New frontier for human factors

Flying Safety,  March, 2002  by Tracy Dillinger,  Tom Luna

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Readers of Flying Safety know the Safety Center periodically reports the percentage of human factors (HF) involvement in USAF mishaps. We have become accustomed to seeing 6080 percent as the range of human factors "causes" in mishap research and articles, based on Safety Center data obtained from safety investigation reports. Yet only a small percentage of all USAF mishaps have dedicated human factors investigations.

For example, in FY00, 933 flight mishaps and events were reported; there were 22 Class As, 84 Class Bs, 397 Class Cs and 430 Class Es. However, this total of 933 represents only Flight mishaps/events. There were 173 Weapons mishaps, 1674 Ground offduty mishaps and 1402 Ground onduty mishaps. Grand total: 4182 mishaps/events. Of those, only the 22 Class A Flight mishaps and five of the Class B Flight mishaps (27 total) had a properly detailed HF investigation and analysis. This is less than 1% of the 4182 total. What is the importance of the HF data that hasn't been collected? It's impossible to say, but looking back over the last ten years in flight, HFs played a causal role in 64% of all Class A mishaps. Even more attention-worthy, over 90% of all the Flight mishaps involving fatalities in the last ten years were caused by human factors.

Unfortunately, since we don't routinely collect or report the HF data on mishaps/events other than flight Class A mishaps, we really don't know the extent of HFs in our other mishaps and events. Yes, we all know human factors are there, but we won't know which human factors, the significance of these factors or ways to proactively address those factors--unless we investigate them. Collecting this data would help with identification of trends and deficiencies that would help us plan, educate and train our people.

Clearly, there is a need in the safety community to investigate and analyze HF data. This means we need to expand the formal investigation of human factors to include our ground, space and missile operations. And in the flight community the investigation of HFs in Class 13, C and E mishaps definitely needs to occur. We all know the difference between a Class A and a Class C can be a nano-second or pure luck. This is a new frontier for human factors--all mishaps, of all categories, from all types of settings.

Why aren't human factors more widely investigated? There are several likely reasons. The "bible," AFI 91-204, Safety Investigations and Reports, only explicitly directs HF investigations for Flight Class A and B mishaps. Most investigators are uncomfortable investigating HF and need better, not more, training in this area. Often, investigators are reluctant to ask for an HF consultant (this generally means a flight surgeon, aerospace physiologist, clinical/aviation psychologist or pilot physician). And lastly, investigators need a better tool to guide them in the HF investigation process.

How should we begin to work towards this enormous task, given decreased manning, increased tempo and generally limited expertise and experience? The Human Factors Working Group here at the Safety Center has come up with a multipronged approach.

First, the aviation module of the Safety Automated System, or SAS, will be coming on line this spring. This data entry system can be accomplished over the internet, at the desk, by any FSO. It is a logic-tree format, guided investigation. System software developers have been working this for a long time--it should be user-friendly, informative and easy. Of course, there might be a bug or two, but overall, it will be a drastic improvement over the current system.

Second, training will expand. This means making sure people know how to investigate HFs, and how to use the SAS and the USAF HF taxonomy. Investigators will also need to know how to recognize when they need an HF consultant, and know how to get one. This training will be built into all safety courses, including the Flight Safety NCO Course, Flight Safety Officer Course, Aircraft Mishap Investigation Course, Aircraft Mishap Investigation and Prevention Course, Chief of Safety Course, and Mishap Investigation Non-Aviation Course, as well as the 1SXX (Safety) CFETP and 4MOXX (Aerospace Physiology) CFETP.

Third, expansion of HF investigations will progress in a step-wise manner. Flight mishap classes A, B, C, and E will begin concurrent with AVSAS implementation. HF investigations for ground A, B and C on-duty mishaps will begin later, with the new ground PAS module. Those will be followed by Ground A and B off-duty HF investigations. The final grouping will be for Weapons classes A and B. Full implementation is targeted for Sep 04. Sequential implementation will allow periodic progress reports and midcourse corrections.

And lastly, guidance in AFI 9 1-204 will be updated to reflect expanded HF investigations. Basically, through improved training and the new SAS tool, we should ultimately have information we can all use to improve our HF investigations.