Kelvin

Thanks Ian. There are another couple of airman attributes I'd say, bedded in your examples . If we start with 1. Human Error is Recognised and Controlled (Flyer40) then add: 2. Self-imposed flying discipline is a widespread practice (Yenn). 3. Double checks occur naturally before deciding on an emergency response (Yenn). Apart from that, there is your willingness to share what you thought led to aircraft damage incident under your control. Priceless, absolutely pricless. More details would be of great interest if you have't already mentioned it yet on this forum. Well, thats three aviator attribute with seven to go. Kelvin (with a long way to go, but three is plenty of light-at-the-end-of-the-tunnel)

In a previous thread on "Is Pilot Error Inevitable" mention was made of, "Safety science considers human error a consequence, not a cause, ie pilots are the inheritors of an accident scenario not the initiators. In this context it's not remotely compatible with the term 'pilot error' as used by the media" from Flyer40.:thumb_up: Given we still have our own views on what it means to be a good pilot and what we do constantly to achieve enjoyable flying, we could add them into say "10 Attributes of an Aviator/Aviatrix" as a foundational concept to measure our own values-driven safety culture. An email I'd received this weekend said, "I quoted an instructor of mine who said that 98% of accidents are due to pilot error, I take great comfort in that as I am in control of these factors". Thats a state of mind on a belief that will impact favourably on performance. Convert that into an attribute like, Human Error is Recognised and Controlled, and you have an airman attribute that can be measured, as simple as that. What else do we believe makes us a good pilot? Kelvin (with a long way to go, to better understand our RAA culture)

Attributes of an airman. Thanks ab, You have certainally given me plenty of scope:chuffed:, but I'll try to break it down into something meaningful and see how it pans out. FAA CULTURE:raise_eyebrow:. It appears that CFI's and CASA set the tone in much the same way as OHS Professionals and WorkCover do in the workplace. The forces behind their influence is consequences. Both rely on systems safety as it applies to high risk operations like transportion, building & construction, mining and petrochemical. Before systems safety we had safety programs, leadership, regulation and more recently psychology (BBS). All these processes have served us well. You would know intuitively that if the culture had been more in tune, the outcomes would have been even better. Like no loss of life, for example. IDEAS:idea:. Culture is a mix of beliefs, values. attitudes and behaviours. Now, we know we can measure culture and the outcomes are predictive. For example, if your mother found a wallet inside a supermarket trolley, you know what she would do about it. You know her principles regarding honesty. If we could establish 10 personal values that makes a good pilot that we could aspire to, we could convert them into imperatives and build them into a five level matrix and assess the values against the levels, we will be measuring our culture. As you know, "What gets measured and rewarded, gets done. The values that are assessed as weak, we can do specific exercises we know will work, to bring it up to the next level. This is leading edge stuff right now. SUGGESTIONS . Notice all the ideas involve what we can do, not management or the regulators. Although, they'd be delighted if we took the iniative to establish and measure our safety culture. We should just sit back now and wait for someone to put a challanging or an opposing point of view on this thread, and go from there. It is an easy process once we have worked through the first value. Then everyone wants to jump in (thats been my experience) and we are on our way. It's very exciting stuff. What do you think? Kelvin (with a long way to go but not on his own)

Tread Lightly Thanks Nev (again), By the very nature of what we do, I agree and suspect there are many who have experienced uncomfortable inflight scenario's and found innovative ways to resolve them to to their own requirements. On the one hand it's not easy to imagine there are human error avoidance systems and concepts that's not already available to modern aviation. On the other, there may be innovations that has not seen-the-light-of-day for want of a bit of encouragement, direction or help. Is it worth our while to try and findout? Kelvin (with a long way to go but who knows where that may lead)

Thanks Facthunter, I have already overloaded your reputation and it wont let me add any more. You are in harmony with Flyer40 (and I expect 100's of others) on this issue of blame that I believe has never done any good, never will and it's just not consistant with safety science. James Reason who has also been around for yonks and published his book called "Human Error" and although I have it on order, I have studied some of his concepts particulrly on his models that views both the human approach and the systems approach in different ways. While PILOT ERROR is emotive it has to be commented on as you have just done. Otherwise we keep sending and receiving the wrong message. Should I change the thread to PILOT SYSTEMS DESIGN? Kelvin (with a long way to go and happy with the journey so far)

Perhaps HPD I think more to the point would be a pilot delayed reaction to either an aircraft or navigational problem. I have just read an article from www.asf.org Safety Advisor Operations & Proficiency No 11 called "Do The Right Thing: Decision Making for Pilots". I found it to very helpful with concepts that negates pilot error. Kelvin (with along way to go and hope the link helps)

Thanks Flyer40, Much of what you and subsequents posts have said fits well with what I have become aware of over 35 years in my professon in OHS. Another OHS Professional and pilot who gained his CPL in the US advised me today to lookup www.gsf.org and I found it to very enlightening. As I become more aware of pilot error avoidance concepts and any widespread understanding there may be, I'm going to be one happy chappie :big_grin:. Kelvin (with a long way to go with a little help)

Case Example: Flight 19 . Thanks Neil and Ben, They had some magnetic compass swing faults that they knew about. They called their tower and explained their off course dilemma. The tower said, "Head due West". Even with compass problems they could have just turned towards the sun to know they were heading West, but they didn't. Two other pilots were heard to have said. "Dammiit, if we could just fly West we would get home; head West dammit" but their leader wouldn't turn. He also wouldn't switch to their emergency channel to allow an immediate fix on their position. He was worried about loosing contact with his pilots who were dependent on his leadership to resolve the problem. They all knew the consequences if they could not resolve their dilemma. Why couldn't they rationalise their single priority under inflight stress? What should we know about what happened that could help us, if needed, through a little behavioural science? i_dunno Kelvin (with a long way to go on understanding inflight stress management)

Thanks Ian,:thumb_up: I suppose we are talking about a Job Safety Analysis which is supposed to be a co-operative effort on what are the forseeable risks, particularly with new tasks. But it is only a prevention tool and I agree it can be misused to setup a blame scenario. On the other hand, industry that is culturally sensitive has no place for blame, you would hope. Pilot error is usually the behavioural component of incident cause that is just as important as the design and enviroment cause elements. Our navigation is now helped along with GPS because we know navigational errors are most likely to occur when things start going wrong during flight. Thats what I'm interested in, systems that addresses pilot error under stress, not while everything is going according to plan. Kelvin (with a long way to go)

Is Human Error Inevitable? "Bermuda Triangle: Secrets Revealed" was televised on CH9 2.5.08 and presented their findings of Flight 19 that took off from Fort Lauderdale, Florida East Coast on 1.12.1945. It was an authorised navigation training flight involving five torpedo bombers (TBM Avengers) with a total of 14 crew with some having only 50hours experience in their Avenger. The flight leader had 2500 flying hours was monitoring the student pilots dead reckoning principles on a navigation exercise over a triangular course. There were differences of opinions after 3:00pm as to where they were and what course they should take to get back to the Florida coast line. They kept going East when some wanted to go West. The last radio message was at 6:20pm that said, "All planes close up tight . . . we'll have to ditch unless . . . when the first plane drops below 10 gallons, we all go down together." They all disappeared sometime after dark. My question is that given the pilot error has occurred and they had radio. two compass each, watches and standard IFF transmitter that did not help them backtrack their error, then why not? Kelvin (who has not started nav training yet).

Inflight Safety Culture Frank, In my profession (OHS) I have come to believe training standards must be kept abreast of performance based technologies. Where we started with Safety Programs (PPE) after WWII and went onto Technology (LOTO), Leadership (DuPont), Regulation (DOL/WorkSafe), Psychology (BBS) and Safety Systems. These steps have served us well but not as well as they could have. Now, the focus is on Sociology (Culture) that impacts on both organisational attributes and individual attitude towards safety. This thread from 23.4.08, went off in another direction on an issue I think was simmering below the surface and beyond my level of experience in civil aviation. While I felt I could not contribute, I found it (CFI structured training) a compelling topic and would like to participate in after I have 100+hours under-my-belt. So, I'll start another thread on my particular interest in human factors and pilot error. Kelvin with regret, in so far as my contribution to this thread.

airsick, I finally got it without going back to the BAK. Wonder if I can change my vote and go with the strength? I'd probably sleep a lot better knowing I have righted a wrong. Kelvin (with along way to go, but no turning back onto the conveyor).

G'Day Brad, I had cause to track my log book from a flying school back in 99. The school had since closed and I was able to conact the former owner who kindly delivered it within days. I'm unawae of any central systematic storage of owner lost log books. But you have come to the right place to find out. Someone here will know. Welcome aboard, Kelvin

Yep, HPD that definately needs clarification. The article relates to a pilot of a Boeing 767 in July 83, looses power at 35000 feet and diverts to a small airstrip at Gimil in Canada. As he approached he could not control speed without flaps and slats. He reverted to a slide-slip technique he learnt as a glider pilot to get it down with 61 passangers. His employers had never imagined the slide slip manoeuvre being applied to a wide-bodied jet airliner. It was an improvisation he had to try in the absents of any other training for a 767 emergency. On a more general note as it applies to RA, I wonder if there can be circumstances that may arise and do not fit with what we understand from our training, as a precursor to an emergency. I'm thinking about clues that are likely to be missed both on the ground and in the air and how well we understand the extent of training we need to have to mitigate these exposures. Kelvin (with a long way to go, and sharing an inner thought)

I have the magazine "Flight Safety Autralia" Jan-Feb 01 edition with a feature article on "The Brainy Bunch. Why they will change the way you think about aviation safety" This bunch (Murino, Reason, Helmreich) had been involved in research that involved thousands of air crew recover from threat and error in normal operations. They say that "Making errors is a fact of life, but recovering from them - particularly when these recoveries involve heroic improvisations - is another matter". They presented as key speakers at the 5th Australian Aviation Psychology Symposium at Manly, Sydney in November 2000. I'm interested in abatement systems of human error. Did anyone get along to that symposium? Is anyone a member of the Australian Aviation Psychology Association www.vicnet.net.au/~aapvpa/ ? Kelvin (with a long way to go and dont mind learning a thing or two along the way)

Thanks Paul, After reading the Aviation Safety Investigation Report - Final, I suspect my CFI, if he could, would say something like, "You dont have to be unduley concerned about how I got into difficulties, because your not intending to work with experimental aircfraft as I was went things went wrong" So, with that in mind I'll get back into the air with sufficient confidence to really enjoy all the challanges as they come along. Kelvin (wth along way to go, but looking forward and not back)

Thanks airstick, What a great idea for limited but essential training with Partners of Pilots Emergency Course. This initiative goes a long way to addressing Inflight Safety Culture and has to be well worth effort. The outcomes would centre squarely on fear reduction and increased team-based competence. I'll be making enguiries through my CFI and go from there. Kelvin (with a long way to go, but less than I started from my first post 4 days ago)

Thanks Kaz, While you may well be an angel without wings, your 'insider' comments underscores all the recent encouragment freely given through this forum to my idol and I. Kelvin (with a long way to go, with my angel)

G'Day Skylark, In welcoming you aboard, you should be made aware that this website can be somewhat additive after finding your way around and in need of information. They come at you in waves like kamikazi pilots without the bombs. Kelvin

Call for innovation on the roads as in the air. Thanks Ben, When you think about road transport where we travel towards each other, seperated by a white line most of the time and with a possible head-on impact of 200kph, there's some obvious work still do do on design and environment accident cause analysis and prevention, big time. Let alone the behaviour element. I wonder if the radio communicatios we use on pending enviromental changes, confirming we've seen each other and what we are intending do at any given time could, in some way, be adapted to road users to improve road safety? The innovator who gets that one right I suspect is going to retire gracefully sooner than later. Kelvin.

Thanks Paul (shfts64), I have downloaded the final report on VH-CIV with some obvious intrebidation, having known the test pilot professionally for a short time. The cause elements (3) have been captured under the "analysis" tab. Someday, I may seperate them as they stand into design, environment and behaviour cause elements to better understand the critical links and impact between the three. Kelvin (with a long way to go and appreciative of the willing help so far) '

Thanks Paul, Reading the report would probably help me rationalise how an experiensed CFI could still become exposed to an out-of-control 4000 feet dive. Are thse reports readily available, do you know? Kelvin (with a long way to go and some 'rough' ground to cover, it seams)

Frank (farri) that's a straight question and I guess you knew the answer could not be the same. :ah_oh: Let's consider Chris's (bush pilot) cloud concern and he decides not to push on through the clouds and selects a freshly plowed level paddock to land in. Thats rather than the surrounding paddocks with grass tussocks and hidden rocks he had just noticed. On touchdown one wheel collapses and the A/C slews a litle and then stops OK. It would be reasonable to say the pilot made the right decision and had he not, the outcome could have been far worse. It could also be fair to say that whatever caused the wheel to collapse, cauld have also flipped the A/C, ignited and incinerated the occupants. The point is we need to consider all three cause elements regardless of the incident outcome i.e., DESIGN: Wheels unsuitable for rough terrain (you can think of more to do with wheel failure) ENVIRONMENT: Low cloud cover, no clear and even landing surfaces, unpredictable weather (you can think of more) BEHAVIOUR: Responded to training and experience givng due regard to the immediate circumstances and lmited options. If there was sufficient fuel the pilot could have stayed airborne longer in the hope an opening appears in the cloud (again you can think of more). I guess the point here is these elements are always there. Sometimes we have to drill-down to find them, but find them all we must. I could go on but hopefully this is sufficient to answers the question. Kelvin (with a long way to go)