RISK AND HUMAN ERROR IN REMOTELY

PILOTED AIRCRAFT SYSTEMS (RPAS)

DEVELOPING A ROBUST PLATFORM FOR IMPROVED RISK MANAGEMENT

JULY 2015
AUTHOR

TRACY LAMB
Aviation Advisor, SGS HART Aviation
ABSTRACT
Remotely Piloted Aircraft Systems (RPAS) This paper identifies human performance REFERENCES
or ‘drones’ are the fastest growing sector factors and their effect in the domain
Hobbs, A. and A. Williamson (2002).
of the aviation industry. Exponential global of risk management systems for RPAS.
“Skills, rules and knowledge in aircraft
interest in RPAS predicts the civil RPAS The interaction and osmotic nature of
maintenance: errors in context.”
market to be worth between USD 62 these unique factors combine to produce
Ergonomics 45(4): 290-308.
billion and USD 400 billion per year by unique and dynamic hazards and risk that
2015 (Wickham 2012). Diverse capabilities, must be treated by a reliable and practical Wickham, C. (2012). “Military drones
low costs, little regulatory guidance and tool. Utilising proven risk management zero in on $400 billion civilian market.”
oversight are characteristics similar to that frameworks and taxonomies such as; REUTERS.
of the chaos of the automobile industry of HFACS, The SHELL Model and Reason’s
the 1920s (Hobbs and Williamson 2002). Swiss Cheese Model, and the principles
If RPAS are to achieve seamless and safe in ISO 31000, a robust approach to risk
integration within civil airspace, and the management has been developed by SGS
commercial sector, a holistic and predictive HART Aviation.
safety/risk management systems model is
needed.

CONTENTS
I. THE DRONE REVOLUTION ...............................................................................................................2

II. THE REAL RISKS OF REAL ‘TOYS’.................................................................................................3

III. THE RESEARCH BEHIND THE SGS RPAS RISK MANAGEMENT FRAMEWORK...............5

IV. HARNESSING THE POWER OF THE RESEARCH ......................................................................8

V. CONTINUAL IMPROVEMENT USING RPAS EVENT DATABASE............................................15

VI. THE WAY OF THE FUTURE.............................................................................................................16

VII. CONCLUSION..................................................................................................................................18

2
I. THE DRONE REVOLUTION
Remotely Piloted Aircraft Systems (RPAS)
are the fastest growing sector of the
aviation industry with recent market
forecasts predicting the civil RPAS market
to be worth between USD 62 billion
and USD 400 billion per year by 2015
(Wickham, 2013). The commercial RPAS
market is experiencing exponential growth,
which is projected to be worth over USD
93 billion worldwide within the next
decade (Washington Post, 2015). Much of
that growth will be reflected in the support
systems and services, with safety and
risk management the essential vehicle in
supporting operations.
This paper is based on findings from
accident investigations, of both aviation
and industrial sectors, focusing on
human error perspectives established
from accident causation models such as
Professor James Reasons’ ‘Swiss Cheese
Model’ 1 and the acclaimed SHELL2 and
HFACs3 models.
SGS HART Aviation has used the research
from these models to develop a world first
in RPAS risk management, an interactive
web-based tool specifically designed for
RPAS operations safety assessments. It is
called the RPAS Risk Management Tool. It
is an indispensable web-based tool for your
laptop, desktop or iPad, and is poised to
set a new standard in the safety of RPAS
operations.
In addition to dynamic growth, RPAS
are diverse in their design, capabilities,
and their applications (Palmer & Clothier,
2013; Weibel & Hansman, 2005). Around
1 Swiss Cheese Model – (Reason, 1990).
2 SHELL – Software, Hardware, Evironmental, Liveware – Liveware interactions (Edwards, 1972).
3 HFACS – Human Factors Accident Classification System (Wiegmann and Shappell, 2003).
the world, many diverse industries are
recognising that using remotely piloted
aircraft systems (RPAS), ‘drones’, or
‘UAVs’ for commercial inspection and
monitoring are yielding extensive benefits
in productivity, safety and efficiency. RPAS
operate in confined and dangerous spaces,
close to energised wires, toxic and volatile
environments, within close proximity (and
sometimes in contact with), industrial
structures and equipment.
Industry sectors are embracing this
technology as a matter of urgency to
maintain the competitive edge in acquiring
the valuable data and imagery that these
systems are capable of collecting. Gaining
data and images using RPAS is achieved
at a faster rate with greater safety and in
most cases more accuracy. In addition to
the data collection efficiency, cost savings
when compared to using conventional
aircraft or helicopters are significant.
Despite the considerable benefits in
utilising RPAS, there are significant risk
factors that must be considered when
using them in commercial applications.
Although removing the flight crew from
the aircraft, and the rigging crew from
high towers and dangerous environments
increases safety, RPAS poses unique
challenges to safety and efficiency.
Research has found that having the
human separated from the machine
produces unique human performance
and risk factors that attract a multitude
of hidden hazards. These unique hidden
or ‘latent’ risk factors emerge as the
most dangerous, due to the innocuous
perception that they are a fun and
harmless addition to your inspection
toolbox.
RPAS mishap rates are up to 300 times
greater than that of general aviation
conventionally piloted aircraft fleets
(Carrigan, Long, Cummings, & Duffner,
2008). This trend of ubiquitous mishap
rates is exacerbated by the unprecedented
growth in the utilisation of RPAS across
many industries.
The supply and demand dynamics of RPAS
have been compared to the initial chaos of
the automobile boom of the 1920s (Hobbs
and Herwitz 2006). RPAS are affordable,
easily accessible and in many countries
have little or no regulatory or corporate
governance.
Even though these devices are available to
the public for recreation, they are classified
as aircraft (ICAO, 2015), and when utilised
for commercial purposes, fall under the
classification of an Aviation Business,
and therefore those who utilise them
are bound by the jurisdiction of the Civil
Aviation Authority in each country.
By the end of 2015, every country that is a
member of ICAO (192 contracting ‘states’
or countries), will be obligated to finalise
and implement legislation for RPAS. Global
harmonisation of RPAS operations is a high
level objective of ICAO, just as all other
aviation operations are harmonised around
the world (ICAO, 2015).
3
II. THE REAL RISKS OF REAL ‘TOYS’
The novelty and ‘fun’ factor of this
affordable equipment attracts users
with little or no professional aviation
experience. It is recognised that this
increases the opportunity for latent risk
producing conditions. Despite this fun
way of carrying out visual inspections,
thermographs, photogrammetric and
infrared data collection, it must be
emphasised that, in the past 13 years
over 10 RPAS crew and observers have
been killed by their remotely piloted
aircraft, and thousands of injuries have
been reported worldwide (Lamb, 2015).
While some people may compare those
fatality rates to that of aircraft accident
fatalities, or even to work related
deaths at heights and in dangerous
environments, the comparative
differences in risk cannot be accepted.
RPAS operations present human factors
challenges different from, and in some
ways greater than, those of manned
aircraft (Gawron 2008). In fact, human
error has been found to be the significant
contributing factor in 60.2% of RPAS
mishaps (Tvaryanas, Thompson, &
Constable, 2006).
With error rates at these elevated levels,
the risk to stakeholder investment,
property and productivity can represent
upwards of millions of dollars. The
shutdown of a hot stack on an oil refinery
can represent a cost greater than USD
7.62 million per day. Electricity supply
interruptions cost industry between USD
26 billion and USD 400 billion annually
(Eto & LaCommare, 2004). A flashover
event within a power line system can
cost in excess of half a million USD, not
withstanding human costs associated
with serious injury or death to the local
crew in the vicinity.

III. THE RESEARCH BEHIND THE SGS RPAS

RISK MANAGEMENT FRAMEWORK
To explore how the human risk
conditions affect the safety of RPAS
in commercial operations, we turn to
HARDWARE
the foundational works of Wiegmann,
Shappell, Edwards, Rassmusen,
Svendung and Reason. These works
are the cornerstone of discovering,
classifying, investigating and treating risk
in complex, high risk environments. The
Human Factors Analysis Classification
System (HFACS) is generally accepted
as the most comprehensive tool THE HUMAN OR ENVIRONMENT
SOFTWARE
for investigation of RPAS mishaps ‘LIVEWARE’
to date (Carrigan, Long et al. 2008,
Tvaryanas and Thompson 2008,
Dolgov and Hottman 2012). These
works are frequently illustrated and
used in conjunction with well known
models, including the SWISS CHEESE
and SHELL models for explaining the
LIVEWARE
interactive, multifaceted and multi-
dimensional nature of causational factors
that contribute accidents in complex
environments.
Figure 1. SHELL Model (Edwards, 1972)

4
One of the most unifying theories in
illustrating accident causation influences
is the ‘Swiss Cheese Model’, developed
by Professor James Reason. It illustrates
how latent risk factors (represented by
the holes in Swiss cheese) can remain
hidden or undiscovered in an operating
system. Accidents are only prevented
by multidimensional layers of safety
defences such as checklists, policies,
procedures, and training, to name a few
(defences are represented by the slices
of cheese).
Accidents are a result of these latent
conditions aligning, through human and
system error or omission, and are usually
the result of multiple failures, such as
poorly written policies, or checklists,
lack of governance or supervision, the
workload of the crew, incorrect training
and other factors too numerous to
mention. When the weaknesses or
‘holes’ in defences line up, the accident
chain of events is allowed to progress
to the mishap or accident, and this
translates into direct and indirect losses.
The Swiss Cheese model has limitations,
in that it fails to identify the exact holes
in the slices, or exactly which types
of failure contributed to the accident
(Wiegmann and Shappell 2003).
“Unfortunately these multi-dimensional
interactions are often hidden from the
IV. HARNESSING THE POWER OF THE
RESEARCH
SGS HART Aviation has unified all
of these strategies and systems to
develop the SGS Risk Management Tool,
which is now one of the world’s most
comprehensive Risk Assessment tools
for RPAS. The tool’s foundations are in
HFACS, a proven reliable and adaptable
classification system that works
synergistically with the principals of
Safety and Risk Management Systems
(SRMSs) as described by (Reason 1997,
Rasmussen and Svendung 2000).
Policy
HAZARDS
POORLY WRITTEN
UNCLEAR
MISSED BY CREW
INEFFECTIVE
Figure 2: Swiss Figure Cheese Model (Reason, 1997)
operator producing opaque systems
that, if not designed properly, can detract
from monitoring and diagnosing system
problems thereby producing accidents”
(Reason, 1990; Wiegmann & Shappell,
2003). Therefore, the application of
HFACS methodologies delivers a more
robust risk management platform.
Then there is the SHELL model of
human factors, first developed by
Edwards, 1972. This is used as a
classification framework with a human
The SGS Risk Management Tool is
proving to be indispensable for safe
and efficient operations. The core
methodology of the “human error
perspectives” is described as cognitive,
ergonomic, behavioural, aero medical,
psychosocial, and organisational. These
perspectives, as they are called, are
used by academicians and psychologists
for analysing human factors in complex
systems, developing cognitive
models, and human error taxonomies
RPAS SAFETY DEFENCES
Procedures
Checklists
Training
LOSSES
factors systems perspective, and
suggests that the human is rarely the
sole cause of a mishap. Like Reasons’
Swiss Cheese model, the SHELL
model is a descriptive, rather than
an analytical model, and therefore
has been extensively applied in the
aviation industry. It was adopted by the
International Civil Aviation Organisation
(ICAO) in 1993, as an industry standard,
as it was more usable for the industry
than the academic model proposed by
Reason (Wiegmann and Shappell 2003).
(Rasmussen 1982, Helmreich 1984,
Reason 1997).
Consequently, the systematic application
of the HFACS has afforded SGS HART
Aviation the ability to develop objective,
data driven, intervention strategies,
harnessing a systems approach to safety
that has been shown to be instrumental
to lowering human error in many
complex operating environments.
5
V. CONTINUAL IMPROVEMENT USING
RPAS EVENT DATABASE
The SGS HART Aviation risk
management tool stores and classifies
all types of RPAS events, from a simple
loss of communications link or software
malfunction, to a major mishap, allowing
the RPAS team quickly and easily
integrate this data into their safety
management system for event tracking
and establishing component reliability,
while also improving safety systems.
Research shows that the accident rate
attributed entirely to human factors is
decreasing more slowly than accidents
attributed to mechanical failure (Rash,
LeDuc & Manning, 2006). This indicates
that as RPASs increase with maturation,
human factors will feature more
prominently as a percentage of the
causal factors in accidents (Hobbs and
Herwitz 2006).
It is vital to note that human risk factors
are variable and dynamic, depending
upon the surrounding multi-faceted
environment in which the RPAS is
VI. THE WAY OF THE FUTURE
Never before in human history has
innovation in aviation been so affordable
and accessible to the public and
industry alike. While the Civil Aviation
Authorities of the world struggle to unite
on harmonious legislation, previously
nonexistent RPAS organisations are now
the highest global earners in financial
6
operating. The levels of automation,
the complexity of the system, and the
number of human interactions all affect
the level risk and hazard types.
The holes in Reason’s Swiss Cheese
model are not static, they move about.
These risk opportunities in RPAS
operations are often opening and closing,
and changing location. Latent hazards
or risks are dependent on opportunities
and relationships between the risk
factors, dynamics of the interaction
between the humans, and also the
human machine interface, the ‘liveware
to liveware’ component in the SHELL
model (Wiegmann and Shappell 2003,
Tvaryanas and Thompson 2008, Dolgov
and Hottman 2012).
Utilising the full function of the
RPAS Event Register is of increasing
importance to track human factor events.
This is comprehensively managed as
part of the SGS HART Aviation Risk
Management tool that harnesses
history. Some predict the invasion of
the ‘drones’ to pose the highest risks to
civil airspace, while some are using this
technology to save and improve lives.
There is no doubt, RPAS, UAVs or
drones, are the way of the future. While
mechanical reliability continues to
improve with an exponential growth in
the data collected from global RPAS
operations to further analyse accident,
mishap and event trends.
While the validity and proven
effectiveness of HFACS continues to
prevail as the cornerstone of taxonomies,
SGS HART Aviation also employs other
methods such as the 4 W’s in Military
Pamphlet 385-40, used by the United
States Department of Defence, (The
methodology of investigating the,
What, Where, When, Why?). These
factors encompass the incident type,
the environment and circumstances,
the causal factors involved and why the
active failures lead to the accident, as
well as what the organisation will do to
prevent further accidents (Dolgov and
Hottman 2012).
Recording all RPAS events and
categorising every aspect in the lead up
to an event, allows the SGS RPAS Risk
Assessment tool to continue to evolve
as a tool for continual improvement,
towards further excellence.
technology, the human component will
only improve with consistent training,
risk awareness and comprehensive risk
management tools.
Humans continue to be the most
complex and dynamic players in the
Remotely Piloted Aircraft System.
(Tvaryanas 2006, Wickham 2012)
BIBLIOGRAPHY
Carrigan, G., D. Long, M. L. Cummings and J. Duffner (2008). Human Factors Analysis
of Predator B Crash, MIT Humans and Automation Lab.
Dolgov, I. and S. B. Hottman (2012). Introduction to Unmanned Aircraft Systems. Boca
Raton, FL, CRC Press, Taylor Francis Group.
Gawron, V. J. (2008). Human Performance, Workload, and Situational Awareness
Measures Handbook. Boca Raton, FL, Taylor & Francis Group.
Helmreich, R. L. (1984). Cockpit management attitudes.
Hobbs, A. and S. R. Herwitz (2006). Human Factors in the Maintenance of Unmanned
Aircraft. Moffett Field, CA., San Jose State University Foundation, NASA Ames
Research Center.
Rasmussen, J. (1982). “Human Errors. A Taxonomy for Describing Human Malfunction
in Industrial Installations.” Journal of Occupational Accidents 4: 311-333.
Rasmussen, J. and I. Svendung (2000). Proactive Risk Mangement in a Dynamic
Society. Karlstad, Sjuharadsbygdens Tryckerie, Boras.
Reason, J. (1997). Managing the Risks of Organisational Accidents, Aldershot :
Ashgate.
Tvaryanas, A. P. (2006). “Human systems integration in remotely piloted aircraft
operations.” Aviation Space and Environmental Medicine 77(12): 1278-1282.
Tvaryanas, A. P. and W. T. Thompson (2008). “Recurrent Error Pathways in HFACS
Data: Analysis of 95 Mishaps with Remotely Piloted Aircraft.” Aviation, Space, and
Environmental Medicine 79(5): 525-525.
Wickham, C. (2012). “Military drones zero in on $400 billion civilian market.” ASX
Tecnical Analysis, Reuters USA, from http://www.reuters.com/article/2012/11/14/us-
science-drones-civilian-idUSBRE8AD1HR20121114.
Wiegmann, D. A. and S. A. Shappell (2003). A human error approach to aviation
accident analysis: the human factors analysis and classification system. Burlington, VT,
Ashgate.
Eto and LaCommare, 2004 - http://emp.lbl.gov/sites/all/files/REPORT%20lbnl%20-%20
55718.pdf
Helmreich, R. L. (1991). Strategies of Study of Flight Crew Behaviour. In International
Civil Aviation Organisation, Report of the Flight Safety and Human Factors Regional
Seminar. Bangkok, Thailand. November 1991.
Rash, LeDuc and Manning, (2006) Clarence E. Rash, Patricia A. LeDuc, Sharon D.
Manning (2006), 9. Human Factors in U.S. Military Unmanned Aerial Vehicle Accidents,
in Nancy J. Cooke, Heather L. Pringle, Harry K. Pedersen, Olena Connor (ed.) Human
Factors of Remotely Operated Vehicles (Advances in Human Performance and
Cognitive Engineering Research, Volume 7) Emerald Group Publishing Limited, pp.117
- 131

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 ABOUT THE AUTHOR
Tracy Lamb
Aviation Advisor, SGS HART Aviation
Tracy has 18 years experience in
commercial aviation, with over 7,000
flight hours as; an airline pilot on the
Boeing 737, a senior flight instructor,
charter pilot in the Australian outback,
including FIFO ops, and as an
international corporate jet pilot around
the Asia Pacific Region.
Being passionate about flying and about
safety, she is a specialist in human
factors, crew resource management,
safety systems and remotely piloted
aircraft systems (RPAS); she is an
ISO 9000:2008 lead auditor, and
conducts audits and inspections on
fixed wing, rotary wing and unmanned
aircraft operators and maintenance
organisations, both internationally and
around Australia.
Tracy holds awards for academic
excellence in her undergraduate and
post graduate qualifications in applied
science (aviation), masters in business
management, human factors and, in
conjunction with RMIT University in
Melbourne, Tracy is active in research
and development, in the areas of safety
and risk management in remotely piloted
aircraft systems. She is also a qualified
Remote Pilot.
ABOUT SGS
SGS is the world’s leading inspection,
verification, testing and certification
company. SGS is recognised as the
global benchmark for quality and
integrity. With more than 80,000
employees, SGS operates a network
of over 1,650 offices and laboratories
around the world.
SGS offers audit and consulting services
to enhance our customers’ business
processes and help them to deliver extra
value, improve quality management and
performance, minimise risk and gain
competitive advantage.
With a global presence, we have a
history of successfully executing large-
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Our people speak the language and
understand the culture of the local
market and operate globally in a
consistent, reliable and effective manner.
TO FIND OUT MORE CONTACT
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