Non-Technical Skills (Source: Hindsight Summer 2018; Leach, Murphy)

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1 Y O U R MONTH L Y S O UR C E F OR SA F ET Y IN F OR MAT ION DECEMBER V OL U ME XVIII ISS U E XII IN THIS EDITION PAGE 1 Non-Technical Skills PAGE 6 New SAFO for Circuit Breakers PAGE 8 Safety Manager s Corner PAGE 10 Quote of the Month CHiCKEN WiNGS Non-Technical Skills (Source: Hindsight Summer 2018; Leach, Murphy) Research has identified seven non-technical skills (NTS) categories and 26 skills that can be applied to any safety critical role or task. Why are these skills important? They have been associated with reductions in incidents and accidents. The term non-technical skills (typically incorporated into crew resource management in aviation) is now common in many safetycritical industries. NTS combine cognitive and behavioral aptitudes and skills to describe how a person undertakes a task. A pilot or air traffic controller has procedures and checklists detailing the tasks and actions they need to undertake. The related NTS for these helps explain how a pilot or air traffic controller carries out those tasks. For example, how do they maintain situational awareness? What information do they consider when making decisions? How do they manage periods of high and low workload? What strategies can/do they use? When there is equal emphasis on how a task is carried out, as much as what the task is, learning, development and performance can improve. Through our research we have identified seven NTS categories and 26 skills that can be applied to any safety critical role or task in our industry (Table 1). The aim is to help staff and the organizations they work for understand human performance, the factors that affect performance and the techniques that can be applied to enhance performance. This increased level of awareness means people are better able to identify opportunities for performance improvement through marginal gains, which is an approach often used in sports, such as athletic cycling. Small, focused, and incremental improvements over time add up to an aggregated, significant improvement. 1

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3 What affects our ability to apply NTS? There are a number of factors that can affect our ability to apply NTS. Based on our experiences working with rail organizations and looking at relevant rail incidents and accidents, a common set of factors seems to affect someone s ability to apply NTS effectively. These include: individual factors (such as memory capacity, assumptions, distractions, workload, attention and perception) job/workplace factors (such as equipment design and usability of procedures) organizational factors (such as leadership, culture, and change management). Our work on NTS therefore tends to focus on two areas: 1. techniques that individuals can apply to help them address the factors above, improve their application of NTS and achieve marginal gains in performance, and 2. approaches that organizations can take to increase the integration of NTS into their business, and help individuals identify and apply their techniques. What techniques can staff apply to make marginal gains? There is no one approach that everyone can apply to achieve marginal gains. However, there are a couple of techniques worthy of consideration. One example is risk-triggered commentary (Figure 1). This technique helps focus our memory so that critical information relating to risk for a given situation and/or task is maintained at the forefront of our mind. Risk triggered commentary involves recognizing a risk and then speaking it aloud, along with the actions to take to mitigate the risk. The technique helps someone to sense check what they are doing, and plan to do and can help to combat the effects of auto-pilot, low or high workload, distraction and incomplete or incorrect assumptions. The verbalization is based on risks, identified through risk assessment and incident and accident investigation, so that it does not become a running commentary of each decision and action undertaken. 3

4 Another example is the short journey concept. This is a technique used by drivers to break down their route. Rather than conceptualizing their route as one journey, they break it down into short journeys, typically station to station. For each short journey they focus on three areas signal, speed and station stop (i.e., length of train and the platform stopping position). This approach can help to focus attention, manage working memory and reduce the possibility of distraction. The technique can also be used by any role where it is beneficial to break procedures or processes down into smaller chunks to help focus attention and concentration. 4

5 What can organizations do? Staff have also developed their own checking routines to focus attention and combat the effects of assumptions, distractions, and auto-pilot attention. For example, some people visually check monitors and screens from top left to bottom right (z scan). Others use 'point and call' when checking and scanning to help them remember important information and indications, especially when such information or indications suggest something unusual or abnormal may be occurring. There are a number of things that organizations can do to support the application of NTS and adopt these approaches. For example: Critical NTS can be part of the staff selection criteria, with suitable tests selected to assess these. NTS can be fully integrated into technical training, competence standards and competence assessments, making it easier for staff to understand how these skills relate and enhance their technical skills and knowledge and the technical tasks they undertake. Incident and accident investigation can explore where a failure in NTS was a contributing factor, along with the factors that contributed to this failure. Leaders, managers, supervisors, trainer, assessors, and incident investigators can all be trained in NTS so they are better able to explain, promote and demonstrate these skills. Rail organizations are also starting to explore the concept of storytelling, where people s experiences are collected and turned into stories so others can learn from them. For example, Network Rail collects stories from signalers who have had an incident. Each story describes how the incident occurred, how the person felt, the reason for the incident, the techniques they now use to help them apply NTS better and the benefits this has brought them. RSSB has also recently been exploring the use of storytelling for route learning. This is where routes drivers need to learn are depicted in story format to help them understand and memorize the route and determine the specific hazards and risks associated with a route. 5

6 What does the all mean for aviation? Although NTS is already used within aviation, pilots, aircrew, air traffic controllers, and safety professionals can consult the RSSB NTS list to see if there are NTS that could be of use to help enhance performance. For instance: Staff and organizations could consider the factors that can affect someone s ability to apply NTS to determine the extent to which these are addressed within training, development and the techniques that staff already apply. Risk-triggered commentary could be applied to a range of aviation roles to help manage situations where tasks can be routine and repetitive, causing cognitive underload and degradation, and novel situations were cognitive workload can increase rapidly. Aviation organizations can check their selection, training, assessment, and incident and accident investigations to understand if NTS is being fully integrated into these areas and the extent to which organizational, job and workplace factors are considered and addressed to support human performance. Storytelling could be used in initial and refresher training as well as during development days, safety days and team/ crew briefings. There is no silver bullet when it comes to safety management and improvement. But improvements at the individual, job, workplace and organizational level can help to achieve marginal gains in performance. New SAFO for Circuit Breakers BY: Steve Witowski, PRISM Source: FAA SAFO18014 The subject of recently released SAFO is identification and manipulation of circuit breakers during abnormal or emergency situation, and was published in response to NTSB recommendation A In several fatal accidents a pilot was unable to identify and pull a circuit breaker (typically associated with an autopilot system) during an abnormal or emergency situation. 6

7 Example: On November 20, 2015, a Beech A36TC, N7FG, descended into Clear Lake, Orlando, FL. The private pilot and the passenger were fatally injured, and the airplane was destroyed. During the flight, while the airplane was flying at 1,700 feet MSL, the pilot advised the controller that for some reason he could not get the airplane's autopilot to disengage. After the pilot's request for assistance, the pilot of another airplane said, pull your circuit breaker. The accident pilot was confused and said that he was relatively new to the airplane. Essential skills pilots should train and practice are: 1. Location and identification of circuit breakers that need to be pulled during abnormal or emergency situations; 2. Proper preflight and ground check of the Flight Director/autopilot system; and 3. Demonstration of all methods used to disengage and disconnect an autopilot. Recommended Action: Student pilots, pilots, flight instructor applicants, flight instructors, flight schools, Title 14 of the Code of Federal Regulations (14 CFR) Part 141 pilot schools, 14 CFR part 142 training centers, and evaluators should familiarize themselves with the information in this SAFO and are encouraged to thoroughly review the manufacturers guidance regarding circuit breakers techniques and procedures during abnormal or emergency situations. Click here to view the SAFO 7

8 Summing Up the Year As the calendar year 2018 comes to a close, consider examining your operation s safety performance. Ask these important questions and discover what the answers reveal. Did we accomplish all our safety goals for the year? Goals should be measurable, so answering this question should be easy. Did we consistently use an internal evaluation program (IEP) to monitor practices and process? Where there significant changes in our operation that we failed to recognize, and therefore didn t perform appropriate change management? Did we review our reporting forms to ensure they are collecting information effectively? If adjustments were necessary, were they made? Did we review our FRAT report form(s) to ensure they are effectively managing risk? If adjustments were necessary, were they made? Did we adequately track all our safety performance indicators (SPIs)? Are the SPIs appropriate and help us manage risk? Are we prepared to set new safety goals for the next calendar year? Where submitted safety reports closed with an effective corrective action? Or did we often bail out and rely on simple communication of the hazard as the sole corrective action (example: Will brief at the next all pilot meeting)? Did our IEP discover findings (discrepancies), and did we effectively correct them? Did we follow-up all corrective actions with assurance checks, making sure they were effective? Was there sufficient safety performance feedback to employees? Was the communication of hazard and risk information effective? Although likely not comprehensive for every operation, this list of questions will help you determine a successful safety management year. A safety performance report is another important aspect of safety communication. Provide the accountable executive with the status of all important markers. Use data from the safety management system (SMS) to provide quantitative descriptions of performance. You can t measure things that didn t happen, but you can measure things that did. For example, Our top ten FRAT risk factors in

9 Use PRISM ARMOR s Safety Intelligence, where your data tells the story using a variety of graphs and charts. If you have any questions about Safety Intelligence, please contact a member of the PRISM support team. Have a great 2019! 9

10 Quote of the Month Every day is a new opportunity. You can build on yesterday's success or put its failures behind and start over again. That's the way life is, with a new game every day, and that's the way baseball is. BY: Bob Feller The safety management take on Bullet Bob s intent is pretty simple. No two days are alike, but regardless just move forward. Don t settle for letting it ride, always build and improve. Baseball and aviation - they have a lot in common. Game plan out every possible detail, yet understand that the unknown or the unexpected can occur, and usually does. Thorough preparation must always precede execution. The game plan identifies weaknesses and examines options to deal with them. With each option comes risk, and when that is assessed the proper choice can be made. Without a game plan, there are no options, just guesses. 10