Human Factors Focus

Transcrição

Human Factors Focus

IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 4° Simpósio de Segurança de Voo (SSV)
Agosto 2011
Katherine Andrea Lemos, Ph.D.
Instituto Técnico de Aeronáuticas
São José dos Campos, Brasil
1 §  Provide an overview of the multiple aspects of
human factors in aviation safety
v Expand beyond widely publicized, traditional concepts
v Tangible examples across the broad spectrum lifecycle
§  Encourage you to consider how human factors
affects aviation safety in your world
v Line operations or management
v Design, certification & continued operational safety (COS)
§  Encourage: Question and Test Assumptions
2 Human Factors: Beyond the Slogan
Prof. Katherine Andrea Lemos, Ph.D.
SSV 2011
© Lemos and Lemos Consul9ng 2011 All Rights Reserved 1 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  Seção 1: 1330 – 1415
v O Que É Fatores Humanos: Fatores Tradicionais
§  Seção 2: 1415 – 1500
v Dados de Segurança e Exemplo de Acidentes
§  Intervalo para Café 1500-1530
§  Seção 3: 1530 – 1615
v Responsabilidade Organizacional e Individual
§  Seção 4: 1615 – 1700
v Considerações de Projeto e Automação
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© Lemos and Lemos Consul9ng 2011 All Rights Reserved 2 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  Accident: Payne Stuart
v  October 25, 1999
v  Learjet Model 35
v  Aberdeen, South Dakota
v  Fatalities: 2 pilots; 4 pax
§  NTSB Probable Cause: “Incapacitation of the flight
crewmembers as a result of their failure to receive
supplemental oxygen following a loss of cabin
pressurization, for undetermined reasons.”
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© Lemos and Lemos Consul9ng 2011 All Rights Reserved 3 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  Human tolerance to Hypoxia is measured as:
v  Time from exposure to an oxygen deficient environment to the
inability to perform normal tasks or take appropriate action.
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© Lemos and Lemos Consul9ng 2011 All Rights Reserved 4 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  Known: Payne Stewart
v  Air shutoff/regulator valves were closed
v  Flow control valve was closed
v  Loss of bleed supply air to cabin
v  No cabin pressurization aural alert at last transmission
v  CVR 30 min only: Cabin pressurization aural alert
v  Hypoxia occurred within a 6 min 20 sec max window
§  Unknown:
v  Reason for closed flow control valve
v  Quantity and quality of oxygen
v  Reason crew did not receive supplemental oxygen
Human Factors: Beyond the Slogan
SSV 2011
9 §  Incident: Kalitta Flight 66
v June 26, 2008 en route Ypsilanti, MI
v Above FL260
v Incomplete loss of pressurization
v Captain hand-flying, declared an emergency
v Captain insists on original destination
v Fellow controller recognizes signs of hypoxia and
commands the aircraft to descend
v ~FL110 the pilot had recovered, and confirms that he
had been suffering from hypoxia
SSV 2011
© Lemos and Lemos Consul9ng 2011 All Rights Reserved 5 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  Accident: Helios 522
v August 14, 2005
v B737
v Grammatikos, Greece
v 121 Fatalities
§  Cabin Altitude Calculations
v 12,500’ Actual, Cabin 10,000’
v 16,650’ Actual, Cabin 13,500’
v 18,200’ Actual, Cabin 14,700’
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12 © Lemos and Lemos Consul9ng 2011 All Rights Reserved 6 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 “My mind clicks on and off... I try letting
one eyelid close at a time when I prop
the other open with my will. But the
effort's too much. Sleep is winning.
My whole body argues dully that
nothing, nothing life can attain is
quite so desirable as sleep.
My mind is losing resolution and
control.”
- Charles A. Lindbergh
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13 §  Fatigue: “State of diminished mental or physical
efficiency.”
Sleep loss Circadian Rhythms FaNgue Aﬀects of faNgue in aviaNon operaNons 14 Human Factors: Beyond the Slogan
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© Lemos and Lemos Consul9ng 2011 All Rights Reserved 7 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  2 hours sleep loss
v  Productivity decreases
by 17 percent
§  4 hours sleep loss
v  Productivity decreases
by 43 percent
-‐ Mark Rosekind, Ph.D. § 
After being awake for 18 hours, mental and physical performance on many
tasks can be like having a blood-alcohol content (BAC) of 0.05.
§ 
After being awake for 23 continuous hours, people perform as badly as
people who have a BAC of 0.12.
- Dawson and Reid, as reported in Reason’s “Managing Maintenance Error.”
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15 The level of error-‐provoking condiNons in maintenance workplaces. 16 -‐ Source: Alan Hobbs, September 2004 Human Factors: Beyond the Slogan
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© Lemos and Lemos Consul9ng 2011 All Rights Reserved 8 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) § 
28/08/11 Accident: American
International Airways
v  August 18, 1993
v  DC-8 freighter
v  Stall and loss of control on
final approach
v  Guantanamo Bay Naval Air
Station, Cuba
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© Lemos and Lemos Consul9ng 2011 All Rights Reserved 9 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 In the 48 hours prior to the accident: The Captain had slept 8 hours
Prior to the accident: The Captain had been awake 23.5 hours
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19 § 
Accident: FedEx 1478
v  July 26, 2002, Tallahassee, FL
v  Collision with trees on final
approach in B727
§ 
Fatigue contributed to
degraded performance for
Captain and FO
v  Long duty day (FO and FE)
v  Early report time (Captain)
v  Lack of adequate sleep (Captain)
v  Multiple takeoffs and landings (FO
and FE)
v  Circadian Disruption (FO)
SSV 2011
© Lemos and Lemos Consul9ng 2011 All Rights Reserved 10 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  Accident: Shuttle America
v Flight 6448
v February 18, 2007
v Cleveland, Ohio
v Runway Overrun in Snow Conditions
§  Contributing factors included captain’s
fatigue and company attendance policy
v Captain suffered from insomnia
v Awake 31 of 32 hours
v Did not “call in fatigued” due to fear of reprisal
SSV 2011
21 §  Featureless Terrain
v Juneau Ice Field: 5th largest ice field in North America
§  1500 square miles of ice, 100 miles long & 45 miles wide
§  Sept 10, 1999
- Clint Johnson, NTSB
v  3 helicopters lost - 1 day
v  1 serious injury
v  5 minor injuries
v  10 people stranded on ice
field overnight
v  4 million dollars in hull
losses
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© Lemos and Lemos Consul9ng 2011 All Rights Reserved 11 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  Pilot Statements
v Elected to cut across ice field instead of staying on
edges
v Light snow shower momentarily reduced his forward
visibility. Could still see mountains in front (about three
miles)
v Slowed helicopter to 70 knots
v No real sense of danger
v “I was sure that I was still about 500 feet above the ice”
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§  Passenger Statements
v Just enjoying the view
v Noticed that the helicopter was slowing down,
and thought they were going to make another
landing
v Thought the helicopter was about 300 feet
above the ice
v Took photo about 20 seconds before impact
SSV 2011
© Lemos and Lemos Consul9ng 2011 All Rights Reserved 12 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  Accident: Gulf Air 072
v August 23, 2000
v Night landing in A320 at Bahrain Intl Airport
v Occurred after 2nd go-around
v Lost outside visual cues 21 seconds prior to impact
v Pilot likely not attending to Primary Flight Display (PFD)
v Pilot pitched aircraft forward with controls
§  Attributed to somatogravic illusion
§  Fatal: 143
- NAMRL Perceptual Study
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- NAMRL
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© Lemos and Lemos Consul9ng 2011 All Rights Reserved 13 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 - NAMRL
SSV 2011
- NAMRL
SSV 2011
© Lemos and Lemos Consul9ng 2011 All Rights Reserved 14 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  Accident: Copterline
v August 10, 2005
v Tallin Bay, Estonia
v Sikorsky S-76C+ Helicopter
v Cumulus clouds – climbing to avoid
§  Extreme vertical acceleration
v 1.5 seconds from +1G to +2.9G
§  Investigation Determined
v Mechanical issue prompted event
§  Human Factors Focus: Ability of crew to recover
SSV 2011
29 § 
Loss of visibility
v  Cloud bases between ‘800 and ‘1400
v  Upset put them at 1600’
§ 
Extreme attitude changes
v  Vertical Acceleration (2.9Gs) although loss of speed
v  75 degree pitch up
v  70 degree left bank (90 deg change in heading)
§ 
Pilot control inputs/recovery attempt
v  Extreme right bank (rotation ~2.5sec/360 degrees)
v  Irregular pitch/roll
v  Pitch/roll stabilizing with continued vertical axis rotation
SSV 2011
© Lemos and Lemos Consul9ng 2011 All Rights Reserved 15 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 §  NAMRL Calculations: Unaware of right yaw
v  “The pilot was unaware of the high rotational velocity in part
due to the normal physiological decay of yaw
perception and did not correct for right yaw.”
Actual vs Perceived / Tau = 7 seconds
Actual Yaw Rate
Perceived Yaw Rate
50
degrees / second
0
-50
-100
-150
-200
9:41:50
9:42:00
9:42:10
9:42:20
9:42:30
time
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“The technology concerned to optimize the
relationships between people and their
activities by the systematic application of
the human sciences, integrated within
the framework of system engineering.”
- Elwyn Edwards in “Human Factors in Aviation” by Wiener and Nagel (1988)
SSV 2011
© Lemos and Lemos Consul9ng 2011 All Rights Reserved 16 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 § 
“Mistake made by a person.”
§ 
“An inappropriate or undesirable human decision or
behavior that reduces, or has the potential for reducing
effectiveness, safety, or system performance.”
§ 
“An action is taken that was ‘not intended by the actor;
not desired by a set of rules or an external observer; or
that led the task or system outside its acceptable limits’”
– Encarta
- Senders & Moray, 1991, as cited in Proctor & van Zandt, 1994.
SSV 2011
33 Human behavior/performance knowledge and principles Front Line Operator 34 Organiza9on & System Safety Design, Cer9ﬁca9on & COS Human Factors: Beyond the Slogan
SSV 2011
© Lemos and Lemos Consul9ng 2011 All Rights Reserved 17 IPEV SSV Simpósio Segurança de Voo Prof. Katherine Andrea Lemos, Ph.D. (ITA) 28/08/11 35 © Lemos and Lemos Consul9ng 2011 All Rights Reserved 18

Human Factors Focus

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