A good day, or a bad day at the office

Depending on your perspective

Human Factors in Aviation
Design Delegation Holders, 20 October 2005

Dr Dougal Watson
Principal Medical Officer
Civil Aviation Authority
Lower Hutt New Zealand
A good day at the office!
 Human Factors:
Whats it mean?

Human Factors in action: On the way to Auckland this morning.

Human Factors:
Whats it mean?
What is Human Factors
and what is it not?

Human Factors = Ergonomics

Human Factors:
Design engineering
 Human Factors:
Definition 1
Human Factors is the scientific discipline
concerned with the understanding of
interactions among humans and other
elements of a system, and the profession that
applies theory, principles, data and methods
to design in order to optimize human well-
being and overall system performance.

International Ergonomics Association (http://www.iea.cc)

 Human Factors:
Definition 2
"Human Factors is about people: it is about people
in their working and living environments, and it is
about their relationship with equipment,
procedures, and the environment. Just as
importantly, it is about their relationships with
other people ... Its two objectives can be seen as
safety and efficiency.''

ICAO Circular 227

Not such a good day at the office!
 Human Factors:
Definition 3

Why do smart people do dangerous /

dumb things?
 Human Factors:
Involves humans.

Human beings by their very nature make

mistakes; therefore, it is unreasonable to expect
error-free human performance. Shappell &
Wiegmann, 1997.
A bad day at the office!
 Human Factors:
Why do smart people do dangerous / dumb things?
Excessive Workload
Physical and cognitive effort involved in task performance.
Lack of Situation Awareness
Whats going on?
Whats likely to happen next?
What will happen if I take a particular action?
Excessive Stress, Fatigue, Uncertainty, etc.
Impacts perceptual-motor performance, decision-making, etc.
Diminished Attention
Too much to attend to at once (overload)
Too little to attend to for too long (underload)
Poor Teamwork and Communication
Often due to poor layout of work space and/or poor layout of command and
communication structure

Quality engineering can help avoid virtually all of these problems

 Human Factors:
Avoiding Errors.
Plan, design, manufacture, and implement
systems that:
Utilise human capabilities;
Cater to human limitations:
Redundancies;
Layered defences;
Fail-safe design etc etc etc
Train & equip humans to:
Utilise the system;
Recognise and minimise their limitations;
Learn from errors.
Not a good day at the office!
 Human Factors:
Domains within Human Factors
Physical
anatomical, anthropometric, physiological and biomechanical
characteristics as they relate to physical activity
Cognitive
mental processes, such as perception, memory, reasoning, and
motor response, as they affect interactions among humans and
other elements of a system
Organisational
optimization of socio-technical systems, including their
organizational structures, policies, and processes
Somewhat artificial delineation, in part reflecting the training
background of the practitioners
 Human Factors:
Who does Human Factors?
Multi-Disciplinary HF Specialists
Some:
Psychologists
Engineers
Doctors
Kinesiologists
Retrained Subject Matter Experts Yes, it is
possible to retrain engineers (pilots and
doctors)
Scientists
Another bad day at the office!
 Human Factors:
What is not Human Factors?
Just applied common sense
Training people to accommodate poor design
Blaming the user
Pilot error
Designers projecting their skills onto users
If its easy for the designer it must be easy for the end user

Human Resources
The Navy
 Human Factors:
Why isnt everyone doing it?
Voodoo Ergonomics
Everyone is an Operator Its just common
sense!
While nobody intentionally designs systems to
interfere with human performance, they may resist
the up-front expense associated with doing it
right.
HF folk have advertised & documented their
benefits poorly
 Human Factors:
What about aviation?
Over the past 40 years, over 80%
of accidents and incidents were
related to the human element and
were largely preventable through
the proper application of Human
Factors principles.
If the accident or incident rate is
to be decreased, human factors
must be better understood and the
knowledge more broadly applied.

http://www.cami.jccbi.gov/AAM-600/610/600Air-HFB.html
A good day at the office!
Human Factors:
Some examples.
Human Factors in Everyday Life:
Medicine
Let he who is without sin
Six accidents involving massive radiation overdose to
patients (1985 - 1987)
Therac-25 radiation treatment device
Controlled remotely

Sloppy engineering one of the most devastating

computer related disasters to date
A combination of technical failures (software and
possibly hardware) combined with human behaviour
resulting in catastrophic radiation overdoses
Voluntary recall of equipment
Risk mitigation => hardware design, software design,
or training?
Human Factors in Everyday Life:
Footpaths
Things that get in your way.
People usually follow footpaths when
theyre convenient.
Many people take the path of least
resistance.
Take a hint from people's behaviour.

What does the savvy civil engineer or

builder do?
 Human Factors in Everyday Life:
Centre High-Mounted Stop Lights

Human Factors innovation

NTSB estimates $910 million savings
pa just in property damage.
Also many millions in medical costs
saved.
$5 million spent in developmental
research and regulatory programs.

What CFO wouldnt see the

attractiveness of over $1 billion annual
return on a $5 million one-off
investment?
A great day at the office!
Human Factors in Everyday Life:
Mop Sink
Things that dont work the
way you expect
Mens washroom in restaurant.
No urinal.
Sign over the mop-sink.
The mop sink looks enough like
a urinal for it to be used as one.
When simple things have signs,
especially homemade signs, it is
usually a signal that they aren't
well-designed.
 Human Factors in Everyday Life:
Call Centre CRT Display
MAIL BOX RENTALS 931 ROSELLE RD SCHAUMBURG 60193 708 893-5705
MAIL BOXES ETC
836 ARLINGTON HEIGHTS RD
1749 W GOLF RD
318 HAY DAY ROAD
ELK GROVE VILLAGE 60007
MOUNT PROSPECT 60056
BUFFALO GROVE 60069
708 956-1112
708 640-7788
708 123-4567
Human Factors innovation
830 W MAIN ST LAKE ZURICH 60047 708 459-7060
126 EAST WING
836 ARLINGTON HEIGHTS RD
1749 W GOLF RD
HOFFMAN ESTATES 60195
ELK GROVE VILLAGE 60007
MOUNT PROSPECT 60056
708 310-4402
708 956-1112
708 640-7788
Mixed-case text, plus highlighting
318 HAY DAY ROAD BUFFALO GROVE 60069 708 123-4567
830 W MAIN ST
126 EAST WING
1749 W GOLF RD
LAKE ZURICH 60047
HOFFMAN ESTATES 60195
MOUNT PROSPECT 60056
708 459-7060
708 310-4402
708 640-7788
of selected listing.
318 HAY DAY ROAD BUFFALO GROVE 60069 708 123-4567
830 W MAIN ST
126 EAST WING
LAKE ZURICH 60047
HOFFMAN ESTATES 60195
708 459-7060
708 310-4402 Saved 600ms in average call
operating time.
Translated to $2.94 million per year.
Mail Box Rentals 931 Roselle Rd SCHAUMBURG 60193 708 893-5705
Mail Boxes etc
836 Arlington Heights Rd ELK GROVE VILLAGE 60007 708 956-1112

1749 W Golf Rd
318 Hay Day Road
830 W Main St
MOUNT PROSPECT 60056
BUFFALO GROVE 60069
LAKE ZURICH 60047
708 640-7788
708 123-4567
708 459-7060
Small investment, small obvious
126 East Wing HOFFMAN ESTATES 60195 708 310-4402
836 Arlington Heights Rd
1749 W Golf Rd
318 Hay Day Road
ELK GROVE VILLAGE 60007
MOUNT PROSPECT 60056
BUFFALO GROVE 60069
708 956-1112
708 640-7788
708 123-4567
improvement, good return at the
bottom-line.
830 W Main St LAKE ZURICH 60047 708 459-7060
126 East Wing HOFFMAN ESTATES 60195 708 310-4402
1749 W Golf Rd MOUNT PROSPECT 60056 708 640-7788
318 Hay Day Road BUFFALO GROVE 60069 708 123-4567
830 W Main St LAKE ZURICH 60047 708 459-7060
126 East Wing HOFFMAN ESTATES 60195 708 310-4402
Human Factors in Everyday Life:
Car Seat Adjustment
Controls with unexpected function.
Want to slide the seat back? Reach down
and pull the lever.
Lever quickly detaches the whole seat.
No-one likely to want to detach a seat while
sitting in it. Move the control to somewhere
it cant be reached while sitting.
Human Factors in (not exactly) everyday life:
Shuttle Cockpit
 Shuttle APU Display
(off-nominal conditions)
Hyd Landing MM 303 MET 10/10:45:35
Landing Gear
1 2 Benefits:
EPS FA1 FA2
LG Ext Isol Man Man
EPS Brk Isol 2
The sub-systems are
EPS
separated (e.g., landing gear,
LG Ext 1 EPS EPS LG Ext 2
NWS S/V

Main Deploy
L MG R MG
Pyro 1 Nose Deploy
NWS 1 NWS 2
NWS Fail brakes, drag chute).
Pyro 2
Brakes Drag Chute
Important information
1 Brk
Iso 1
2 Brk
Iso 2
3 Brk
Iso 3 Arm
CDR PLT
X X
(landing gear) is displayed at
EPS
FA1
Man
EPS
FA2
Man
EPS
FA3
Man
Dpy
Jet
X X
X X
the top.
SSME Repo
Color-coding separates
1/2 1/2 Full
Brakes
Fail
different components such as
L
Brake Press
R L
Tire Press
R labels and data.
Hyd OB IB IB OB Nose XXXS XXXS XXXS XXXS
1- 3 XXXXS XXXXS XXXXS XXXXS Mn IB XXXS XXXS XXXS XXXS Off-nominal elements are
2- 3 XXXXS XXXXS XXXXS XXXXS OB XXXS XXXS XXXS XXXS
color-coded.

This display is a work-in-progress which needs to undergo testing and evaluation. Even after revisions, it might not be implemented on the shuttle because of budget constraints or other factors.
Human Factors in (not exactly) everyday life:
Challenges on ISS for Emergency Escape
Problem Disorientation & lack of ISS architectural awareness
Disorientation reported on ISS in Node 1, as well as Mir
On-orbit is the first experience with the entire lay-out of ISS
Visiting Crews will not have time to learn the ISS layout
Disorientation can increase translation time and impact efficiency & safety
Solution: Phosphorescent Emergency Egress Path
Placards

Icons & Arrows

Indicate distinct multiple egress
paths to the specific vehicles
Icons & text provide redundant
cueing
Adaptable to location within ISS
Russian Text for the Soyuz when
used in the FGB and SM
Phosphorescent
Selfilluminatedrelativeto
surroundings
Facilitate identification in reduced
visibility conditions
Change out every 2 years
Human Factors in Aviation:
C150
Human Factors not
always right.
Human Factors expert
analysis.
Inconsistent design wrt
throttle and carbie heat
controls.
HowCessna150s
aremade
 Human Factors in Aviation:
Light aircraft emergency fuel management
Checking or changing fuel supply in an emergency?
 Human Factors in Aviation:
S35 & V35 Bonanzas
Change fuel tank in an
emergency.
Fuel control handle under the front
of the pilot seat, on the left beside
cabin wall
Seat often needs to be slid back to
access control
Especially for a short-ass pilot
like me
Sliding seat back can make full
control input impossible.

Otherwise a great aeroplane.

 Not such a good day at the office!

Nothing new under the sun

Human Factors in Aviation:
Cali Air Disaster
AA965 B757 21DEC95
Classic case of human error
complicated by sleep
deprivation.
Programmed autopilot to lock
on to Romeo beacon instead
of Rozo.
Caused slow turn into a
mountain.
150 killed.
Cockpit voice recorder
captured crew complaints of
excessive fatigue, yawning,
etc.
1997 Pulitzer Prize
Human Factors in Aviation:
C-141 Starlifter
Human Factors in design
40 years ago. Multi-role aircraft concept
employing roll-on / roll-off alternative
mission kits.
Kits heavy and complex and required lots
of time and effort to install.
HF analysis of mission profiles and
equipment needs lead to complete
restructuring of equipment deployment.
$500k investment lead to $5M initial
savings.

What would your CFO think?

 Its all a matter of perspective
Speedbird 245: Caution, FOD
Speedbird 245: Youre number two
hazard ahead!
behind a Cessna. Beware wake
turbulence!
 Human Factors in Aviation:
British Midlands Air Disaster (Kegworth)
B737-400 08JAN89
Fan blade in left engine detached during climb
=> compressor stall.
Crew throttled back right engine & shuddering
stopped. Right engine shutdown.
Almost normal emergency approach for some
time then increased vibration again from left
engine and then abrupt loss of power.
Couldnt restart right engine.
Aircraft struck a field adjacent to M1 motorway.
47 dead, 74 seriously injured.

A problem of perceptual sets where pax and

cabin crew had noted smoke from the left engine
but the information was inadequately
communicated to the flight deck.
There must be a human factors message in this somewhere
 Please!!!
Human Factors, aviation, and you.
- A plea to the engineers involved in aviation
- Good human factors in the design, development,
manufacture, and maintenance of aircraft and aviation
systems will reduce safety failures big time!
- Good human factors will also financially benefit your
employer
- Good ergonomics is good economics (google-it!)
 Human Factors Resources
Internet
Books, Reports, & Magazines
Massey, Auckland, & Otago Universities
RNZAF (Not the Navy though)
Colleagues, Clubs, & Societies
Private Companies

Formal training of our people

Whenever we talk about a pilot who has been killed in
a flying accident, we should all keep one thing in mind.
They made a judgment. They believed in it so
strongly that they knowingly bet their life on it. That
their judgment was faulty is a tragedy,

Every engineer, instructor, supervisor, doctor, and

contemporary who ever spoke to them had the
opportunity to influence their judgment, so a little bit
of all of us goes with every pilot we lose.