Chapter 5

Safety

Introduction

70–80 percent of accidents are caused by human error. Your initial reaction may be to blame
the people involved, asking why professionals make so many mistakes. Historically,
accident investigations took a similar approach, and the pilots were typically assigned
blame. Unfortunately, blaming and firing the crew involved in an accident did little to prevent
similar accidents from recurring in the future.

It is essential to understand that aviation professionals do not take safety for granted; they
are dedicated to their work and have every intention of doing a good job. Nevertheless, this
makes it difficult to understand the high rate of accidents caused by human error.

The reality is that all aviation professionals have one common limitation: they are all human
beings. Although humans have a remarkable capacity for critical thinking and creativity, we
also have natural and predictable limitations associated with our mental and physical
abilities. The science of human factors explores these human limitations and applies that
knowledge to the design and operation of aviation systems.

When exploring why human error is the primary cause of accidents, there are two
complementary philosophies:

1) Human factors: The mistakes of individuals contribute to accidents and therefore need
to be studied and understood through the scientific discipline of human factors (which
explores factors like fatigue, decision-making, and communication).

2) Safety management: Human error is a symptom of underlying problems that need to be

understood from an organizational approach through safety management (which attempts
to proactively identify and eliminate risks throughout the entire company/organization from
senior management decisions to the actions of front-line workers).

Human Factors

Historically, the aviation industry had a reactive approach to safety. After a major accident
occurred, the investigation would reveal a weakness or concern, which the industry would
then correct. If a flaw was identified on a type of airframe or engine, an airworthiness
directive would be issued to have that flaw fixed on all airframes or engines of that type. This
approach was very successful in reducing accident rates by improving the mechanical
aspects of aircraft.
If no mechanical or structural malfunction could be identified, accident investigators would
turn their attention to the flight crew to determine if someone broke a rule or made a mistake.
Historically, the emphasis was on determining responsibility for the accident: what
happened, who did it, and when it took place. Over time, the number of accidents caused by
mechanical factors went down at a much quicker rate than the number of human-caused
accidents.

Human Factors Training for Pilots

In 1979, the United States’ NASA held a workshop called Resource Management on the
Flightdeck, intended to bring airlines and researchers together to discuss the prevalence of
aviation accidents caused by human error. This workshop had a global impact, which led to
crew resource management (CRM) training, which is now a required component of pilot
annual training programs. CRM instruction teaches pilots to use all available resources,
including those on the aircraft and support on the ground, to achieve safe and efficient flight.

CRM training explores human factor issues that relate to pilot errors, with emphasis on
communication, leadership, stress, fatigue management, and decision-making. Many
airlines involve several employee groups (pilots, cabin crew, maintenance) in annual CRM
training to facilitate a culture of teamwork.

In modern aviation, the NOTECHS (non-technical skills) framework is commonly used as a

standardized structure for CRM training and assessment. There are four NOTECHS
categories and several subcategories:

1) Cooperation: team building; considering others; supporting others; and solving conflict.

2) Leadership and Managerial Skills: use of authority and assertiveness; providing and
maintaining standards; planning and coordination; and workload management.

3) Situational Awareness: awareness of aircraft systems; awareness of time; and problem

definition and diagnosis.

4) Decision-Making: option generation; risk assessment and option selection; and outcome
review.

One challenge with modern classroom-based CRM training is that it can be very theoretical
and seem inapplicable to the real world. Professionals in the classroom may understand the
concepts, but be unable to apply them to their professional environment. For example,
understanding the importance of proper decision-making is far different from actually
making the correct decision in a critical real-world situation.
Those who study human factors have identified several issues of particular importance to
aviation operations.

Culture

Culture impacts human behavior. Aviation professionals are affected by three layers of
culture:

1) Organizational—Each company fosters its own culture, setting the expectations for
professional behaviors.

2) Industry—The aviation industry itself has a culture, which establishes high-level

expectations about what it means to be an aviation professional. The aviation industry has
always had a culture of responsibility, punctuality, and pride in the field. However, there are
also occasional negative aspects of the aviation culture associated with individuality or
questioning procedures.

3) National—People develop different shared cultural values and expectations, depending

on where they were raised. In a multicultural world, there are challenges in working on a team
with people whose cultures take different approaches to expectations, teamwork, and
gender roles.

Crew Collaboration and Communication

Crew collaboration and communication extend human capabilities. For example, a Captain
and First Officer working together should be more capable than a single pilot, which is why
certain aircraft types require two-pilot crews. Occasionally, issues can arise where crew
members do not effectively work together. This can be caused by a steep authority gradient
(a strict Captain and a timid FO), poor collaboration (where a Captain wants to handle all
flight tasks, and the FO does very little), or poor communication (where crew members do
not discuss their thoughts or actions, making it impossible to collaborate to accomplish a
task).

Mental Health and Stress

Historically, there has been a reluctance among aviation professionals to discuss or treat
mental health concerns. This problem is made worse by the fact that professional licenses
require medical certification. To retain their medical certificates, professionals may choose
to lie about or conceal mental health concerns, avoid treatment, or self-diagnose and self-
treat. Although severe mental illness is rare, one study of civil aviation pilots determined that
23.7 percent of those with a heavy workload were suspected to have common mental health
disorders (such as anxiety or mood disorders) with severe depression experienced by up to
12.6 percent. Mental health concerns are second only to cardiovascular issues as the most
common reason for aviation professionals losing their medical certificates [10]. To promote
safety, the aviation industry must move to support those suffering from mental health issues
and devise treatment plans that allow people to be monitored and return to work when
possible.

Fatigue

Fatigue is a complicated issue linked to reduced physical and mental performance and
alertness. Fatigue is associated with a variety of factors, including sleep requirements,
continuous hours awake, and circadian rhythms. Cumulative sleep debt is a risk for aviation
professionals, who may get less than adequate sleep for several days in a row because of a
trip or duty schedule.

Continuous hours awake can also negatively impact performance. A period of 20 to 25 hours
of wakefulness negatively impacts performance to the same extent as a blood alcohol
concentration of 0.10 percent (a level of intoxication deemed unsafe for driving).

Lastly, fatigue can result from jet lag—when a person’s natural sleep/wake schedule is out
of sync with the day/night schedule of his or her current location. Jet lag is common among
crews of long-haul flights, who may spend only a few days in a foreign destination before
piloting an aircraft back home.

Situational Awareness

Situational awareness refers to a person’s mental picture of his or her environment. There
are three components to situational awareness:

1) perception of the relevant environment (e.g. other aircraft or mountains);

2) understanding of the situation (how elements of the environment may impact a flight);
and

3) prediction what risk those elements may pose to a flight.

Errors can be made on all three levels: a pilot may not perceive another aircraft during visual
flight, a controller may misunderstand a position report, or a maintenance engineer may not
be able to predict how his or her actions could impact a flight.

Organizational Approach to Safety

Historically, the aviation industry’s approach to safety was reactive. After an accident
occurred, changes would be made to improve the safety of the entire industry.
The modern approach is for organizations to integrate a safety management system (SMS)
into their operations. Rather than a reactive approach, this approach is proactive as it
actively seeks out sources of risk and eliminates them before any harm is done.

SMS are based on an organizational safety philosophy, meaning that to achieve safety, it is
necessary to consider all aspects of an organization from high-level management decisions
to the actions of front-line employees.

Organizational Approach to Human Error

The organizational approach to safety asserts that a safe system is not one without risk, but
rather one that identifies hazards and works to reduce the associated risk proactively (before
an accident occurs); and a safe aviation industry cannot be achieved by States or operators
working in isolation. It requires a coordinated effort from all stakeholder groups involved with
air transportation.

Rather than seeing a pilot’s mistake as the singular cause of an accident, the organizational
approach considers that mistake just one of a sequence of failures that took place at
multiple levels within the organization. James Reason’s Swiss cheese model helps to
describe the relationship between these levels. Reason proposed that an aviation
organization can be thought of as “layers of Swiss cheese” with each layer representing an
element of the company, from front-line employees up to high-level management [21].

Each layer has holes, which represent weaknesses in the system called latent failures.
Latent failures can be thought of as accidents waiting to happen—an example would be a
wet floor that does not immediately cause an accident but has the potential to cause a slip
or fall. Front-line employees can also cause an active failure, which is a mistake that has
immediate consequences.

Building on Reason’s work, the human factors analysis and classification system (HFACS)
describes human error on four levels: (1) unsafe acts of operators, (2) preconditions for
unsafe acts, (3) unsafe supervision, and (4) organizational influences [22].

1) Unsafe acts of operators include errors (honest mistakes); and violations (intentional
rule-breaking).

2) Preconditions for unsafe acts include environmental factors (adverse physical or

technological environment); condition of operators (poor mental or physiological state); and
personnel factors (crew resource mismanagement and lack of personal readiness).

3) Unsafe supervision includes inadequate supervision; planned inappropriate operations;

failure to correct problem; and supervisory violations.
4) Organizational influences include resource management; organizational climate; and
organizational process.

International Safety Regulations

As the aviation industry shifted toward an organizational approach to safety, ICAO took a
leadership role in ensuring uniformity around the globe. In 1997, ICAO launched the Global
Aviation Safety Plan (GASP), based on a series of recommendations developed by the Air
Navigation Commission (ANC) and industry representatives. The GASP work continued, and
in 2005, the Industry Safety Strategy Group (ISSG) worked with ICAO to develop a global
aviation safety roadmap. This roadmap is the foundation of the global framework for
coordinated safety policies, guiding future work of the GASP. Membership in the ISSG
includes representatives from Airbus, Boeing, Airports Council International (ACI), Civil Air
Navigation Services Organisation (CANSO), International Air Transport Association (IATA),
the International Federation of Air Line Pilots’ Associations (IFALPA), and the Flight Safety
Foundation (FSF).