Introduction to Human Factors and Safety Culture
#FlySafe GA Safety Enhancement Topic
Over the last 50 years, we’ve seen tremendous progress toward reducing the rate of fatal general aviation (GA) accidents. We now have fewer than six accidents and only about one fatal accident per 100,000 hours of GA flying. That is impressive! We’ve come a long way, but to continue that success and get that rate even lower, we’ll need to seek a few new ways to improve safety. Part of that involves human factors research, looking at ways humans succeed — and fail. It also involves finding ways to reduce or eliminate the risk of failure and stressing the importance of a safety culture.
Time of Transition
We’re in the midst of a new way of thinking about safety. We are transitioning from a reactive culture, where we wait for something to go wrong and then fix it, to a proactive and just culture that treats aviators fairly and employs safety risk management to improve safety.
Reactive cultures are known for the blame-shame-retrain method for pilots who are involved in accidents and incidents. The trouble with this approach is that you must have an undesirable event before you begin to think about how to avoid it. And if you focus your attention on individuals rather than systems and environments, you’re often setting up folks for future failures.
There’s a better way …
Proactive cultures seek to:
- identify hazards associated with flight operations,
- assess the risk that those hazards would negatively impact safety,
- and either eliminate those risks or mitigate them to acceptable levels of safety.
Proactive cultures are also just cultures and still hold people accountable for their actions, but — if they are complying with established regulations, policies, and procedures — the focus will be on the system and not just the individual. Just cultures will always ask, “What happened?” rather than, “Who’s responsible and how should they be punished?”
The FAA’s Compliance Program is helping further the evolution toward a just safety culture. The program’s objective is to identify safety issues that underlie deviations from standards and correct them as effectively, quickly, and efficiently as possible. It stresses a collaborative problem-solving approach (i.e., engagement, root-cause analysis, transparency, and information exchange) where the goal is to enhance the safety performance of individuals and organizations. You can read more about the Compliance Program in the Jan/Feb 2024 issue of FAA Safety Briefing.
SMS and You
Proactive cultures often feature formal Safety Management Systems, or SMS, which are frequently used in aviation organizations but can be useful for individual pilots as well. An SMS consists of 4 foundational components:
🛩️ Safety Policy — a top-down commitment to safety. In large organizations that means safety is paramount for the CEO all the way to the latest entry-level new hire. For individuals, it means an unwavering commitment to safe operations.
🛩️ Safety Risk Management — a formal process that identifies potential hazards, assesses the likelihood that identified hazards will negatively compromise operations, and predicts what the consequences will be should a mishap occur. Safety risk management also identifies ways to either eliminate hazards or mitigate them to an acceptable level of safety.
🛩️ Safety Assurance — monitors and feeds back results and best practices from the safety risk management process. This feedback is used to refine processes and procedures.
🛩️ Safety Promotion — actively and constantly demonstrates the commitment to safety. In other words, safety promotion is walking the talk.
You can learn more about how SMS works and how adopting a personal SMS can help improve flight safety in the article here.
On a more individual level, let’s take a look at three essential elements that support a personal commitment to safety. They are:
- Safety Risk Management ✅ — A structured process consisting of hazard identification, risk assessment, and risk elimination/mitigation.
- Pilot Proficiency 👨✈️— maintaining a level of performance equal to or exceeding requirements for normal and emergency aircraft operations. Proficiency can be facilitated through the FAA’s WINGS program, using a personal minimums checklist, or evaluation and coaching from a flight instructor.
- Technology 💻 — effective use of information and automation technology to increase flight safety.
While we’ve made great strides in addressing risk through SMS and Safety Risk Management achieving further progress with safety will require a closer look at the art and science of human performance.
The Human Element
The term “human factors” refers to the wide range of issues affecting how people perform tasks in their work and leisure environments. Human factors study applies knowledge of the human body and mind to better understand human capabilities and limitations. This allows us to better design tasks and technology to optimize the relationship between human operators and the environments within which they work.
Few aviation accidents result purely from technical factors. In around 70–80% of cases, deficiencies in human performance contribute directly to the outcome.
World War I and World War II spawned rapid improvements in aircraft design and performance. This also resulted in increased aircraft complexity. Accident experience prompted aircraft designers to consider human performance requirements that continue to this day, especially with the growing complexity of aircraft systems, automation, and tasking.
Knowing when and where humans are likely to make mistakes has helped us to understand that errors rarely occur in a vacuum, but rather within organizational and operational systems. That allows us to design safety management systems that feature error-tolerant processes with built-in checks and balances and complementary assistive technology.
In addition, information from flight data and cockpit voice recorders during accident investigations over the years has identified deficiencies in crew resource management. That discovery led to the crew resource management and single-pilot resource management processes that are successfully practiced today.
Challenges remain, however, whether it’s over-reliance on technology, the pilot shortages that strain existing operations and resources, the expansion of new National Airspace System (NAS) entrants, or the continued need to stay focused on safety and security systems. How individuals and groups meet these and other operational challenges has a lot to do with culture.
Safety Culture
The beliefs, attitudes, norms, and values that people within an organization share are described as organizational culture. You could describe culture as, “the way we do things around here.” Safety culture is an essential part of organizational culture. It affects the way the organization manages safety and therefore, the ultimate effectiveness of its safety management system.
Robust safety management programs employed through a team of dedicated, proficient people can enable organizations to perform incredibly difficult and dangerous tasks in safety. For example, military demonstration teams can perform thousands of flight demonstrations without a mishap not because they are lucky, but because every member of the team — from the commanding officer to the newest member — is an active member of the organizational safety culture.
Dr. James Reason, a noted psychologist and human factors expert, produced a model of the five key ingredients of effective safety cultures.
Let’s see what attributes individual pilots might exhibit in support of each ingredient:
🛩️ Informed Pilots — gather all available information before flight and identify hazards that may compromise safety. They eliminate or mitigate the risks those hazards pose before takeoff and continuously update their assessments with new information en route.
🛩️ Reporting Pilots — do not hesitate to discuss and learn from errors they make. They strive to report objectively and without bias. They seek guidance and coaching from flight instructors and peers.
🛩️ Learning Pilots — are constantly learning from their experiences and from those of their peers. They participate in continuing education and proficiency training and they use lessons learned to improve their operational procedures.
🛩️ Flexible Pilots — are flexible in their relationships and in their mission planning and execution. They are willing to adapt to changing conditions and priorities, but only if they can maintain an equivalent or higher level of safety.
🛩️ Just Culture Pilots — understand that errors are inevitable and that they have a responsibility to disclose them in order to provide information useful to crafting more effective processes and procedures. They expect to be treated fairly but also to be held accountable for their actions — especially those that are violations of policy, procedure, or regulation.
We hope this has brought to light the importance of having a robust safety culture and how better understanding human factors can help us more effectively manage risk in the aviation environment.
Want to Learn More?
Nine new Human Factors courses based on the Australian Civil Aviation Safety Authority’s Safety Behaviors — Human Factors for Pilots are available on FAASafety.gov. The course modules focus on safety culture, human performance, communication, teamwork, situational awareness, decision-making, threat and error management, human information processing, and design and automation. The courses are eligible for credit in the WINGS Pilot Proficiency Program.
Many are familiar with the “accident chain” — a series of circumstances, events, and decisions that lead to an accident. Log in today and complete your training to learn how to “break a link in the chain” and prevent an accident.
FAASTeam Events (January 2024)
- In-person/Fly-in Seminar 👨✈️🛩️ — Jan. 15, 18:30 Eastern, Columbia Metro Airport (CAE), S.C.
- Online Webinar 💻 — Jan. 16, 18:00 Eastern
- In-person/Fly-in Seminar 👨✈️🛩️ — Jan. 18, 19:00 Central, Lewis University Airport (LOT), Ill.
- In-person/Fly-in Seminar 👨✈️🛩️ — Jan. 25, 11:30 Central, Ankeny Regional Airport (IKV), Iowa
