SAFETY FINAL

From our initial discussions of this subject and the significance of Maintenance Human Error & Ground Accidents, the average cost per year world-wide is:

$10 billion dollars

The "Swiss Cheese" model of human factors shows how "holes" line up in each of the "barriers" to human errors as they progress through the causal sequence. If the errors go through all of the barriers:

An Accident Occurs

From our initial discussions, . . . is concerned with human dimensions, measurements, and demographic ranges throughout the human population.

Anthropometry

Which of the following "Barotrauma's" could result in a ruptured eardrum?

Barotitis Media

Which of the following aircraft has the highest rate of gear-up landings, primarily due to the design and positioning of the flap and landing gear levers:

Beechcraft Bonanza

From our discussions on Ignorance or Lack of Training, asking an experienced pilot landing an airplane "when do you flare" just before the flare, forces them to think and fall back on which of the following skills, causing them to make a bad landing:

Decisional

In considering the four types of Hypoxia, ingestion of alcohol produces which of the following types:

Histotoxic

In terms of workload, a pilot who has reached his/her level of "task saturation" while flying will likely:

start "spilling" or ignoring task demands, regardless of severity or priority

From the research being carried out at the Western Electric Company in the 1920's, which of the following theories determined that human beings change their behavior if they believe they are being observed:

the "Hawthorne Effect"

In the discussion of the "Go Airlines" CRJ-200 incident which happened in 2008. The incident in which both pilots fell asleep on a flight from Honolulu to Hilo, Hawaii and overflew the big island by 30 miles before ATC was able to wake them up. What illness did the Captain suffer from, this was the first time it was ever implicated in contributing to a pilot falling asleep while flying?

Severe Obstructive Sleep Apnea

Why did the Continental Express Flt 2574 (EMB-120 Brazilia) crash near Eagle Lake Texas in 1991?

-Maintenance crew left 47 screws out of the top leading edge Horiz stabilizer skin. -the horizontal stabilizer separated from the vertical fin causing the aircraft to depart controlled flight, which was then unrecoverable by the pilots.

Which of the following statements properly defines "Airmanship"?

-A sound acquaintance with the principles of flight. -The ability to operate an aircraft with competence and precision. -The exercise of sound judgment that results in optimal safety and efficiency.

In our initial discussions, the two Southwest Airlines accidents at Burbank and Midway Airport both involved:

-houses or structures around all sides of the airport -no or small overrun areas beyond the paved surface -short runways

The average retention capacity for Short-Term Memory in humans is about:

7 - 9 digits for 20 seconds

Considering the first class of human error, in the case accidents involving the Boeing 727 approach/landing accidents in 1965, what did the NTSB ultimately conclude the problem was?

-the Captains flying each at the time of accident had few hours in it & inadequate transition time into the aircraft from the older aircraft they had a lot of experience in -there was nothing inherently wrong with the B727, just the senior pilots unfamiliarity with it.

In our discussion of Maintenance Human Error, the case study involving American Flight 191 at O'Hare in 1979 involved a method to change out wing-mounted engines which:

-used large forklifts to support and move the engine -was first developed and recommended by 2 AA mechanics in Tulsa

From the short video contained in the Errors Induced by Psychology powerpoint, "Why Smart People Do Dumb Things", list the 4 reasons it happens, the briefly describe how each one works (or give an example the video used for each one).

1. Cognitive Miserliness: People capable of intelligent reasoning, but who don't apply that power effectively. Rely too much on gut feelings. Example is apparent intelligent people can fall for fake news if they rely too much on the gist rather than the details 2. Motivated Reasoning: Due to an emotional pull of an argument, we can think very one-sided. Example is it allows you to rationalize poor business ventures or a failed love affair. 3. The curse of Expertise: After years of experience in a job, people may begin to work on auto-pilot, and that automatic decision making can sometimes miss vital information 4. The Too-Much-Talent Effect: Smart people can act stupidly thanks to people around us. A sense of conflict and competition within a group can reduce each member problem solving skills and creativity. One or two arrogant members can ruin a team dynamic and reduce performance of whole team.

From the presentation, "Titanic and the 7 Classes of Human Error", identify at least one example for each of the 7 Classes of Human Error:

1. Design Errors Inadequate lifeboat capacity- more people could of been saved 2. Ignorance or Lack or Training Largest ship ever built Most officers & senior crew came from sail era- nobody was fully prepared 3. Deliberate Action/Inaction Captain Smith cancelled scheduled lifeboat drill set for 14 April. -training could of helped panic that set in, no one knew what to do 4. Physiology Hypothermia effects on lookout's level of attention directly effected survival after the ship sank 5. Psychology Captain & crew's belief that the ship was unsinkable.- ego was to big 5.5 Perception (illusion errors) Dark, moonless night and flat calm sea state Made ability to see iceberg hard 6. Environmental Errors British Board of Trade-lifeboat issues/16v32 7. Crew resource errors Radio operations-personal messages took priority, causing receipt of iceberg warnings to be delayed American Inquiry Report blamed Capt. Smith & lack of lifeboats British BOT Inquiry Report blamed Capt. Lord of Californian & lack of lifeboats

Briefly list and discuss the "Failure to..." items which are the 7 ways that Cockpit Resource Error manifests. Apply the 7 "failures to..." to the crash of United Flight 173.

1. Failure to Prioritize-first priority any time flying is FLY THE AIRCRAFT. No matter what else happens: FLY THE AIRCRAFT! All other things can be done after that. In UAL they were not focused on flying the aircraft, instead just focused on one problem not looking at anything else. 2. Failure to Delegate: You have another pilot in the cockpit, work together, give them tasks. In UAL they all were focused on landing gear problem, the captain should have delegated tasks to other crew-members. 3. Failure to Communicate- is ALWAYS 2-way. This goes along with delegating. In example of UAL if the captain would have communicated with his crew they would have decided who is doing what, and the problem would have been avoided. 4. Failure to Monitor-Pilots need to be looking at all instruments regularly. Pilots are very bad at this. UAL shows this by both pilots failing to monitor how much fuel they have remaining. 5. Failure to follow Procedures/Regulations: Make sure to be following all guidelines set up by FAA and the airline you are working for. 6. Failure to Command-over command, under command, neutral. 7. Failure to Use Available Information-sometimes its right in front of us. To see, you must first look. In UAL all they had to do was look up in front of their face at the instrument and none of them did this causing a fatal accident.

The . . . model (my personal favorite) of human factors was developed by Dr. Stanley Roscoe and C.O. Miller:

5-M's

Which type of Long Term Memory is the one in which we store memory of events or occurrences?:

Episodic memory

Each of the following is one of the "7 Classes of Human Error" EXCEPT

Errors induced by Sociology

The SHEL(L) model of human factors was originally developed by Edwards, and modified and adapted into its current form by:

Frank Hawkins

From our discussion of the history of Human Factors, the discipline of "Scientific Management" was invented by:

Frederick Taylor

In our discussion on Cockpit Resource Error, we examined the case study of Eastern Airlines Flight 401, the L-1011 which crashed into the Everglades near Miami in Dec. 1972. What was the air traffic controller's failure which resulted in the pilot's on 401 misunderstanding what he was asking them when they descended below his radar coverage?

He used the phrase "EAL 401, how are things going out there", instead of "Eastern 401, say altitude"

In the SHEL(L) Model, the . . . interface reflects the interaction between the aircraft and the pilot:

Liveware-Hardware

In our discussion of Maintenance Human Error involving American Airlines Flt. 191 at Chicago-O'hare in 1979, we looked at the decision to use forklifts to change out wing engines on DC-10 aircraft as it applied to the Hierarch of Human Error. Which of the following was the only entity in the entire chain of command (and of the Hierarchy) to say, "no, this is not a good idea and we recommend strongly that it not be done!" Everyone else involved in the decision-making thought it was a great idea.

McDonnel-Douglas

The most commonly used "Personality Preference" type test is based on Jungian psychology and identifies "preferences or tendencies". The test is the...

Myers-Briggs Type (preference) Indicator

The term . . . is defined as a decrease in ability to focus or pay attention during a task which heavily involves monitoring over long periods of time.

Performance Decrement

From our discussion on Maintenance Human Error, we reviewed the FAA's "Dirty Dozen" which were the 12 pre-conditions they identified as unsafe acts leading to accidents. The first one was "FATIGUE". Name 9 more.

Stress, Complacency, Communication, Awareness, Distraction, Lack of knowledge, Teamwork, Lack of resources, Pressure

The first airline accident in which "Jet Lag" (Circadian Desynchronization) was identified as a factor in the accident was:

The China Airlines Boeing 747-SP in-flight upset 350 NM from SFO in 1985

What is still the worst single-aircraft crash in airline history?

The Japan Airlines Flight 123 Boeing 747 crash in Japan in 1985.

In the mishap from question #6 (Eastern 855, L-1011, Miami) , why did the mechanics fail to put in the necessary components before installing the parts in each engine?

There had been a recent procedure change relating to getting new parts from maintenance stores. Before, the necessary components were already installed on the parts, now the mechanics had to install the components on the parts before putting them in the engines.

In considering the PSA B727 (Flt 182)midair collision with the Cessna 172 at San Diego in 1978, why did the crew of the 727 stop looking for the reported traffic?

They thought they saw it and there was really a second one still in front of them that they hit

From our initial discussions of human factors, which of the following accidents prompted United Airlines to develop the first Cockpit Resource Management programs?

United 173, DC-8, Portland, OR in 1978

From Japan 123 (questions 17 & 18), once the aft pressure bulkhead blew out and pressurized the tail fin, which then blew most of the vertical fin off, what else failed which ultimately caused the loss of control which resulted in the crash?

all 4 hydraulic systems were located side by side in the fail and they all 4 were ruptured by the forces from the explosive decompression, when all of the fluid was lost, the aircraft became uncontrollable.

From the video regarding American Airlines Flt 1420, the MD-82 which crashed at Little Rock, Arkansas in June 1999; and the class worksheet for the video and accident, briefly identify the major factors regarding the crash---answer the following questions:

What is happening to the weather as they get closer to LIT? As the plane is getting closer to its destination, the weather continues to deteriorate. ATC issues a weather advisory to show severe thunderstorms in the area of Little Rock, but thinks there is a gap at LIT for them to fly through. The crew also sees lightening while on approach. What happens during their first approach? On their first approach, they are told to expect runway 22L, but they are soon advised of a change in wind direction and speed. This leads the Captain to request a change to a runway 4R so they can land into the wind. In order to land on the opposite runway, they had to move away from the airport causing them to lose visual on the runway. As they moved out a thunderstorm had appeared over the airport. When does the Captain consider diverting to the alternate? The captain never even considers a diversion. During the second approach, what is the weather doing? As they approach for the second time, they lose visual of the airport causing them to request an ILS approach. As they line up on final they are facing the heart of the thunderstorm. Because of the storm the pilots rushed to land, leading them to skip multiple items on their checklist. The RVR goes down to 3000 and the pilots become unsure of if they should land. What critical information does the Captain not have regarding the crosswind? The crosswinds are way over the limit to land. As they continue on the visibility also drops below the limit. Earlier stated the Captain and First Officer were discussing the limitations for crosswind and they were both wrong. They had only stated the limitations for a dry runway and the airport they were landing at was raining. What is happening to the Captain's situational awareness as they continue? As they continue on the Captain only further loses

What type of mission was the U.S.S. Greenville (nuclear attack submarine) conducting when she collided with and sank the Ehime Maru?

a "Distinguished Visitor Program" (demonstration/familiarization) cruise for civilian CEO's

The "Cambridge Cockpit" was created by the British during World War 2 to conduct research on the pilot-control interfaces using a real cockpit taken from:

a Supermarine Spitfire

What kind of mission was Riddle 02, the 172S which had to conduct an emergency landing on the dirt strip near Arcosanti at Cordes Junction flying that day:

a post-maintenance test flight after a new engine installation.

From our discussion of Aviation Ground Accidents, we examined a ramp deplaning accident in which the co-pilot of a corporate aircraft dropped his pen while descending the aircraft stairs. What did he impale himself on when he tried to retrieve it?

a static wick

___________________ is the term for the highest point in the 24 hour circadian rhythm for each of the bodies systems, the point at which each of us is at the highest state of alertness and performance capacity:

acrophase

From the Japan Flt 123 crash in 1985 (accident in question 17), why did the aft pressure bulkhead blow out?

after the accident 7 years prior, the Boeing repair team which had gone to Japan to fix the aircraft had improperly repaired the damage to the aft pressure bulkhead which made the repaired section much weaker and fatigue cracks ran much faster than expected.

Considering the Air Midwest (U.S. Airways Express) Beech 1900 crash in Charlotte, NC, which failures came together with the aft CG to cause the crash:

an outsource mechanic's misrigging of the elevator control system in the aircraft so that downward pitch control was reduced by over 50%. That work was done7 flights previously

Considering the Over the Counter (OTC) medications we all ingest, which has the most significant effect on pilot performance:

antihistamines

From our initial discussions, what phase of flight do most aircraft accidents happen in?

approach and landing

____________________is the capability an individual has to learn.

aptitude

"Anchor Sleep" is defined by the FAA as:

at least 4 hours long at the pilot's home domicile

________________is a visual illusion in which a static light appears to move when stared at in the dark.

autokinesis

Human beings are classified as a "predator" species. We can tell this by:

because our eyes are positioned in the front of our skull

In considering leadership, which of the following is the only manifestation of a person's actions or inactions that we can directly see (During our Psychology discussion):

behavior

What is the most commonly ingested drug in the United States (and most of the world for that matter)?

caffeine

Caffeine is chemically in the same plant-based pharmacological family as:

cocaine

Considering FAR 91.17a,b,c,& d, how much alcohol is legal for a pilot to ingest before flying?

considering 91.17 a, b, c, & d, none

From the 3rd class of human error (Deliberate Action or Inaction), what did one of the crewmembers of the Marine EA-6B Prowler do with the videotape they had been making when they got back to Aviano AFB, Italy after they collided with and cut the cable causing the gondola to crash killing 20 people? The video would have shown their low altitude and the collision with the cable, but another crewmember had already mentioned the video.

destroyed the tape

As we discussed in class, a pilot who engages in aerobatics near an airport area where he/she knows there are plenty of people watching is most likely operating at the _____________level:

ego or esteem

In our discussion on "Fatigue", we identified 3 types of fatigue. Which of the following answers is this description for: ______________ fatigue is caused by wearying effects of working under trying conditions or performing psychologically disagreeable tasks.

emotional fatigue

The psychological process of. .. . is that whereby we anticipate an event or occurrence, making us much more likely to detect or solve it:

expectancy

______________ is the difference between perception and reality:

illusion

Pilot's generally poor diet habits can result in "transient" or "reactive" hypoglycemia. This is usually caused directly by:

ingestion of too much sugar too fast

The most significant common factor in all the ways the "Induced by Design" class of human error causes people to make mistakes is:

non-standardization

In our discussion of the 6th Class of Human Error (Environment), some of the strongest "distractions" involved in producing human error by pilots come from:

problems with the aircraft

A pilot who has been prescribed a medication by a doctor, but is not sure it is legal under the FARs to fly while taking it should:

refer to one of the on-line sites which specify "approved, not recommended, or prohibited for flight".

A common factor, which turns out to be a very fertile venue for human error to occur in aircraft maintenance, which was discussed in both the American Airlines DC-10 (Flt 191) accident in Chicago and the Continental Brazilia crash near Houston in our discussion of maintenance human factors, is that the work done on the accident aircraft was spread over...

shift changes

From our discussion of "Aviation Ground Accidents", which type of ramp accident causes the most injuries, according to a study by the Flight Safety Foundation?

slips, trips, and falls.

How were the investigators of Air France 447, the A330 that disappeared on a flight from Rio to Paris in 2009, able to figure out that the crash was caused ultimately by a failure in airmanship rather than something more technical?

the French government was able to recover the flight recorders and the CVR & DFDR told the story.

What set of evidence ultimately caused the investigation to focus on the pilot's complete loss of situational awareness as they all tried to figure out why the automation stopped working and they then failed the ultimate test of airmanship and let the aircraft crash with the loss of all aboard.

the French searchers found the wreckage of the aircraft on the ocean floor and recovered the flight recorders nearly 2 years after the crash, both of which still had intact and readable memory.

In what "era" did the first attempts at understanding human performance and efficiency in a workplace setting begin?

the Industrial Revolution

In the discussion of Maintenance Human Factors, we discussed the Eastern Flt 855 accident involving the L-1011 flying from Miami to Nassau, Bahamas. What did the mechanics fail to install in the engines of the aircraft which led to the failures:

the O-rings in the chip detectors which were changed out before the flight

From the 3rd Class of Human Error (Deliberate Action or Inaction), we examined the Czar 52 B-52 accident at Fairchild AFB in 1994, the end of the accident sequence (and "proximate event") which directly led to the loss of control and crash was caused primarily by:

the aircraft commander's failure to advance throttle fast enough before maneuvering into a hard roll during an unexpected go-around after the practice routine had been completed.

From our discussion of the Japan Airlines Flight 123, the Boeing 747 that crashed about 32 minutes after take-off from Tokyo, what kind of accident happened to the aircraft 7 years earlier which directly led to the failure which caused the crash?

the aircraft had a tailstrike after a botched attempted go-around

The "Accident Profile" for general aviation pilots showed that the most common type of person to have an accident was a 35-year old male with a private certificate and 100-500 hours. This was developed by:

the aviation insurance industry

From the discussion of the accident involving Northwest Airlines Flight 255, the MD-82 which crashed at Detroit in August 1987, what did the pilots fail to properly deploy before attempting the takeoff, which caused the aircraft to stall and crash, killing all but 1 aboard?:

the flaps

Why did JFK Jr. crash the Piper Saratoga he was flying in 1999, killing everyone aboard?

the hazy conditions offshore just after sunset disoriented him resulting in a spiral to the surface

In the case study involving the Chalk's Ocean Airways Grumman Mallard which crashed at Miami in 2005, the cause of the crash was...

the in-flight separation of the right wing due to undetected metal fatigue in the spar.

What involvement did the mechanic's checklist have in causing the oil system failure in Riddle 02 (the 2 previous questions about the ERAU Cessna 172S at Cordes Junction)?

the lead mechanic used "powerstamping" to sign off all of the items on the checklist all at once after all the work had been completed and both mechanics missed it.

In the crash of Eastern 401, what had actually failed on the aircraft?

the lightbulb for the nose gear landing light

From our initial discussion of the "Induced by Design" class of human error, we looked at an accident case involving a Northwest Airlines Boeing 727-225 that crashed near Thiels, New York in December of 1974. The aircraft was on a re-positioning flight from JFK to BUF with only the pilots and FE on board. As it climbed in the dark and stormy night, the Captain referred several times as to how fast their airspeed was increasing. The aircraft reached top of climb at 25,000 ft, departed controlled flight, and entered a spin which continued to impact. What did the co-pilot incorrectly switch off that led to everything else that caused the crash?

the pitot tube anti ice switches which caused the tubes to ice up and the airspeed indicator became an altimeter become

In our discussion of Air France 447, the A-330 which crashed into the ocean on a flight from Rio to Paris, what was the first failure which then cascaded into a complete automation failure (all 3 primary flight computers and both back-ups failed) causing the aircraft to default into "alternate law" which in Airbus-speak means all envelope protections are gone. Or more simply, the pilots must manually fly the aircraft with the primary flight controls.

the pitot tubes all iced up, causing loss of all of the dynamic air pressure sensing.

What caused all the oil to come out of the engine on Riddle 02 (the 172S in the previous question)?

the plastic shipping plugs in the hollow propeller shaft had not been properly replaced by the required steel plugs.

In our first discussion about human factors, we considered the relationship between the Hierarchy of Human Error and the Multilinear Event Sequence approach to accidents. The pilot is most directly involved in the Multi-Linear accident sequence at:

the proximate event

The World's worst airline accident was almost completely the result of a series of human errors. This was:

the runway collision between 2 B747s at Tenerife in 1977

In considering the crash of Ethiopian Airlines flight 302, the B737MAX which crashed shortly after takeoff last year, what did the pilots both fail to keep track of, which was the main reason they couldn't use the manual trim wheel to move the horizontal stabilizer to correct the nose-down position of the stabilizer after the MCAS system failed?

they had failed to look at the airspeed which reached almost 500 kts because the autothrottle was still in "takeoff-climb power" mode

Why did the United Airlines flight 173, the DC-8 at Portland, Oregon in 1978, which caused United to create the first CRM programs, crash?

they ran out of fuel

In the Helios Air B737 accident in Greece in 2005, the aircraft had a subtle, but rapid decompression, resulting in the crew losing consciousness, with the subsequent crash and loss of all aboard. The main reason the pilots failed to react properly and use their emergency oxygen was:

they thought it was a configuration problem and not a real decompression and they both passed out before they could react.

The pilots on Air France Flight 447 should have been able to stabilize and fly the A-330, even with all the automation and protections gone, by simply relying on basic pilotage and airmanship, and using the analog back-up instruments (on the upper left of the center instrument panel) for flight reference information.

true

In examining the 'input' part of the aviation "Decision-making" model, we find that in humans most of the external sensory information comes to us through the. . . channel:

visual