HumanFactorsChecklist

ByDrAnthonyCiavareliiand
ThomasSather
NavalPostgraduateSchool
AdaptedbyKentLewis
SignalCharlie

SensoryPerceptualFactors
Misjudgeddistance,clearance,alGtude,
speed,etc
FalsePercepGonsduetovisualillusion
ContributorycondiGons:
Featurelessterrain(desert,water,drylakebed)
Dark
Blackholeapproach
No/falsehorizon
Mountainousterrainorslopingrunway
Rotordownwasheects

Rotordownwasheects
Anomalouslighteects
LowcontrastobjectorpoorilluminaGon
Lookingintobrightsunorshadows

FalsepercepGonduetovesGbularillusions
Corioliscrosscoupling(spiningsensaGonduetovesGbular
oversGmulaGon)
Somatogravic(ginducedfalsepitchupordown)
Somatogyral(falsesensaGonofangularrotaGon)
Gexcess(errorinperceivingactualangelofbank)

 SpaGalDisorientaGon/VerGgo

TypeI:Unrecognizedormisoriented(lossof
aVtudnalorientaGonwithoutawareness)
TypeII:Recognized(verGgoortheleans)
TypeIII:IncapacitaGng(e.g.ginducedvesGbular
ocularcoupling)
CondiGonsthataectsenseofbodyposiGonoraircraX
aVtude:
1. Lossofvisualcues/aVtudereferences
2. AcceleraGonrelatedillusions
3. AdversephysiologicalcondiGon(drug,dehydraGon,
faGgue)

 LossofSituaGonalAwareness
Types:
1. GeographicdisorientaGon(onavigaGonrouteor
map,lost)
2. GenerallossofSA(didnotperceivehazards)
3. ErroneoussituaGonassessment(misinterpreted
situaGonorcondiGon)
4. Perceptualtunnelling
5. FailedtopredictoranGcipatechangingcondiGons
6. Falsehypothesis
7. ConrmaGonbias
8. Workloadtask/Gming

 AdenGonFailure
Types:
1. Missedightchecklistitems,calloutorcrew
challenge
2. Failedtomonitorightprogressormaintain
instrumentscan
3. FailedtorespondtocommunicaGonsorwarning
4. ControlacGonerrors(motorresponseslipor
memorylapse)
a)
b)
c)
d)
e)

Forgottoset/move/resetswitch(lapse)
UnintenGonalacGvaGon(slip)
ControlsubsGtuGon(slip)
Controlreversal(slip)
Controladjustment/precisionerror(slip)

CondiGonsthatinuenceAdenGonandSituaGonAwareness
1. InadenGon
2. Channelizedortaskxated(perceptualnarrowing)
3. DistracGon(internal,external)
4. Taskoverload(excesstaskingwith/withoutmission
performanceGmepressure)
5. CogniGveworkload(problemsolvingworkloadorinformaGon
overload)
6. HabituaGon(old/previouslearnedhabitinterference)
7. ExcessstressorfaGgue
8. Excessmissiontaskingorworkload
9. InadequatebriengorpoorightpreparaGon
10. Inadequatetrainingorexperienceforthemission
11. NegaGvelearningtransfer(i.e.newaircraXtransiGon)
12. Adverseweather/meteorologicalcondiGons
13. AdverscockpitenvironmentalcondiGons
14. TacGcalsituaGonordisplayinformaGonoverload
15. LowaircrewmoGvaGonorpoorightvigilance
16. Poorcockpitdesign(controldisplaylocaGonordataformat)

SensoryPerceptualRiskManagement
ProvideconGnuededucaGonforpilotsandair
safetyreps
EngageFAAAMEsandindustryaeromedical
organizaGons
Establishweathergo/nogodecisioncriteria
UGlizemissionanalysismatrix
EstablishSOPsandprotocolsforknownhigh
riskmissions(night,weather,faGgue,training)

MedicalandPhysiologicalFactors

SelfMedicated
Underinuence
Knownillness
Excesspersonalstress
FaGgue
NutriGon
GLOCorgexcess
HypoxiaorhypervenGlaGon
Other

 CondiGonsthatleadtoadversemedical/
physiologicalstate
1. MissionfaGgue(ondutyover12hours,late
nightorearlymorning02000600
2. CumulaGvefaGgue(excessphysicalormental
workload,circadiandisrupGonorsleeploss)
3. CumulaGveeectsofpersonaloroccupaGonal
stress(exceedspersonalcopinglimits)
4. EmergencyightcondiGon/workloadtransiGon
5. MedicalorphysiologicalprecondiGons
(precedingstateofhealth,tnesslevel,
hangover,dehydraGon,etc)

MedicalandPhysiologicalFactor
RiskManagement
Documentmedicalandphysiological
qualicaGons
Protectaviatorsunderhighstressdueto
humanfactors
Sharehumanfactorshazardreportsof
physiologicalincidents
Useaeromedicalteamresources
UseCIRPandEAP

KnowledgeorSkillFactors
Inadequateknowledgeofsystems,procedures
(Knowledgebasederror)
Poorightcontrol,airmanshiporpooraccuracyof
ightmaneuvering(Skillbasederror)
Misuseofrulesorincorrectperformanceofcockpit
task(Rulebasederror)
Types:
A. Failedtoperformrequiredprocedure(s)
B. Usedwrongprocedureorrule(s)
C. Missedstep(s)inaprescribedsequence
D. Performedstepsoutofsequence

 CondiGonsthatleadtopooroperaGonalperformance
1. Belowrequiredprociencyorcurrencystandards
2. Poorperformancetrendand/ordocumentedight
apGtudedeciencies
3. Lowighthours(totalorintypemodel)
4. LackedessenGaltrainingforspecictasks
5. LackedrecentmissionorightcondiGons
(instrument,night,weather,etc)
6. TransiGonpilot
7. MarginalAviator(documentedhistoryofpoor
performanceorightviolaGons)

KnowledgeandSkillFactor
RiskManagement

Establishprociencyandcurrencystandards
Enforcestandardsinajustmanner
Assesstrainingprogramagainststandards
Documenttrainingresults
Useremedialtraining
Removeorprotectmarginalaviators

PersonalityandSafetyAVtude

Padernofovercondence
PadernofexcessmoGvaGon
AngerorjobfrustraGon
Hotdogging
AsserGveornonasserGve
Lackedcondencetoperformtaskormission
YieldedtooperaGonalpressuretoperformin
hazardoussituaGon(fromcommandorpeers)

 ContribuGngfactorsthatleadtopoorsafetyaVtude
1. Habitualhighrisktaker
2. Overcondence
3. Marginalorhighriskaviator
4. ExcessmoGvaGon(nolimits)
5. Poorcommandclimateorsafetyculture(lackof
adequatesupervision)

PersonalityandSafetyAVtude
RiskManagement

IdenGfychronichighrisktakers
Usejudiciouscrewassignmentandscheduling
Conductperiodichumanfactorsreview
UseHumanFactorsBoardtomanageatrisk
aviators

JudgmentandRiskDecisionFactors

KnowinglyacceptshighrisksituaGons
Misjudgedactualriskofmission(complacency)
Didnotmonitorightprogress/condiGons
IncorrecttaskprioriGes
Knowinglydeviatedfromsafeprocedure
IntenGonallyviolatedsafetystandardorregulaGon
Knowinglyexceededpersonallimits
KnowinglyexceededaircraXlimits
Knowinglyexceededprescribedmissionparameters
Yieldedtosocialpressure

 CondiGonsthatcontributetoinappropriaterisk
judgment
1. Hotdogorhighriskaviator
2. ExcessmoGvaGon
3. Uncontrolledlifestress
4. TooasserGveornonasserGveinterpersonalstyle
5. Inuencedbypoorcommandclimateorsafety
culture(lackofadequatesupervision)

JudgmentandDecisionFactor
RiskManagement
Enforcego/nogocriteria
Illustratejudgmentbyexample
Providecrewjudgmenttrainingand
evaluaGon
Monitorandcorrecthighriskbehavior
DeveloppersonalSOPs(mins)

CrewCoordinaGonFactors

Inadequatemissionplan,brieforpreight
FailedtocommunicateplanorintenGons
Failedtousestandardlanguage
Misunderstoodorunacknowledged
communicaGons(readbackhearback)
Inadequatechallenge,crosscheckormonitoring
Withheldvitalsafetydata
PICfailedtoleadanddelegate
PICfailedtouseallavailableresources
Interpersonalconict

 CondiGonsthatcontributetopoorcrewcoordinaGon
InadequatetrainingincommunicaGonsandcrew
coordinaGon
InadequateSOPforuseofcrewresources
WeaksupportfromcommandforaircrewcoordinaGon
doctrine
Aircrew/cockpitrankandexperiencegradients
Commandsafetyculturedoesnotsupportcrew
concept

CrewCoordinaGonFactor
RiskManagement

EstablishCRMprotocolsandSOPs
ProvideCRM(Team)training
ConstructmissiontaskSOPs(crewtasks)
BriefanddebriefCRMevents(ASRS)
UsespecictrainingtoteachandlearnCRM
tasksandskills

DesignandSystemFactors
Usedwrongswitch,leverorcontrol
Misreadormisinterpretedinstrumentreading
Couldnotreachorseecontrol
Couldnotseeorreadinstrumentorindicator
Failedtorespondtowarningsignalorwrong
response
Modeconfusion
AutomaGoncomplacencyorfascinaGon

CondiGonsthatcontributetodesigninducederrors
1. PoorprimaryaircraXcontrolsordisplayarrangement
2. Inadequateprimarydatadisplayordataformat
3. Hardtoreadinstrumentdata(Textsize,font,color,glare,
lighGng)
4. IncompaGblecockpitcontroldisplayacGvaGonorresponse
5. Inadequatehazardadvisoryorwarningdisplay
6. Poorcockpitdesignlayout(vision,reach)
7. Poorhumancomputerdisplayinterface/usability(error
pronedesign)
8. PoorsystemsinstrucGon
9. InadequateaviaGonsystemssupportorfaciliGes(navaids,
airport,airtraccontrol)
10. Nonstandardcockpitlayout
11. InappropriatetypeorlevelofautomaGon,orexcess
operaGonalmodecomplexity

DesignandSystemsFactors
RiskManagement
TrainandtestaircraXsystemsknowledge
Flybythebook
IdenGfyaircraXlimitsandtolerances
IdenGfyfaultycockpitlayout,controlanddisplay
designs
Publishhazardreportsandrecommenddesign
changesFlightOps
ConsiderAirports,ATC,Manufacturers(AircraX,
Engines,Avionics),Contractors

SupervisoryFactors
Inadequatescheduleorcrewassignment
Failedtomonitorcrewrest/duty
Failedtoestablishadequatestandards
Failedtomonitorcompliancetostandards
FailedtomonitorcrewqualicaGon/training
Failedtoscreen/removehighriskaviators
Failedtoestablish/monitorqualitystandards
IntenGonallyviolatedordirectedotherstovioatestandards,ruleor
regulaGon
Commandfailedtomonitor,perceiveandassessactualmission
risks,withrespectto:

EnvironmentalhazardsandoperaGngcondiGons
Missiontaskingandaircrewskilllevel
Aircrew,andsystemlimitaGons(AircraX,maintenance,Airports,ATC,
Dispatch,ightops

 CondiGonscontribuGngtosupervisoryfailures
1. Excessopstempo,organizaGonalworkload(imposedby
commandorsystem)
2. Poorcommandsafetyclimate/culture,laxsafetysupervision
3. Inadequatestandardsand/orlowperformanceexpectaGons
4. Commanddidnotprovideadequateresourcestosupportsafe
missionaccomplishment
5. Commanddidnotadequatelytrainthemishappilotorcrew
6. Commandersdidnotsetagoodexample,orsetabadexample
7. Supervisorsdidnotprovideadequatecommitmentoremphasis
onsafeoperaGons
8. CommandhaspoorcommunicaGonsup/downcommandchain
9. Commandhasnosystemoweaksystemformanagementof
highriskaviator
10. CommandhasweakprocessforoperaGonalriskmanagement
11. Commanddidnotprovideadequateaeromedicalofhuman
factorstraining
12. Commanddidnotenforceaeromedicalstandards

SupervisoryFactor
RiskManagement

EstablishposiGvecommandclimate
Setthesafetyexample
IncludesafetyadvocacyasorganizaGonalgoal
Setclearperformancestandards
MonitorcompliancetoSOPs
Knowyourselfandyourteam
Keepanopendoorandopenmind
Correctpoorperformanceandnoncompliance
Rewardsafebehavior
Embedriskmanagement

OrganizaGonalFactors
ProducGon
RiskManagement

RegulatoryFactors
ProducGon
ProtecGon
ProbableCauseparadigm

References
HumanFactorsChecklist:AnAircraXAccident
InvesGgaGonTool,AppendixB:CrewResource
Management
(NavalPostgraduateSchool,SchoolofAviaGon
Safety,Ciavarelli&Sather,2002)
hdps://www.netc.navy.mil/nascweb/sas/les/
hfchklst.pdf

ThankyouforyourdedicaGontotheconGnuous
improvementofaerospacesafety
KentLewis
kent.lewis@alpa.org
lewis.kent@gmail.com
(817)6921971