events" attributable to human factors. A simple break in the chain can prevent the threat from developing into a series of events that jeopardizes the safe outcome of the flight.
It doesn’t matter whether you are flying solo or with 16 crew members, 300 passengers, a lone CEO or Seal Team Six. Your aircraft might weigh 3,200 pounds or 650,000. Your piloting career might span three decades or three months. The threats we face as pilots do not discriminate, forgive or reward based on such criteria. What does matter is the professionalism we bring to the cockpit as pilots.
Even when flying solo, there are other members of the crew and resources available to us such as the dispatcher, another pilot on the frequency, flight watch, or even a phone relay from a ground station. How we cultivate and use these resources are as important as recognizing their potential. It is important for each member of the crew, beginning with the captain, to set the tone for open and effective communication. Our ability to accurately combine a fusion of judgment, experience, and resources into a plan, while effectively communicating our plan is important. Equally important is to continuously monitor and assess your situation, making changes to your plan and communicating those changes to the rest of your crew. Always leave yourself a way out and don’t hesitate to abandon a plan that is no longer viable. Viability is as subjective as flying itself, but a good benchmark for success it to ask yourself, "Was the safe outcome of the flight ever in question?" As you continually accesses and evaluate your plan, identify potential new and existing threats. Articulate them to your crew.
Did you misunderstand a clearance? Incorrectly sequenced a waypoint? Forget to set a switch to its correct position? Miss a step on a checklist? Did you notice, but were hesitant to speak up? Often, someone in the crew identifies a threat, but may feel uncomfortable mentioning it for a variety of reasons. It is not about who’s right, it is about what’s right.
What about self-imposed stresses? Pilots tend to be task-oriented individuals, eager to accomplish the task at hand safely, professionally and efficiently. Yet who among us has not ever felt rushed? Pressured to make an ETA or get ahead of the weather? How did you handle it? What about get home-itis? Are you adequately rested? Are you sick? Sometimes you really have to think about the Superman syndrome. Sometimes we become the threat and don’t realize it.
Technology plays an increasing role in our cockpits and all other aspects of how we fly and communicate inside and outside the aircraft. The avionics suite has become another and often overlooked member of the flight crew. Studies have demonstrated that increased automation, designed to reduce workload and fatigue can actually have the opposite effect during certain phases of flight. Avoid allowing the task of working the FMS, aka "the box," overshadow basic pilotage. Many new pilots of FMS-equipped aircraft recognize the phrase "Hey why is it doing that!?" More experienced pilots of FMS-equipped aircraft are more likely to say "Hey, it’s doing that again!?" A great rule of thumb is to match the appropriate level of automation for the current conditions and phase of flight. Have you ever found yourself in a situation where both pilots were heads down at the same time? So who was flying the aircraft, and which pilot was monitoring? Pilots are task oriented, get it done types! So if one pilot is having a problem with the box, let’s get in there too! Hey, two heads are better than one! Ah, the temptation.
For pilots with aircraft equipped with autopilots, you are no stranger to the antics of "George." I recall one of my friends in the Coast Guard explaining that when it came to the potential of an over torque "George is a bit of a cowboy with the collective." I also thought he could be a little heavy handed with the auto-throttles on the Super 80. This George guy gets around! But most of the time, George does a pretty good job. As part of the team, it is a good practice to not only keep an eye on George, but also annunciate to the other pilot when you activate or deactivate George. Equally as important is to articulate to the monitoring pilot when you change from one mode to another such as HDG to LNAV.
But too much of a good thing can create compliancy. An over dependence on technology can result in a loss of situational awareness. When the technology works really well, a tendency might exist to become reliant and almost insidiously, let your guard down to the point where you can get hurt.
At the beginning of my flying career as a U.S. Army aviator, there was an adage about the pilot who wasn’t flying monitoring the standby load meter. While much of the emphasis has been towards the role of the captain, setting the tone, fostering open communication and communicating the plan, the role of the pilot monitoring should not be discounted. The role of the pilot monitoring is equally as demanding if not more challenging than the flying pilot. For this reason, the airlines developed the monitored approach concept. This method not only employs the use of standardized callouts, but also establishes the first officer (or co-pilot) as the pilot flying the approach, and the captain as the pilot who lands. This way the pilot can monitor the performance of the first officer flying the approach and make the decision to land. If the captain doesn’t take control of the aircraft at minimums, the first officer executes a go-around. Automatically. Everyone is familiar with their role and responsibility prior to beginning the approach and the aircraft is under positive control at all times. Remember flying your last approach to minimums, while also going heads up to see if you were going to breakout and land? Wasn’t much fun was it! Did that effectively utilize the capability of your crew? How about the available technology? Could you have organized your resources ahead of time to provide the maximum benefit and level of safety?
Using the concept of a flying pilot and a pilot monitoring has proven to reduce workload, increase situational awareness and reduce operational errors. Establishing an open line of communication between each other and the automation, articulating your intentions and communicating your plan will allow everyone to understand and contribute towards the safe outcome of the flight.
The human factors science helps us better understand the relationship of pilots, aircraft and technology. It also aids us in better understanding our role, threats and solutions while working with technology and each other.