Pilot Error, Human Factors, or just a bunch of Hogwash?!

[Jedi Doc]

I've been recently reading a lot about the DoD's response to aviation (and other class A) accidents. I read the original book on the Human Factors Analysis and Classification System (HFACS) by the US Navy creators Doc Wiegmann and Shappell.

Basically, the book contends:

1. Aviation has gotten super safe, but accidents still happen from time to time.

2. When accidents do happen, they are predominantly caused by human factors (~70-80% of the time).

3. It is important for the safety process and future accident prevention to identify specific human factors and the standardized taxonomy that should be used is the HFACS framework.

I completed this research writing a recent blog post: https://goflightmedicine.com/human-factors-analysis/

What do pilot members and investigating officers think about the value of this framework? Useful product or academic dribble?

[zrooster99]

Drivel, I believe, is the word you're looking for.

[Tonka]

Premise 3 is false, We know the problems: read just about any thread in these here forums to find them, categorizing into human factors code is as useless as categorizing your dogs shit color when he drops a turd on the carpet... It's a secondary/tertiary effect that makes for pretty charts but does nothing to address what the problem is or how to solve it.

You want to fix aviation, at least military aviation, you make it your only priority and make sure, absolutely, nothing else matters.

We'll stop crashing airplanes when get back into the business of flying them.

[08Dawg]

I think studying human factors is fine. The more we know, the more we understand, the better we can train. Aviation's gotten to the point where the man is the weak link in the chain. I think the problem right now is that the DoD HFACs, at least as it's implemented in AFSAS for any mishap, is clunky and a bit forced. You have to parse through a bunch of different errors and find the one that most matches what you think happened. Haven't tried to push a report through yet without one, but when I was at AMIC, the word was "good luck submitting an AFSAS report nowadays without specifying any human factors".

[pawnman]

The problem is, it's now gotten to the point where even mechanical failures end up with some kind of human factor as a note, causal or otherwise.

"Well, it looks like the #3 engine suffered a catastrophic failure...but the copilot said he had only gotten 5 hours of sleep the night before, so that may be a contributing factor as well..."

[BFM this]

Most safety investigations that I've seen have done a decent job of sorting out the CFs, Fs, and NFWODs. For the most part, this thread is drivel, imo.

FWIW, I'm probably biased, having a degree in HF. Actually, I took a few classes with Doc Weigmann at Illinois; great prof, and I don't remember him coming off as peddling tripe to further a rabbit trail agenda.

If anything these days, its this, to some degree:

We'll stop crashing airplanes when get back into the business of flying them.

[TreeA10]

I think some of it will be useful but most will be just categorizing and useless efforts to solve a very complex problem due to the human involved. If we could solve human error, experienced golfers would never be off hunting errant golf balls.

[stract]

I was the IO for a Class A where the mechanism of failure was completely mechanical. During the 4 months of the investigation (including several "pauses" for technical analysis), there was never a HF person assigned to the SIB, nor was one ever volunteered. When I sent the draft Tab T to AFSEC to review about a week out from the outbrief to COMACC, I got back "but you need an HFAC in there" and the ACC HFACS chief was hastily summoned to assist. Since this person had not spent the last 4 months on the SIB like the rest of us, it was ridiculous to expect any useful input at that point.

There is an HFAC for Acquisition/Design that we ultimately ended up throwing in there to appease the AFSEC QC review. The MOFE process then removed this as a causal factor 90 days later due to lack of evidence to support the claim. I'm so glad we modified our Tab T for that end result.

In between convenings of the Class A SIB, I was the SIO of a Class B. The causal findings revolved around a mechanic and a QA supervisor at an overhaul facility failing to ensure a bolt inside a component was properly torqued. The time between the overhaul and the mishap was 4 years, so it's not like I could get any useful info from them; he mechanic no longer worked for the company anyway and I had no way to track him down. AFSEC wanted me to invent HFACS to assign to these two individuals with no shred of evidence (they QC rejected my final message the day my Class A SIB reconvened for the final push to the finish line). Luckily my NAF (convening authority for the Class B) went to bat for me and we were able to get the final supplemental pushed through.

AFSEC also told me I had too many acronyms in my one-liner (insert eye roll here). Well if you only give me 40 fucking characters, I have to abbreviate somewhere!

I think the QC process at AFSEC is broken. It should occur BEFORE the SIB deconvenes. What's the purpose of having an AFSEC rep (telephonic or in person) if their review and input to the SIB/SIO isn't good enough to pass muster?

If every final message needs an HFAC, which is definitely the vibe I have received in the last several years from AFSEC, then the IOs need to be better trained on HFACS, and the convening authorities need to provide an HF consultant to every. single. investigation. The problem right now is that IOs are being forced to simply invent a link to an HFAC when one might not be present, thus skewing the data over time.

[HiFlyer]

Premise 3 is false, We know the problems: read just about any thread in these here forums to find them, categorizing into human factors code is as useless as categorizing your dogs shit color when he drops a turd on the carpet... It's a secondary/tertiary effect that makes for pretty charts but does nothing to address what the problem is or how to solve it.

You want to fix aviation, at least military aviation, you make it your only priority and make sure, absolutely, nothing else matters.

We'll stop crashing airplanes when get back into the business of flying them.

Personally, I also agree Premise 3 is at least partially false. It should read something like: "It is important for the safety process and future accident prevention to identify specific human factors, when they are material to the accident, and the standardized taxonomy that should be used is the HFACS framework." Any human activity has some human factors, but I believe one of the keys to a good accident investigation is separating actual cause from things that are present but are "non-cause". Legislating causes because they are politically popular actually masks the serious issues that need to be addressed.

As for the last sentence, we'll stop crashing airplanes only when we stop flying. It's an inherent risk that humans cannot remove. The goal is to reduce them as much as possible by fully understanding the human, environmental, and mechanical factors. However, mechanical failure, the physical environment, and human stupidity are not subject to absolute control. On the bright side, we've done a pretty good job over the last 30 years in bettering our designs and understanding the environment. The stupidity part remains a challenge.

[TreeA10]

Try to make something idiot proof and someone always comes up with a better idiot.

[dvlax40]

ok gonna throw my hat in the ring, not a military aviator yet, but spent the better part of my undergrad (industrial design and engineering) researching aviation accidents and how human factors in the design and layout of the systems impacted the humans and how they operated them.

in almost EVERY case, human performance was not the issue, but improper training or poor documentation/instrument and control layouts were to blame. now yes, there were people that would point out humans designed these systems so it was still a human factors issue, but we are always going to have these issues until machines start building machines... and im not looking forward to that lol

but seriously, pilot error is a word that upsets me very much, because the pilots are usually doing the best damn job keeping the airplane flying. Meanwhile ive done functional checkrides in GA aircraft where the autopilot is trying its best to crash the airplane

[HiFlyer]

The last board I was involved with (granted it was 20 years ago) the term "pilot error" was not is use. The term was "Operator Error", since the problem could have been the pilot, but also could have been the Nav, or the Load, or the Flight Engineer, or a human on the ground in some circumstances, etc.

Edited November 24, 2014 by HiFlyer

[dvlax40]

The last board I was involved with (granted it was 20 years ago) the term "pilot error" was not is use. The term was "Operator Error", since the problem could have been the pilot, but also could have been the Nav, or the Load, or the Flight Engineer, or a human on the ground in some circumstances, etc.

this reminds me of the aeroperu flight that crashed because the ground crew covered the static ports with speed tape vs using the correctly colored maintenance tape. the result of the pilot missing it being covered (was the same color as the skin) during his midnight walk-around. They then go on to blame the actions of the two pilots for not instantly recognizing what was going on flying on a cloudy night with not ground reference.

the moral of the story is the maintainers did not follow protocol which put the pilots in a bad situation where they did everything to recover. but it was still termed pilot error.

[guineapigfury]

this reminds me of the aeroperu flight that crashed because the ground crew covered the static ports with speed tape vs using the correctly colored maintenance tape. the result of the pilot missing it being covered (was the same color as the skin) during his midnight walk-around. They then go on to blame the actions of the two pilots for not instantly recognizing what was going on flying on a cloudy night with not ground reference.

the moral of the story is the maintainers did not follow protocol which put the pilots in a bad situation where they did everything to recover. but it was still termed pilot error.

I think that one was covered in that play where they act out the accident transcripts? That shit was hard to watch.

[raimius]

As much as I hate the "blame the pilot" game, there plenty of times where the flight crew were the primary link in the crash.

...even when your instruments go wonky, you have got to figure out that pulling back on the controls for 1 minute-plus is going to cause a stall.

[Tonka]

As for the last sentence, we'll stop crashing airplanes only when we stop flying. It's an inherent risk that humans cannot remove.

I really don't think so, it might come at a tremendous cost but we could reduce our mishap rate to a fraction of what they are now and eliminate "crashes" (from a HF cause). The reason we typically don't have that vision is because me make dudes IPs at like 5 hours of flying time, and the more we watch each other screw up the more we believe...well, pilots just do dumb stuff from time to time. We have to got to change that mindset, that's not normal.

Not sure of the answer, but how many of the mishaps involving spacecraft cite the crew on board as causal? I bet the percentage is dramatically lower then the military mishaps rate in the same category. If true then maybe we can better eliminate those category of mishaps by finding out what NASA does.... Would you admit that most people see Astronauts as infallible when compared to military pilots? Do you really think they are super human, comparably? No... the difference is they focus solely on their mission and they train their freaking arse off to cover every possible scenario down pat, so when the fit hits the shan they react the right way... They are no smarter than us In that sense, the subconscious reacts the way it is trained to. If we don't train it to that level you get freaking great Christmas parties planned but bent metal too.

Go watch "how it's made" where the dude is sewing a shoe together, I bet he makes a million flawless shoes every year with a high school education. Because he's done it so much he can recognize a problem in the thread or leather that will affect a shoe 5shoes from now. What we do is really no different in principle, we just don't get dudes 10,000 hours to recognize problems before the exist.

Yes I just compared flying with shoe making. If we gave dudes 10,000 hours before making them A-codes we would be some awesome shoe makers.

[MD]

One thing for sure about aviation is, we really aren't finding new ways to crash aircraft. Most often, it's ways we already know and have known about.

[HiFlyer]

I really don't think so, it might come at a tremendous cost but we could reduce our mishap rate to a fraction of what they are now and eliminate "crashes" (from a HF cause). The reason we typically don't have that vision is because me make dudes IPs at like 5 hours of flying time, and the more we watch each other screw up the more we believe...well, pilots just do dumb stuff from time to time. We have to got to change that mindset, that's not normal.

Not sure of the answer, but how many of the mishaps involving spacecraft cite the crew on board as causal? I bet the percentage is dramatically lower then the military mishaps rate in the same category. If true then maybe we can better eliminate those category of mishaps by finding out what NASA does.... Would you admit that most people see Astronauts as infallible when compared to military pilots? Do you really think they are super human, comparably? No... the difference is they focus solely on their mission and they train their freaking arse off to cover every possible scenario down pat, so when the fit hits the shan they react the right way... They are no smarter than us In that sense, the subconscious reacts the way it is trained to. If we don't train it to that level you get freaking great Christmas parties planned but bent metal too.

Go watch "how it's made" where the dude is sewing a shoe together, I bet he makes a million flawless shoes every year with a high school education. Because he's done it so much he can recognize a problem in the thread or leather that will affect a shoe 5shoes from now. What we do is really no different in principle, we just don't get dudes 10,000 hours to recognize problems before the exist.

Yes I just compared flying with shoe making. If we gave dudes 10,000 hours before making them A-codes we would be some awesome shoe makers.

I didn't say we couldn't improve, I just said we'd never stop crashes as the poster commented, particularly from "when we get back to the business of flying them." Shit happens, knowing the correct way doesn't mean we'll always execute properly, stuff breaks, humans make mistakes. Strive to reduce, but don't expect absolute success.

Edited November 25, 2014 by HiFlyer

[dvlax40]

I think that one was covered in that play where they act out the accident transcripts? That shit was hard to watch.

true, but to think the whole thing started on the ground, its pretty sad. there was another one where the maintenance crews had improperly set the elevator controls because the repair manual was confusing and the plane crashed because of the reduction in control authority. that crash was not labeled pilot error, but it shows that the small mistakes on the ground are compounded 100 fold in the air.

I also think as others have stated, there is a large gap between the way civilians, military, and astronauts all train and practice to fly that can effect the frequency and severity of accidents. hell a great point would be SFLs in the GA community vs the Military

[AZwildcat]

Yes I just compared flying with shoe making. If we gave dudes 10,000 hours before making them A-codes we would be some awesome shoe makers.

That's part of the great conflict of interest within the Air Force...we don't fly enough at home, we don't recognize, reward or value excellence in flying, we handicap ourselves with too many rules and regulations in the name of safety, we downplay the aviator and make sure the finance guy feels special and the whole base shows up for the fun run/suicide awareness/don't rape people day, and worst of all we force out our best/brightest along with all their valuable experience while the turds float to the top to lead us further down the drain.

[Stitch]

That's part of the great conflict of interest within the Air Force...we don't fly enough at home, we don't recognize, reward or value excellence in flying, we handicap ourselves with too many rules and regulations in the name of safety, we downplay the aviator and make sure the finance guy feels special and the whole base shows up for the fun run/suicide awareness/don't rape people day, and worst of all we force out our best/brightest along with all their valuable experience while the turds float to the top to lead us further down the drain.

Nailed it. Give that man a Klondike bar....

No different in Maintenance. Lots of, not all of course, good MX folks have had enough. They see opportunity and sometimes big bucks on the outside and that's where they go.

[HiFlyer]

Interesting discussion about the experience issue, but nothing new. My father-in-law joined the Army Air Corps in 1939 (and went to Hawaii, where he was posted to Wheeler Field on Dec 7th) and retired in 1969. He told the same stories (post-WWII and post-Korea). I joined in 1967 and saw the cycle at least twice (post-Vietnam and post-Cold War) plus observing the current situation). In each case we seemed to survive.

As one senior individual pointed out to me, developing all that experience is fine, but when one situation winds down, it usually takes a decade or so before we step in it again, and by then that 10-15 year experienced "old head" bubble is now at the 20-25 year point in their careers and either got out, retired or are serving in upper staff positions, of which there are relatively few. The few old guys left can't fill all the company-grade crew pig positions you need lots of bright and shiny young guys to fill.The old experience fills leadership and staff positions to try and pass on their "lessons-learned". It seems to me that most of the Captains and Majors that complain the loudest don't want to leave the cockpit to fill that role, so they don't serve much of a purpose in later years except to block up the rated pipelines; the young guys you'll need later can't get in and/or gain the experience. That's not a popular opinion in some circles, but that's the reality of it. That situation occured after WWI, and the result of not forcing out people left us entering WWII with a force of 40-50 year old Captains and Majors that couldn't effectively operate in WWII's environment (particularly in the Army, according to my father-in-law).

It's an "up-or-out" system, implemented as a result of the problems revealed after WWI (I believe the Brits had the same problems), and if you really want an effective force at the ready for the future, you have to live with it despite its warts.

Edited November 26, 2014 by HiFlyer

[Tonka]

As one senior individual pointed out to me, developing all that experience is fine, but when one situation winds down, it usually takes a decade or so before we step in it again, and by then that 10-15 year experienced "old head" bubble is now at the 20-25 year point in their careers and either got out, retired or are serving in upper staff positions, of which there are relatively few.

I get it, in fact that is perfect setup for most of the military... It's effective and efficient. However aviation has changed, dramatically, over the past few decades. When we "gen" back up and lose a few airmen and planes in the process, we are no longer talking $100,000 and 5 months training; it is beyond exponentially higher than it was. Nor are we talking the same percentage, we lose one p51 and pilot that is nothing compared to losing one f22 and pilot... Not that I'm belittling the value of a life, I certainly am not, but the effect on our militaries ability to wage war is dramatically decreased with respect to the loss of the latter. They are truly irreplaceable.

If we were really serious about reducing mishaps, pilot training would be completely different. From UPT, to initial, to continuation, we would have triple the number of sims, they would all be connected, scenarios would be random, difficult, challenging, you would fly it until you could recognize and react flawlessly. You would train, continually. Exercises would be tough, failures would be common. Flying hours would be abundant.

We keep saying that we can never eliminate the human element, but we really haven't scratched the surface with respect to training aviators as best we can. What if we lost a missile crew, missile, and war head 5-6 times of year, do you think we would nonchalantly sit back and say, "that's the cost of having missiles."

I will just never understand why losses are so acceptable in aviation... I'll go out on a limb and say, with a few exceptions (fatigue, depression, altered mental state, impromptu air show, etc...), anytime we use a human factor code or label it "pilot error" we are masking the problem and therefore the solution. It is so much easier and cheaper to blame an individual rather than fix the system that produced him.

[Butters]

Not sure how many of you remember this crash back in June of 2012. Looks like the thread it was posted in got deleted. NTSB released the probable cause last November. I think you can chalk this up to human error.

https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20120607X54234&key=1&queryId=70e7c65d-f910-41cc-bd2f-a6f34cf4b074&pgno=4&pgsize=50

NTSB Identification: ERA12FA385

14 CFR Part 91: General Aviation

Accident occurred Thursday, June 07, 2012 in Lake Wales, FL

Probable Cause Approval Date: 11/24/2014

Aircraft: PILATUS AIRCRAFT LTD PC-12/47, registration: N950KA

Injuries: 6 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The instrument-rated pilot activated the autopilot shortly after takeoff and proceeded in a west-northwesterly direction while climbing to the assigned altitude of flight level (FL) 260. Light-to-moderate icing conditions were forecast for the area; the forecast conditions were well within the airplane's capability, and the pilot of a nearby airplane reported only encountering light rime ice at the top of FL260. About 26 minutes 35 seconds after takeoff, the airplane's central advisory and warning system (CAWS) recorded activation of Pusher Ice Mode at FL247, consistent with pilot's activation of the propeller de-ice and inertial separator; the de-ice boots were not selected. Less than a minute after the activation of Pusher Ice Mode, an air traffic controller cleared the flight to deviate right of course due to adverse weather well ahead of the airplane. The airplane then turned right while on autopilot in instrument meteorological conditions (IMC) at FL251; about 4 seconds into the turn, with the airplane indicating about 109 knots indicated airspeed and in a right bank of less than 25 degrees, the autopilot disconnected for undetermined reasons. The pilot allowed the bank angle to increase, and about 13 seconds after the autopilot disconnected, and with the airplane descending in a right bank of about 50 degrees, the pilot began a test of the autopilot system, which subsequently passed. Recovered data and subsequent analysis indicate that the pilot allowed the bank angle to increase to a minimum of 75 degrees while descending; the maximum airspeed reached 338 knots. During the right descending turn, while about 15,511 feet and 338 knots (about 175 knots above maximum operating maneuvering speed), the pilot likely applied either abrupt or full aft elevator control input, resulting in overstress fracture of both wings in a positive direction. The separated section of right wing impacted and breached the fuselage, causing one passenger to be ejected from the airplane. Following the in-flight break-up, the airplane descended uncontrolled into an open field.

Examination of the separated structural components revealed no evidence of pre-existing cracks on any of the fracture surfaces. Postaccident examination of the primary flight controls and engine revealed no evidence of preimpact failure or malfunction. The flaps were found in the retracted position, and the landing gear was extended; it is likely that the pilot extended the landing gear during the descent. The horizontal stabilizer trim actuator was positioned in the green arc takeoff range, the impact-damaged aileron trim actuator was in the left-wing-nearly-full-down position, and the rudder trim actuator was full nose right. The as-found positions of the aileron, rudder trim, and landing gear were not the expected positions for cruise climb. Examination of the relays, trim switch, and rudder trim circuit revealed no evidence of preimpact failure or malfunction, and examination of the aileron trim relays and aileron trim circuit revealed no evidence of preimpact failure or malfunction; therefore, the reason for the as-found positions of the rudder and aileron trim could not be determined. Impact-related discrepancies with the autopilot flight computer precluded functional testing. The trim adapter passed all acceptance tests with the exception of the aural alert output, which would not have affected its proper operation. The CAWS log entries indicated no airframe or engine systems warnings or cautions before the airplane departed from controlled flight. A radar performance study indicated that the airplane did not enter an aerodynamic stall, and according to the CAWS log entries, there was no record that the stick pusher activated before the departure from controlled flight.

Before purchasing the airplane about 5 weeks earlier, the pilot had not logged any time as pilot-in-command in a turbopropeller-equipped airplane and had not logged any actual instrument flight time in the previous 7 years 4 months. Additionally, his last logged simulated instrument before he purchased the airplane occurred 4 years 7 months earlier. Subsequent to the airplane purchase, he attended ground and simulator-based training that included extra flight sessions in the accident airplane, likely due to his inexperience. The training culminated with the pilot receiving his instrument proficiency check, flight review, and high-altitude endorsements; after the training, he subsequently logged about 14 hours as pilot-in-command of the accident airplane. Although the pilot likely met the minimum qualification standards to act as pilot-in-command by federal aviation regulations, his lack of experience in the make and model airplane was evidenced by the fact that he did not maintain control of the airplane after the autopilot disengaged. The airplane was operating in instrument conditions, but there was only light rime ice reported and no convective activity nearby; the pilot should have been able to control the airplane after the autopilot disengaged in such conditions. Further, his lack of experience was evident in his test of the autopilot system immediately following the airplane's departure from controlled flight rather than rolling the airplane to a wings-level position, regaining altitude; only after establishing coordinated flight should he have attempted to test the autopilot system.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

• The failure of the pilot to maintain control of the airplane while climbing to cruise altitude in instrument meteorological conditions (IMC) following disconnect of the autopilot. The reason for the autopilot disconnect could not be determined during postaccident testing. Contributing to the accident was the pilot's lack of experience in high-performance, turbo-propeller airplanes and in IMC.

Edited February 26, 2015 by Butters