THE HUMAN FACTORS ANALYSIS FOR SAFETY

Contributed by Wing Commander Srinivas Bhamidipati

 

Skill Based Errors

 

Have you seen any incident happening which occurred due to an inadvertent activation or deactivation of control switches of an equipment and then action remained notices or unnoticed.

 

Do you have a checklist made in the ATC that is followed everyday ? How exhaustive is it ? Are there any areas left out in the checklist.

 

Area there any procedures or sequence of actions that you have observed which are in wrong sequence ?.  Such as any emergency recovery procedure etc.

 

Are there any occurrences of failure of coordination which resulted in inappropriate responses leading to over controlling or under controlling .

 

Are there any factors in the ATC which contribute to breakdown of visual scan in your day to day routine ? Has there been any unsafe situation owing to this cause.

 

Decision Based Errors

 

How you noticed any new procedure being implemented without proper evaluation, which could lead to inappropriate decision and subsequent unsafe situation? i.e. formal risk-assessment procedures are not possible. 

 

Have you  ever rushed through necessary actions as  dictated by the situation and  performed   actions too quickly and  the rush in taking  action lead to an unsafe situation.

 

Have you  ever delayed through necessary actions as  dictated by the situation and  performed   actions delayed  leading  to an unsafe situation.

 

Have ever ignored a caution/warning because the caution or warning was not clear from the pilot’s RT call ?  

  

Violations

 

What  aspects it the ATC do  you consider that are prone to lead into violations in controlling The unsafe acts committed by aircrew generally take on two forms, errors and

violations. 

 

Could identify  errors/violations by aircrew which could be related to an unauthorized approach, non-adhere to departure procedures,  Failed to comply with SOP  etc

 

Violations are deliberate, so how frequently do you see willful disregard for rules and instructions (Whether aircrew or ATC)   and lead to an unsafe situation. 

 

Risk of violating published procedures was recognized, consciously assessed and honestly determined by  the individual, crew or team to be the best course of action.  Routine “work-arounds” and

 

Are there any unofficial procedures that are accepted by the aviation community as necessary for operations are  also captured under this code. 

 

Do any violations in your airbase by a single individual or small group of individuals within a  unit , have leadership sanction? Do any habitual violations get overlooked not resulting in

disciplinary/administrative action

 

Are there violations that are  isolated to specific individuals rather than larger groups

 

PART II – Preconditions to unsafe acts

 

Physical Environment

 

How is the work environment for people working around you such as runway controllers, airmen on look out , airmen on watch, people in the crash crew etc. Some highlights may be brought out.

 

Do you find the working environment comfortable vis-à-vis facilities in the ATC/Radar cabin i.e. cooling, good headsets, radios,    

 

Is your vision in the ATC restricted by windows, sunlight Etc to a point where normal duties are affected.

 

Does the glass of the ATC vibrate with intensity during a take off or landing to the extent of causing  distraction in your normal duties.  

 

When analyzing  the work scenario of the CFFR team what stresses are they subject to i.e.   Cold , Heat  , poor lighting , location of the CFT vehicle and noise interference etc .

 

Are there seating constraints  in terms of   design of the seat which may  create an

unsafe situation.

 

 

Technical Factors

 

Are there factors in the ATC or CFFR Bay where tower design factors or  vehicle design factors or lack of automation affect the actions of individuals , which may result in human error or an unsafe situation.

 

Do you have problems with the instrumentation or gadgetry available in the ATC or GCA in terms of  design, reliability, lighting  and  location  are inadequate and create an unsafe situation. These would be factors which would limit  situational awareness or warning about such systems . i.e. Workspace Incompatible with Human working

 

Is the visibility restricted from the ATC due to it’s location vis-à-vis approach area and  movement areas  and create an unsafe situation.   

 

Is the condition of the communications equipment  a factor which is  inadequate or  at times  

unavailable to support  ATC demands.

 

Do you have adequate facilities to receive and transmit flight plans and mission details .

 

Cognitive Factors

 

Are factors in a mishap if cognitive or attention management conditions affect the perception or  performance of individuals and result in human error or an unsafe situation.

 

Is inattention or the exclusion of comprehensive  situational information or Cognitive Task Over-saturation  seen in your ATC ?

 

Have you observed confusion and/or Distraction as leading to an individual being unable to maintain a cohesive and orderly  awareness of events and required actions  and experiences a state characterized by bewilderment, lack of clear thinking, or (sometimes) perceptual disorientation.  What lead to the confusion i.e. unnecessary telephone calls etc

 

Are there any factors in your checklist that are misplaced and results in the

interruption and subsequent failure to complete the original task or results in skipping

steps in the original task.

 

Have you ever gone through attention breakdowns? memory failures often appear as omitted items  in a checklist, place losing, or forgotten intentions . Reasons causing for frustration during day to day working

 

Psycho-Behavioral Factors

 

In the aviation environment prevalent around you  are there factors which indicate that an  individual’s personality traits, psychosocial problems, psychological disorders or inappropriate motivation may create an unsafe situation.

 

Are there any players in aviation you have come across who are  under the influence of a strong positive or negative emotion and that emotion interferes with duties  i.e. emotionally unstable.

 

Are there any personalities who tend to be overconfident  about their sphere of work and have in the past  created an unsafe situation.

 

Are there aviation players who are known to intentionally commits to a course of action that results the air situation to  become unsafe. i.e. such as pressing to descend /climb , cut across others circuits without clearances etc.

 

Do you work with players who have inadequate Motivation  or  Misplaced Motivation ?

 

Do you work with overaggressive individuals or crew or with individuals with excessive motivation to Succeed .i.e. when the individual is preoccupied with success to the exclusion of other task factors leading to an unsafe situation.

 

 Are there individuals who suffer with Get-Home-Itis/Get-There-Itis  in your operating scenario who would like to complete a mission or reach a destination for personal reasons, thereby short cutting necessary procedures or exercising poor judgment, leading to an unsafe situation.

 

Is excessive work leading to a motivational exhaustion/Burnout .  i.e. effects of high operations  for a longer time period than a safe limit affecting ops capability.

 

Have you done  actions or inactions where the heart is in the right place, but you did not have the appropriate knowledge available or just simply chose poorly.  

 

Adverse Physiological State

 

Have you used prescribed Drugs which have had  a measurable effect interfering with ATC performance.

 

How frequently are you subject to overexertion leading to degrading task performance  ? Do you attribute the cause to shortage of qualified air traffic controllers ?

 

If you answer to the above is “Yes” , then are you also handling secondary duties that require a lot of your time outside ATC shifts..  

 

As an individual is Circadian Rhythm Desynchrony  is begun to affect your health conditions . i.e. when the individual’s normal, 24-hour rhythmic biological cycle (circadian rhythm) is disturbed and it degrades task performance. ( Can be caused due to night work or irregular shifts that are long and do not give any rest times.

 

 

Is there physical task over-saturation ? If yes at an average how many hours do you work every week?

 

When you are fatigued and require to take a break do you get someone to relieve you during the duty. 

 

Do you exercise regularly and get to eat well in the right meal timings ? How rigorous is the environment  to degrade performance because of reasons such as traditional “delays in meals

 

Physical/Mental Limitations  

 

Do  you come across individuals in the environment who  temporarily or permanently lacks the physical or mental capabilities to cope with air situations and who because of this  insufficiency may cause an unsafe situation. 

 

Technical/Procedural Knowledge

 

Do  you come across individuals in the environment who  display Lack of knowledge and/or deficiency in the training , which may cause an unsafe situation.  (Exposure to information at a point in the past does not imply "knowledge" of it.)

 

Perceptual factors

 

Have you seen misperception of Operational Conditions .i.e. when an individual misperceives or misjudges altitude, separation, speed, closure rate, road/sea conditions, aircraft/vehicle location within the performance envelope or other operational conditions and this leads to an unsafe situation. 

 

Personnel Factors

 

Do any/all  of following factors exist in the aviation scenario around you which indicate towards:

 

1. Poor team resource management affecting ATC/Aircrew practices , conditions or actions of individuals which result in human    error or an unsafe situation.  

2. Poor coordination , Communication and/or Planning Factors which affects  

3. preparation and execution of a mission and may result in human error or an unsafe situation.

4. Crew/Team Leadership factor that fails to facilitate a proper working climate. This  includes establishing and maintaining an accurate and  shared understanding of the mission and actions on the part of all crew  and other  players such as ATC/AD units . 

5. Steep Rank/position authority gradient causing performance to be degraded. i.e. A senior aircrew trying to oppress a junior   ATCO by forcing clearances .  This could also relate to assertiveness when individuals failed to state critical information .

6. Failure on part of the aircrew to state Critical Information  in an accurate or timely manner.

7. Failure on part of  individuals to use standard RT .  

8. Failure on part of individuals to complete all preparatory tasks associated with planning the mission, resulting in an unsafe situation. 

9. Miscommunication resulting out of misunderstood, misinterpreted, or disregarded  communication. 

Do you  carry out regular rigorous exercise program or a physically active lifestyle to adequately support your stressful job demands.

 

Do you drink ? What is your drinking pattern over the week ? 

 

Do you take Drugs , Supplements  or Self medicate  that could interfere with your job performance. This includes nicotine or caffeine in sufficient quantities to cause impairment  of normal function. This also includes any  chemical compound taken for purposes of prevention of disease, treatment of disease, weight management, mood alteration, birth control or sleep management, etc.  

 

Does your shifts let maintain a  state of good dietary practices or are they

inadequate to fuel the brain and body functions resulting in degraded performance

 

Is there adequate Rest factored between your two shifts , also taking into account your secondary duties. 

 

Is aircrew briefing a forum to brief for the flying or does it also result in some aircrew getting into a “Q & A” session  as overconfidence, arrogance, and other pernicious  attitudes will influence the likelihood that a ATS violation is committed

 

 

PART III – Unsafe Supervision

 

Are there occasions when the ATC functions without adequate Supervision and hence leading to creating a risk without  any oversight resulting in possible human error or an unsafe situation.

 

Does the ATC Leadership or appropriate ATS authority step in when oversight  is inadequate or when the availability, competency, quality or timeliness of leadership, supervision or oversight does not meet task demands and creates an unsafe situation. Inappropriate supervisory pressures are also captured under this code. 

 

Are you aware of  “supervision – modeling”  when an  individual’s learning  is influenced by the behavior of peers and supervisors and when that learning manifests itself in actions that are either inappropriate to the individual’s skill level or violate standard procedures and lead to an unsafe situation.

 

Describe Local Training Issues/Programs which are considered inadequate

or unavailable (etc) which can create an unsafe situation. (The failure of an individual

to absorb the training material in an adequate training program does not indicate a

training program problem).  

 

 Is there a supervision – personality conflict is a factor when a supervisor and individual member experience a "personality conflict" that leads to a dangerous error in judgment / action.

 

Planned Inappropriate Operations

 

Is a factor in a mishap when supervision fails to adequately assess the hazards associated

with an operation and allows for unnecessary risk.  It is also a factor when supervision

allows non-proficient or inexperienced personnel to attempt missions beyond their

capability or when crew or flight makeup is inappropriate for the task or mission. 

 

Is a limited experience controller ever told handle air situation which may actually be beyond Capability and however is doing so because supervisor / leadership has directed personnel to undertake tasks beyond their skill level .

 

Have you observed any planned  issues of  ATCO pairing and improper manning. That is when two individuals with marginal skills are paired together  ? 

 

 Do you  resort to conduct of flying activity when some crucial aids and/or facility is not available . Who clears the flying in that case? Is it recorded in the log books.

 

Have you in the past seen ever that the mishap causal chain of events could be traced back up the supervisory chain of command. Describe the event . Has there been  a failure to correct a Known Problem  .

 

Failure to Correct Known Problem

 

Are there factors where the supervision or chain of command has failed to correct known deficiencies in documents, processes or procedures, or fails to correct inappropriate or unsafe actions of individuals, and this lack of supervisory action creates a daily unsafe situation. 

 

Does the supervision fail to identify an operator or aviator who exhibits recognizable risky behaviors or unsafe tendencies or fails to institute remedial actions when an individual is  identified with risky behaviors or unsafe tendencies.

 

Does the operations Management fail to correct known hazardous practices, conditions or guidance  that allows for hazardous practices within the scope of his/her command

 

Have you notices deliberate aircrew violations which have been unnoticed or a rule was willfully violated. Describe

 

Is the last landing time or green period religiously followed?

 

Are there deficiencies in the system that are “known” to the supervisor, yet are allowed to continue uncorrected 

 

Supervisory Violations

 

Are there supervisory acts of omission when unit (organizational) and operating rules have not been enforced by the normally constituted authority.

 

Are there any supervisor’s de-facto policy which is in the form of a unwritten or “unofficial” policy , perceived and followed by individual, which has not been formally established by the properly constituted authority and may lead to an unsafe situation.

 

Has any senior in the aviation activity directed violation of existing  regulations, instructions or technical guidance. 

 

How much importance is given to currency as a factor in the ATC working  when an individual has not met the general training requirements for his job and is considered  “non-current” and supervision/leadership inappropriately allows the individual to perform the job.

 

Do you face of failure of Leadership  affecting your day to day working. Please elaborate specifics aspects of the case.

 

 

PART IV – Organizational Influences  

 

 

Resource/Acquisition Management

 

Are there factors in that in the ATC which result in poor error management or

creates an unsafe situation. If yes then categorize under the following heads:-

 

1. Air Traffic Control Resources resulting in when inadequate monitoring of airspace, en-route nav-aids or language barriers in air traffic controllers cause an unsafe situation. Please include the resources of the runway controller and the CFFR team.

2. Availability and reliability of airfield resources such as runways, taxiways, ramps, terminal ATC resources or nav-aids, lighting systems, SOF/RSU resources or the environment surrounding the airfield are inadequate or unsafe.  

3. Does the ATC get support of the other crucial support facilities such as messing , accommodation , opportunity for recreation or rest are not available or adequate and this creates an unsafe situation.  This includes situations where leave is not taken for reasons other than the individual’s choice. 

4. Poor acquisition Policies  which result in procurement of  vehicle, equipment or logistical  support allowing  inadequacies , which may cerate an unsafe situation. 

Poor selection Policies leading to placing personnel with  inadequate aptitude creating an unsafe situation. 

 

Shortage of AFSOs

 

Poor Informational Resources  and Support when weather, operational

planning material or other information such as flight plan messages necessary for safe operations planning are not available.

 

Does the ATC receive required financial resources to complete its assigned task or any  deficiency  creates an unsafe situation. 

 

Organizational Climate

 

Identify organizational  variables including environment, structure, policies, and culture which influence individual actions that may result in human error or an unsafe situation. This aspect encompasses :-

 

1. explicit/implicit actions, statements or attitudes of unit leadership set unit/organizational values (culture) that allow an environment where unsafe task demands or pressures exist. 

2. when an individual perceives that their performance on a task will inappropriately impact an evaluation, promotion or opportunity for upgrade and this pressure creates an unsafe situation. 

3. when  the chain of command of an individual or  structure of an organization is confusing, non-standard or inadequate and this creates an unsafe situation. 

Do you think that the job of an air traffic controller is motivating enough to keep you doing a good safe job

 

Are there any jobs which are carried out by the ATC but actually are someone else’s’ job ? Please bring out details.  

 

Organizational Processes

 

Does the ATC have adequate procedural guidance/publications such as ICAO documents,  checklists, graphic , depictions, tables, charts or other published guidance ?

 

Is the concept of operations at your base in any  way flawed or accepts unnecessary risk and this flaw or risk acceptance leads to an unsafe situation or uncontrolled hazard.

 

Are program oversights  or any programs  implemented without sufficient support, leading  to an unsafe situation.

 

How do you describe Unsafe Acts of Operators and how frequently do they happened and what action is taken after that .

 

Do any of the aircrew get into any unwanted discussion on RT concerning aspects related to weather , with an insistence to get airborne?