Human Factors Accident/Incident Checklist

A checklist from the Flight Safety Foundation of human factors to be aware of when flying.

Sensory/Perceptual Factors
1
1. Misjudgment of distance, clearance, altitude, speed, etc
2
2. False perception because of visual illusion
3
Conditions that contribute to impaired visual performance:
4
-Featureless terrain (e.g., desert, dry lake, water)
5
-Darkness/low visibility
6
-"Black-hole effect"
7
-No horizon or false horizon (unreliable visual attitude reference)
8
-Mountainous terrain or sloping runway
9
-Helicopter-rotor downwash effects
10
-Anomalous light effects (e.g., causing flicker vertigo)
11
-Low contrast of objects to background or poor illumination
12
-View into bright sunlight/moonlight
13
-Shadows
14
3. False perception because of vestibular (inner-ear) disturbance
15
Types:
16
-Coriolis (spinning sensation because of vestibular overstimulation)
17
-Somatogravic (gravity-induced false sensation of a pitch-up)
18
-Somatogyral (false sensation of rotation)
19
4. Spatial disorientation/vertigo
20
Types:
21
-Unrecognized (loss of altitudinal awareness)
22
-Recognized (vertigo)
23
-Incapacitating (e.g., vestibular-ocular decoupling induced by rapid acceleration/deceleration forces)
24
Conditions that affect sense of body position or aircraft attitude:
25
-Loss of visual cues/attitude reference (especially with no natural horizon)
26
-Acceleration (g) forces
27
-Adverse medical condition or physiological condition (e.g., alcohol/drug effects, hangover, dehydration, fatigue, etc.)
28
5. Loss of situational awareness
29
Types:
30
-Geographic disorientation (e.g., deviation from route, operation outside chart limits, loss of position awareness)
31
-General loss of situational awareness (e.g., failure to perceive hazardous condition, such as controlled flight into terrain)
32
-Erroneous situational assessment (misinterpretation of situation or condition)
33
-Failure to predict/anticipate changing conditions
34
-False hypothesis/confirmation bias (persistent false perception or misconception of situation)
35
6. Attention failure (e.g., failure to monitor or respond when correct information was available)
36
Types:
37
-Omission of checklist items, standard call, or crew challenge
38
-Failure to monitor flight progress or to maintain instrument scan
39
- Failure to respond to communication or warning
40
-Control-action error:
41
--Failure to set/move/reset control switch (lapse)
42
--Unintentional activation of control switch (slip)
43
--Control-substitution error (slip)
44
--Control-reverse error (slip)
45
--Control-adjustment/precision error (slip)
46
Conditions that affect attention and situational awareness:
47
-Inattention (focus on information unrelated to flight-deck tasks/flying)
48
-Channelization, fixation (psychological narrowing of perception)
49
-Distraction (preoccupation with internal [mental] event or with external event)
50
-Task overload (excess tasking with or without schedule pressure or task-performance-time pressure)
51
-Cognitive workload (problem-solving concentration or information overload)
52
-Habit influence/interference
53
-Excessive flight crew stress or fatigue
54
-Excessive mission tasking or workload
55
-Inadequate briefing/flight preparation
56
-Inadequate training/experience for mission
57
-Negative learning transfer (e.g., during transition to new aircraft)
58
-Adverse meterological condition
59
-Tactical-situation overload/display-information overload
60
-Inadequate flight crew motivation/inadequate flight vigilance
61
-Inadequate flight-deck design (control/display location or data format)
Medical and Physiological
1
1. Self-medication (without medical advice or against medical advice)
2
2. Influence of drugs/alcohol
3
3. Cold or flu (or other known illness)
4
4. Excessive personal stress/fatigue
5
5. Inadequate nutrition (e.g., omitted meals)
6
6. G-induced loss of consciousness or g-induced illusion
7
7. Hypoxia
8
8. Other medical or physiological condition
9
Conditions that may cause adverse medical/physiological state:
10
-Mission tasking or job fatigue (e.g., on duty more than 14 hours, late-night operations or early morning operations)
11
-Cumulative fatigue (e.g. excessive physical workload, mental workload, circadian disruption or sleep loss)
12
-Cumulative effects of personal stress or occupational stress (beyond stress-coping limit)
13
-Emergency-flight-condition/workload transition (from normal operation to emergency operation)
14
-Medical or physiological preconditions (health/fitness, hangover, dehydration, etc.)
Knowledge and Skill
1
1. Inadequate knowledge of systems, procedures, etc. (knowledge-based error)
2
2. Inadequate flight control/airmanship, or inadequate accuracy and precision of flight maneuvering (skill-based error)
3
3. Misuse of procedures or incorrect performance of flight-deck tasks (rule-based error)
4
-Failure to perform required procedure
5
-Use of wrong procedure or rule(s)
6
-Failure to conduct step(s) in prescribed sequence
7
Conditions that lead to inadequate operational performance:
8
-Demonstration of performance below required proficiency standards or currency standards
9
-Demonstration of inadequate performance of documented flight-aptitude deficiencies
10
-Low flight hours (total/type)
11
-Inadequate essential training for specific task(s)
12
-Inadequate recent experience or inadequate experience in flight condition (e.g. , instrument flight rules, night, weather, etc)
13
-Transition (learning new aircraft system)
Personality and Safety Attitude
1
1. Demonstration of overconfidence in flying ability
2
2. Demonstration of excessive motivation to achieve mission
3
3. Reckless operation
4
4. Demonstration of anger/frustration on the job
5
5. Demonstration of stress-coping failure (e.g., anger)
6
6. Overly assertive or nonassertive
7
7. Inadequate confidence to perform tasks/activites
8
8. Acquiescence to social pressure (from organization or peers) to operate in hazardous situation/condition
Judgment and Risk Decision
1
1. Acceptance of a high-risk situation/mission
2
2. Misjudgment of mission risks (complacency)
3
3. Failure to monitor flight progress/conditions (complacency)
4
4. Use of incorrect task priorities
5
5. Intentional deviation from safe procedure (imprudence)
6
6. Intentional violation of standard operating procedure or regulation
7
7. Intentional disregard of warning (by human or aircraft system)
8
8. Noncompliance with personal limits
9
9. Noncompliance with published aircraft limits
10
10. Noncompliance with prescribed mission profile/parameters
11
11. Acquiescence to social pressure (from organization or peers)
12
Conditions leading to poor safety attitude and risky judgment:
13
-History of taking high risks (personality-driven)
14
-Pattern of overconfidence (aggrandized self-image)
15
-Documented history of marginal performance/failure
16
-Excessive motivation (did not know limits)
17
-Reputation as a reckless pilot
18
-Failure to cope with life stress (anger/frustration)
19
-Overly assertive or nonassertive (interpersonal style)
20
-Influenced by inadequate organizational climate/safety culture (e.g., lack of adequate supervision)
Communication and Crew Coordination
1
1. Inadequate mission plan/brief or preflight
2
2. Failure to communicate plan/intentions
3
3. Failure to use standard/accepted terminology
4
4. Inadequate understanding of communication or failure to acknowledge communication
5
5. Inadequate crew coordination (challenge, cross-check)
6
6. Intentional withholding, by a crewmember, of vital safety data
7
7. Failure of the pilot-in-command to lead/delegate
8
8. Failure of the pilot-in-command to use all available resources
9
9.Interpersonal conflict/crew argument during flight
10
Conditions leading to inadequate communication/coordination:
11
-Inadequate training in communication/crew coordination
12
-Inadequate standard operating procedures for use of crew resources
13
-Failure of organizational safety culture to support crew resource management
System Design/Operation
1
1. Use of wrong switch/lever or control
2
2. Misinterpretation of instrument indication
3
3. Inability to reach/see control
4
4.Inability to see/interpret instrument/indicator
5
5. Failure to respond to warning
6
6. Selection/use of incorrect avionics system operating mode (mode confusion)
7
7. Over-reliance on automated system (automation complacency)
8
Conditions that contribute to design-induced flight crew errors:
9
-Inadequate primary aircraft control/display arrangement
10
-Inadequate primary display data or data format
11
-Incompatible flight deck control/display activation, or aircraft-response mapping
12
-Inadequate hazard advisory or warning display
13
-Inadequate flight deck design (controls or displays outside crew vision or reach)
14
-Inadequate human-computer-display interface/usability (error-prone design)
15
-Inadequate system instructions/documentation
16
-Inadequate aviation-system support or facilities (navigation aids, airport, air traffic control)
17
-Nonstandard flight deck layouts (conducive to negative habit transfer)
18
-Inappropriate type or level of automation, or excessive mode complexity
Supervisory and Organizational
1
1. Inappropriate scheduling/crew assignment
2
2. Failure to monitor crew rest/duty requirements
3
3. Failure to establish adequate standards
4
4. Failure to monitor compliance with standards
5
5. Failure to monitor crew training/qualifications
6
6. Failure to identify/remove a known high-risk pilot
7
7. Failure to establish/monitor quality standards
8
8. Intentional violation of a standard or regulation
9
9. Failure to perceive or to assess correctly mission risks, with respect to:
10
-Evironmental hazards/operating conditions
11
-Mission tasking and flight crew skill level
12
-Aircraft and equipment limitaions
13
Conditions leading to supervisory failures:
14
-Excessive operations tempo/organizational workload (imposed by the organization or organizational chain)
15
-Inadequate organizational safety culture
16
-Inattention to safety management (inadequate safety supervision)
17
-Inadequate work standards/low performance expectations
18
-Inadequate/bad example set by supervisors
19
-Inadequate safety commitment/emphasis by supervisors
20
-Organization lacked an adequate system for monitoring and correcting hazardous conditions
21
-Supervisors did not promote and reward safe behavior or quickly correct unsafe behavior
22
-Organization didn't have adequate policies and procedures to ensure high-quality work
23
-Organization had inadequate job-qualification standards or training program
24
-Organization had inadequate internal communication
25
-Organization had no system or inadequate system for management of high-risk pilots
26
-Organization had inadequate process or procedures for operational risk management
27
-Organization didn't provide adequate aeromedical/human factors training
28
-Organization didn't ensure sufficient involvement of medical and occupational health specialists
29
-Organization didn't establish or enforce acceptable medical/health standards
Created by GregP. This checklist is public.
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