Meteorological service providers around the world provide industries and entities with critical meteorological information. These include;
- Antarctic operations
- Government agencies
The Australian Bureau of Meteorology is a globally respected agency
Aviation more than any other industry has included Meteorological service providers as an integral part of the management of safety and the reason BoM personnel are undergoing Human Factors training
The next two days:
- High Reliability Industries
- Organisational Safety
- Normalisation of Deviance
- WHS vs QMS vs SMS
- Safety Culture
- Human Factors
- HF Models
- HF application
- (HF Case studies)
- HF Exercise
- HF Role Play
- HF and the BoM
High Reliability Industries
High reliability industries repeatedly deliver successful, predictable results in a dynamic, technologically complex, time-constrained, and high-hazard environment. Examples of HRIs include;
- off-shore Oil and Gas,
- nuclear industry,
- space exploration,
- heavy mining
Hallmarks of High Reliability Industries are;
- Look for low frequency/High consequence events
- carry out deliberate actions to achieve predictable results
- maintain a sense of ‘chronic unease’ (sometimes called ‘respectful distrust’)
- HROs learn how to ‘fail in a safe way‘, and then ask ‘how did we contribute to this failure?“
Consider how much weather has in influence on HROs
- Sydney Hobart Yacht Race
- Mildura Virgin and Qantas diversion flights
- Kenn Borek Twin Otter Antarctica
The Australian Bureau of Meteorology is often inexorably linked to low frequency, high consequence events
International Civil Aviation Organisation (ICAO)
ICAO consists 192 member states and was formed in Chicago in 1944
Agreement on a set of standardised practices for international air travel, supported by Annexes which defined the different components.
Annex 1 – Personnel Licensing
Annex 2 – Rules of the Air
Annex 3 – Meteorological Services
Annex 4 – Aeronautical Charts
Annex 5 – Units of Measurement
Annex 6 – Operation of Aircraft
Annex 7 – Aircraft Nationality and Registration Marks
Annex 8 – Airworthiness of Aircraft
Annex 9 – Facilitation
Annex 10 – Aeronautical Telecommunications
Annex 11 – Air Traffic Services
Annex 12 – Search and Rescue
Annex 13 – Aircraft Accident and Incident Investigation
Annex 14 – Aerodromes
Annex 15 – Aeronautical Information Services
Annex 16 – Environmental Protection
Annex 17 – Security
Annex 18 – The Safe Transportation of Dangerous Goods by Air
Annex 19 – Safety management
Chapter 2 of Annex 3
2.1.2 This objective shall be achieved by supplying the following users: operators, flight crew members, air traffic
services units, search and rescue services units, airport managements and others concerned with the conduct or development
of international air navigation, with the meteorological information necessary for the performance of their respective
Meteorological information. Meteorological report, analysis, forecast, and any other statement relating to existing or
expected meteorological conditions.
2.2.9 The meteorological information supplied to the users listed in 2.1.2 shall be consistent with Human Factors
principles and shall be in forms which require a minimum of interpretation by these users, as specified in the following
Note.— Guidance material on the application of Human Factors principles Human Factors Training Manual (Doc 9683).
The Civil Aviation Safety Authority (CASA) is implementing a program of regulation reform to improve, strengthen and reinforce aviation safety within Australia.
Regulations are written based on experience and outcomes – often negative.
In accordance with the ICAO SARPs, the reforms will put in place a range of safety measures including the requirement for SMS for most commercial aviation operations and maintenance.
CASA policy and guidance
|Civil Aviation Act (CAA)||Civil Aviation Act (CAA)||Act of Parliament|
|Civil Aviation Regulations (CARs)||Civil Aviation Safety Regulations (CASRs)||Parliamentary tabling and law|
|Civil Aviation Orders (CAOs)||Manual(s) Of Standards (MOS)||Written by CASA with enforceable legislative powers|
|Civil Aviation Advisory Publications (CAAPs)||Advisory Circulars (ACs),
Acceptable Means of Compliance (AMC)
Guidance Material (GM)
|Advisory only, no head of power but defines compliance requirements|
CIVIL AVIATION SAFETY REGULATIONS (CASRs)
The table above shows the evolution of Regulatory reform since 1988 when the Civil Aviation Act came into power. The implementation of the CASRs CASAs Regulation Reform program is ongoing.
Regulation reform is occurring so that Australian legislation is;
- Located in one place
- Aligned with international best practice
- Based of past lessons learnt
- Responsive to advances in global aviation
SMS and Human Factors training are two of the common requirements applicable to all organisations affected by the aviation regulation reform program.
CASA SMS RESOURCE KIT
The 8 booklets are;
- Booklet 1 – Safety Management System Basics
- Booklet 2 – Safety Policy and Objectives
- Booklet 3 – Safety Risk Management
- Booklet 4 – Safety Assurance
- Booklet 5 – Safety Promotion
- Booklet 6 – Human Factors
- Booklet 7 – SMS for small, non-complex organisations
- Booklet 8 – Workbook
The associated SMS videos are hosted through the CASA YouTube channel
CIVIL AVIATION ADVISORY PUBLICATIONS (CAAPs)
There are 4 CAAPs from CASA regarding SMS;
- SMS-1(0) Safety Management Systems for Regular Public Transport Operations
- SMS-2(0) Integration of Human Factors (HF) into Safety Management Systems
- SMS-3(1) Non-Technical Skills Training and Assessment for Regular Public Transport Operations
- SMS-4(0) Guidance on the establishment of a Flight Data Analysis Program (FDAP) – SMS
Current SMS requirements
|Air Traffic Service Providers||Part 171, 172 & 173||Apr 03|
|Certified Aerodromes||Part 139 International||Nov 05|
|Certified Aerodromes||Part 139 Other Certified||Jan 07|
|Air Operators||CAO 82.5 (RPT – high capacity)||Jul 09|
|CAO 82.3 (RPT – other than high capacity)||Feb 10|
|Approved Maintenance Organisations||Part 145||Jun 13|
|Flying Training Organisation||Part 142||Sep 14|
|Note CASR Part 141 do not require SMS but are ‘strongly encouraged’ to adopt SMS|
Future SMS requirements – CASA Briefing December 2018 – Made December 2018
CASR Part 119 – Australian air transport operators (certification and management)
…Deals with the certification and management for air transport operators and applies to all operators with an Air Operator’s Certificate (AOC) for current charter, RPT or air ambulance operations.
Part 119 includes requirements for a Safety Management System (SMS), training and checking and for human factors and non-technical skills training – all scaled to the size and complexity of the operation…
CASA – December 2018
121, 133, 135 and 138, implementation by 25 March 2021
Part 145 for 133, 135 and 138…??
|Australian Air Transport Operations – Large Aeroplanes||Part 121||Greater than 8618kg certified for more than 10 seats or more|
|Australian air transport operations – rotorcraft||Part 133||Includes helicopters, gyroplanes or powered-lift aircraft|
|Australian Air Transport Operations – Small Aeroplanes||Part 135||Less than 8616kg certified for 9 seats or less|
|Maintenance organisations (non RPT)||Part 145||Still subject to CASA/Industry consultation|
|Aerial work operations||Part 138||SMS requirements subject to risk based assessment|
|Note: Air Transport is a flight conducted for cargo or passengers, for hire or reward, and is publically available|
The key CASA statement regarding an organisation’s SMS is ‘
‘…tailored to meet the size and complexity of the organisation…’
‘…Human Factors is to be integrated in to the SMS…’
The concept of organisational safety
Organisational safety and ICAO adaptation of it have been evolving since the early 1990s. It came as a recognition that both human and organisational factors contribute to an accident, incident or significant event. The Piper Alpha disaster in 1988 and the subsequent Lord Cullen inquiry into it had a significant impact on the evolution of Integrated Safety and Safety Management Systems.
ICAO utilised the work of Professors James Reason and Patrick Hudson (among others), that brought organisational failures and safety culture as foremost consideration in accident causation.
The basics of modern SMS were derived from the outcomes of the Cullen inquiry and were based of the failings that resulted from Piper Alpha
The elements in the management of safety were;
- Management commitment and responsibility
- Appointment of key safety personnel
- Management accountability
- Third party interface
- Emergency response planning
- Safety documentation
- Hazard identification
- Safety risk assessment and mitigation
- Safety performance monitoring
- Safety investigations
- Management of change
- Continuous improvement
- Safety education and training
- Safety communication
Normalisation of deviance and practical drift
Practical drift is the movement away from baseline performance
Becoming used to doing things differently is Normalisation of Deviance
The averaging of practical drift is normalisation of deviance
Every accident will include some form of normalisation of deviance
‘We’ve been doing it this way for years’
‘We haven’t had an issue yet’
An absence of evidence is not evidence of absence…
Take special note of what is said at 1:15 to 1:30 for class discussion
WHS vs QMS vs SMS
Let’s consider the humble Elevated Work Platform – used to access high points on aircraft and inside the hanger
It is maintained ‘In-house’ by company workers
There is an un-serviceable handrail on the platform that could fail under normal operational conditions of use
This could have serious or no consequences depending on the situation at point of failure.
Let’s consider the worst case scenario occurring and investigate from WHS, QMS and SMS perspectives looking at;
From a WHS perspective;
From a QMS perspective
From the SMS perspective
A WHS Hazard is something with the potential to do harm
An Aviation Hazard is a condition of object with the potential to cause or contribute to an aircraft incident or accident
For example; inadvertent manipulation of aircraft throttles in a hanger could have potential to;
- Injure personnel working on other parts of the aircraft
- affect throttle rigging and maintenance compliance
- ultimately affect the safety of the aircraft if the manipulation is not detected
Every organisation has a safety culture. The question is how good is it?
The courage for safety
Without a safety culture, you don’t have a SMS – it’s that simple. If people don’t feel empowered to contribute to it, they won’t feel inclined to be engaged with it, and therefore not be protected by it.
Human Factors, both positive and negative, influence the safety culture in an organisation
Safety culture needs to be resilient. It must be able to be felt despite breaches of confidence, lapses by individuals and inevitable mistakes. However it will never survive management indifference.
Preservation of the safety culture comes with Management commitment.
It can also be damaged by management losing sight or focus on what the safety aims and objectives are.
…The rig has an effective SMS and a sound safety culture. As management are aware, safety culture is essential for the running of an SMS and must be ‘fair and just’. If rig personnel trust in ‘fair and just’ they will report without inhibition. Issues arise when breaches of say, Life Saving Rules are seen as inflexible in outcome (ie – run off the lease) when the context of the human error is not considered. Should a breach be deliberate, willful or flagrant, there is no question that consequences should be punitive. However should the error be a result of Human Factors, it needs to considered in context, and the outcome be a learning experience as part of a fair and just safety culture. The real danger when breaches of directives such as the Life Saving Rules are seen as the ‘Sword of Damocles’, personnel will simply stop reporting breaches to protect their jobs, and the safety culture will be lost…’
Extract from internal safety review to management for a Bass Strait exploration drilling rig
The Evolution of Safety Culture
Is it possible to change a culture?
Human Factors is a science in its own right. (In the modern age is usually also associated with Non Technical Skills – HF/NTS.)
Cockpit Resource Management (CRM) in the 1980s (Keggworth Air disaster in 1989)
Crew Resource Management in the 1990s – also CRM but now with a recognition that is was more than just pilots involved with the safe operation of an aircraft – to today’s requirement to integrate HF/NTS into SMS.
Personnel in aviation are highly trained in Technical skills – flying or maintaining aircraft – but it is the cognitive ability of successful HF/NTS that allows them to be highly proficient in the employment of these skills.
HF/NTS includes understanding and awareness of;
- Leadership (and ‘followship’)
- Alcohol and Other Drugs
- Situational Awareness
- Decision making
- Threat and Error Management
- Graded assertiveness
- …and others
QF 1 into BKK 1999
Human Factors is about human performance, behaviour, error, and an understanding of how humans interact with procedures, technology, environment and other humans.
Ultimately it is unsafe behaviours and actions that lead to accidents.
Behaviours are influenced by multiple inputs, commencing in the formative years when our personalities are being formed.
Human Factors is about how individuals behave within a system
- What people do when no one is looking
- Will people tell you what they did wrong when no one knew
⇒ Verifiable compliance
Human factors in medicine vs aviation
United flight 173 – 1979
Elaine Bromiley – NHS – 2005
Turning to aviation for guidance
The Reason Model
The Reason model of accident causation describes how the breach of multiple system defences could result in an accident. Professor James Reason also argued that single point failures in complex systems like aviation should not be consequential. The defence failures (breaches) could be both active or latent failures.
.An Active failure could be described as something that a conscious decision (regardless of the motivation), resulted in a defence layer being breached.
Example; maintenance crews using work-a-rounds to achieve operational efficiency when they know a procedure might be contrary to SOPs.
A Latent failure is more insidious, it lies in wait and unknown until discovered.
Example; An organisational manual that details company procedure, that happens to be contradictory to OEM manual perhaps prohibiting such action. The OEM manual was not thought to be checked on the assumption that the SOP writer had already done so.
The SHELL Model
The SHELL The model is used by ICAO to identify where HF breakdowns might occur.
The encompassing culture needs to be considered to expand the scope and the and understand the full spectrum of HF influence, both positive and negative.
Breakdowns between the human – the Liveware component in the middle – and any of the surrounding components, can lead to HF consideration and possible error.
Any interaction must include the central liveware. Human Factors breakdown do not include Hardware-Environment failures. An example of this might be a lightning strike at an airfield leading to failure of ground based navigational equipment. Clearly this could affect the safety of flight but it is not a human failure.
Human Factors Analusis and Classification System (HFACS) could be used as an alternative to SHELL model. It is based on James Reason’s accident causation model (Swiss Cheese) and was developed for the USAF.
The HFACS framework provides a tool to assist in the investigation process and target training and prevention efforts. Investigators are able to systematically identify active and latent failures within an organisation that culminated in an accident. The goal of HFACS is not to attribute blame; it is to understand the underlying causal factors that lead to an accident.
While the first use of the HFACS framework occurred in the US Navy where it originated, the system has spread to a variety of industries and organisations (e.g. mining, construction, rail and healthcare). Over the years, the application reached civil and general aviation. Regulators (particularly the FAA) have explored the use of HFACS as a complement to pre-existing systems.
Exercise – SHELL, Active and Latent failures, cultural influences
Time: watch video 10 minutes. Group work 30 minutes. Class discussion 20 minutes
Watch the following short video.
In groups write down the active and latent failures, the SHELL model breakdowns and the cultural influences
What were the active Failures?
What were the latent Failures?
What were the cultural influences?
Style Tone and Level
The BoM brand?
The BoM product
Communication challenges for the BoM – internal and external?
Reliance on third parties for communication of BoM products
Teamwork. Means never having to take all the blame yourself!
The balance of Leadership – Process – Culture is the key
(Biggest challenge to medical)
‘Three legged stool’
Performance excellence work cycle
Objective ⇒ Plan ⇒ Brief ⇒ Execute ⇒ Debrief ⇒ Lessons learnt
What are the Traits (qualities) and Principles (behaviours) of leaders?
Visible leadership actions?
The Hawthorn effect
“If the problem can be solved why worry? If the problem cannot be solved worrying will do you no good.”
How do we manage someone who is stressed at work?
How does work stress us?
How does our stress affect our external stakeholders
How do our products affect our stress levels?
Fatigue has a disproportionate involvement in aircraft accidents
Fatigue and weather are often linked in these accidents
Alcohol and other drugs
CASR Part 99
Requirement for Drug and Alcohol Management Plan
The risk to aviation
Threat and Error Management (TEM)
Can be traced to Line Operations Safety Audit (LOSA) concept developed between UT and Delta Airlines
Threats – generally defined as conditions, events or errors that occur beyond the influence of the line personnel, increase operational complexity, and which must be managed to maintain the margins of safety.
- Anticipated: thunderstorms.
- Unexpected: in-flight malfunction.
- Latent: equipment design, tight scheduling.
Errors – Actions or inactions by line personnel:
- Lead to deviations from organisational or operational intentions.
- Unmanaged or mismanaged errors frequently lead to undesired states.
- Errors in the operational context tend to:
- reduce the margins of safety, and
- increase the probability of an undesirable event.
Examples of errors would include:
- Not maintaining approach within stabilised approach parameters.
- Mis-reading or not understanding Weather.
- Misinterpreting an ATC clearance.
Undesired States – what Threats and Errors lead to and relate to circumstances where normal safety margins are reduced.
Examples could include
- selection of an incorrect flight management system mode,
- incorrectly configured aircraft or being below the minimum safe altitude during an approach.
Ineffective threat and/or error management may lead to:
- compromised situations, and
- reduce margins of safety aviation operations.
Often considered the last stage before an incident or accident.
Situational Awareness (SA)
SA changes, between individuals, within individuals
Generally – SA comes with experience – but not necessarily
BoM ⇒ ‘Environmental SA’
Loss of SA
SA is a large contributor to Perception ⇔ Reality
Loss of Situational Awareness will be part of the next accident
‘The safe and efficient handling of the aircraft both in the air and on the ground‘
QFI FLTLT Smith to OFFCDT McKay, Point Cook circa 1987
United flight 173 into Portland Oregon 1978
NHS Elaine Bromley 2005
QF1 into Bangkok 1999
AirNZ/XL Airways Perpignan 2008
Human Factors Exercise
Time: 30 minutes to disassemble and create instructions. 30 minutes to reassemble. 60 minutes to repeats with reverse roles. 30 minute class discussion.
This in an exercise in creating a product that needs to be passed to another group.
Discuss as a class:
- What worked?
- What didn’t?
- What are the lessons learnt?
- What improvements can be made?
- What are the takeaway observations from the exercise?
Antarctic Station Role play exercise
Time: 30 minute role play meeting. 30 minute class discussion
You are part of a leadership group at an Antarctica Station. There is a meeting to discuss a critical scientific operation involving Aircraft, Inflatable Rubber Boats and associated personnel. The operations will be over the next three days including personnel living in the field overnight.
It has been a long and difficult season and many scientific projects have not achieved their aim due to weather and other operational reasons.
The meeting consists of;
- The Station Leader – has overall responsibility for operations.
- The BoM representative – provides the forecasts and weather information for Antarctic operations
- Senior Pilot – responsibility for all aviation activity
- Boat Master – responsibility for all boating operations
- Senior Field Training Officer – responsible for all personnel operating in the deep field
Casey Station is the Antarctic station on the continent where all local operations are coordinated
Kingston is the Australian Antarctic Division Headquarters in Hobart who manage the whole Antarctic program and science projects
The meeting is chaired by the Station Leader and the aim is to determine the operational activity over the next three days.
The Meteorological briefing was highly technical in presentation. There are significant discrepancies in what the models are predicting.
The aim of the meeting is to determine the operational activity for the next three days.
You will role play one of the people in this meeting. Act to the role described and not what you may do in your real role.
Human Factors challenges in BoM
Consistency in decision making event to event
Consistency in decision making forecaster to forecaster
Focus on significant future event at expense of others
Holding nerve on a forecast event
Dealing with conflicting models
Handling the media roller coaster of a predicted event
Pressure from external agencies
End of Shift syndrome – reluctance to issue warnings
Lack of observation data against forecast
Post event criticism
High workload with low resource support
Stress distracting forecaster sharpness and concentration
Impact of warnings on society
Dealing with Aircrew
Increasing reliance on automated products
Face to face briefings