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Accidents and Incidents: It’s All Human Factors

By By Andrew Parker, managing editor | July 1, 2010
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From left to right, Jerry Allen of Baines SImmons, Bristow’s Tim Rolfe, Immanuel Barshi from NASA and Chris Baur, Rotor & Wing columnist. Photo by Andrew D. Parker

A panel of speakers at the Rotor & Wing 2010 Safety & Training Summit on June 8 reiterated the importance of an “active safety culture” within an organization and argued that everything in aviation boils down to human factors. The Summit in Denver drew experts together from various sectors of the industry. Chris Baur, president of Hughes Aerospace Corp and a Rotor & Wing columnist, moderated the “Human Factors in Helicopter Operations” at the Summit.

“The important thing to remember about the accidents and incidents that do happen, that we can learn from, is that it really is all human factors,” said Immanuel Barshi, senior principal investigator of human-systems integration for NASA. He related a story about a good friend that died in an accident when a main rotor blade separated from a CH-53.


“It was not a pilot error, but it was still human factors. And in a sense, it’s redundant to say, because rotor blades don’t make mistakes. [When] equipment fails it not the equipment’s ‘fault,’ it’s either a human that didn’t design it right, or a human that didn’t build it right, or a human that didn’t maintain it right, or operate it right. It’s always human factors.”

Tim Rolfe, Bristow European Operations chief training captain for the Sikorsky S-92, is involved in the company’s safety management systems (SMS) program. He says that organizations must first define an acceptable risk level. “Having determined that, we really need to go ahead and identify hazards that can present themselves to us in our daily operations. … Our job is to manage risk to an acceptable level, and that’s largely done through the training side of any organization. We have to set and modify existing procedures to mitigate against the risks we have identified.”

Rolfe explains that working for Bristow, which has “an active safety culture, and a system of processes that allow pilots to identify those hazards, risk-assess those hazards and then put procedures in place—I’m totally sold on the SMS idea. It is entirely necessary to have a very active safety culture at the center of your SMS, it’s not good enough to just have the processes in place.”
Rolfe added: “You’ve got to have buy-in at all levels, from the CEO to the guy that sweeping the hangar floor. We need to educate everybody.”

Jerry Allen is managing director of Baines Simmons Americas, which conducted a series of assessments involving more than 2,000 helicopter technicians under its safety culture organizational review and evaluation (SCORE) program. “The effect of human factors programs is not necessarily the one that we hoped that it would be,” Allen explained. He pointed to figures that show 53 percent of respondents disagreed (44 percent) or strongly disagreed (9 percent) with the statement, “Before I start a job, I’m always given the necessary information.” A total of 41 percent agreed or strongly agreed, and 6 percent did not agree or disagree. When asked, “We often have to rush jobs due to unrealistic deadlines,” 84 percent agreed/strongly agreed, 8 percent disagreed and 7 percent answered neither. Other trends in the Baines Simmons numbers indicate that 81 percent agreed/strongly agreed with the statement, “We usually manage to complete a job despite the non-availability of the specified equipment/tools,” while 12 percent disagreed and 8 percent said neither.

Rolfe pointed out the contrast between how a pilot who manages to survive an emergency situation is viewed, versus one who does not. “If a pilot actually saves the day—despite the fact that he’s using poorly put together standard operating procedures, a checklist with errors in it, just faces some bad luck or finds himself in a situation where the [weather] forecast has been inaccurate—but he saves the day, how do we describe the pilot?”

The pilot “could absolutely be the hero, so there’s a dichotomy,” he said. “The pilot could be the bad guy, but the pilot could also be in control of the heroic outcome. And we need to take that into account when we address the human factors risks that are presented to us in the cockpit.”

Barshi asked attendees: How many people are 100 percent reliable, 100 percent safe, 100 percent of the time? “By definition, half of your time you are performing below your average. And if you’ve been around flying long enough, I’m sure you’ve walked away from flights where you said, ‘I should not have flown, I should not have taken that flight.’ It’s really useful to be lucky, but it’s hard to control.” For videos from the Summit, visit Rotor & Wing's Safety and Training Channel.

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