Human Factors/SMS/CRM Training and Consulting---The Aviation Consulting Group

The economy is awful. Fuel prices are at record highs. Airlines are barely profitable. Some airlines are merging as an only means of survival. There is a forecast shortage of experienced air traffic controllers. Runway incursions and near mid-air collisions are all over the news. The FAA has been complacent on its oversight and enforcement responsibilities. Does anyone see a problem here?...

What the Media Should Know about Aircraft Accidents

By Robert Baron, Ph.D

Another plane crash. Another deluge of phone calls from the media asking what caused the plane to crash. Speculation is immediately and unhesitatingly articulated by witnesses, passersby, and experts. "Lightning must have brought it down" says one. Another says, “He thought the airplane was just traveling too fast to stop." Pretty presumptuous for an eyewitness; extremely presumptuous for a non-pilot. Yet, the media, in their call to action, begin to use these very accounts as an explanation as to why the airplane crashed. Amidst rampant speculation, the media have their story; albeit lacking necessary credibility...

Cockpit Discipline: Violating the Sterile Cockpit Rule and Ignoring other Standard Operating Procedures can Lead to Tragedy

Corporate Airlines Flight 5966

By Robert Baron, Ph.D

In a string of recent aircraft accidents there has been an emerging and very disturbing theme. It appears that non adherence to standard operating procedures and violations of the sterile cockpit rule are becoming far too common, often with tragic results. In one of the most recent accidents, the unprofessional actions by the flightcrew were contributory to a crash that claimed 13 lives, including the captain and first officer...

Conflict in the Cockpit: Can't we all Just get Along?

By Robert Baron, Ph.D

This paper addresses leadership, followership, and decision skills as they apply to flight crewmembers. Most pilots display a mastery of these skills. Unfortunately, there are a small number of pilots who lack these and other interpersonal skills and can become a danger to the safety of flight. Two case studies are presented where there was such a breakdown in teamwork that the environment in the cockpit became hostile, abusive, and outright dangerous. Crew resource management training addresses many of these interpersonal issues and references to FAA Advisory Circular 120-51E (Crew Resource Management Training) are included for further edification...

SOS for your SMS: A Brief Look at Airport Safety Management Systems

By Robert Baron, Ph.D

An airfield maintenance truck accidentally transgresses an active runway and causes a runway incursion. Although there is no actual collision between the truck and an aircraft on short final (that is forced to go around), the event is something that the pilots, maintenance crew, and air traffic controllers will not soon forget. The cause of the transgression is due to the inability of the maintenance crew to hear the tower’s last minute hold short instructions because the volume on their radio was turned down. Even though this event was fictitious, I am sure all airport managers can identify with real, similar experiences. More on this example shortly...

The Challenges of an Error Reporting System

By Robert Baron, Ph.D

On first mention, many of the managers and supervisors I speak with are supportive of the idea of an error reporting system (ERS) in their organization. The benefit of an ERS is fairly obvious; if errors are reported then fixes can be implemented and errors can be diminished or in some cases even eliminated. This in turn creates a safer working environment as well as reduced vulnerability to litigation. Yet, in light of all these benefits, many organizations have failed to adopt and support a formal ERS...

A Review of the Literature Pertaining to Decision Making in Aviation

By Robert Baron, Ph.D

A review of the literature in aviation decision making was conducted to explore some of the theoretical and practical applications that could be beneficial to pilots. Improper decisions have been implicated in more than 50% of general aviation accidents. While there is an increased research component in this important domain, there still appears to be an overall lackadaisical attitude in fully addressing aeronautical decision making skills during initial pilot training where it will be most beneficial. Technical skills alone are just not enough to make a safe pilot. It is intended that this paper will shed additional light on how pilots make decisions and how those decisions can be erroneously influenced by basic cognitive limitations...

Aircraft Accident Investigations: Have we Lost Touch With the Behavioral Approach?

By Robert Baron, Ph.D

As aircraft become more technologically advanced, the causes of accidents are becoming less attributable to mechanical factors. On the other hand, human error continues to be problematic with 60%-80% of all aircraft accidents having a human error component (Federal Aviation Administration, 2004). According to Wiegmann and Shappell (1997), "Although the overall rate of aviation accidents has declined steadily during the past 20 years, reduction in human error-related accidents have not paralleled those related to mechanical and environmental factors." From this, we can surmise that it is much easier to make airplanes safer from a technological approach than from the human approach. This is a truism and the adage 'to err is human' is a testament to the problem...

Transformational Leadership in Aviation Operations

By Robert Baron, Ph.D

Leadership in aviation may be decomposed into two important domain levels; the broader organizational level and the more narrowly focused flight deck (pilot) level. While the organizational level shares responsibility for both profit and safety, the primary responsibility for pilots is safety (not to discount the fact that just one unsafe act committed by the pilot can negatively influence at least short-term profits)...

Aviation Training: Methods and Anecdotes to Help Understand how we Learn

By Robert Baron, Ph.D

This paper looks at how people learn. Although there is an emphasis on learning in the aviation environment, the same principles can be applied outside of the aviation domain, such as high school and college learning, company training, enrichment courses, online learning, etc. The topics are discussed in a way that can be useful to both instructors and students. Specific topics include how people learn, barriers to effective learning, how to improve learning, and testing methodologies. The information is presented as a combination of research-supported data as well as anecdotal contributions by the author...

Barriers to Effective Communication: Implications for the Cockpit

By Robert Baron, Ph.D

The communication process encompasses every single part of our daily being. The use of both verbal and non-verbal communication is the very basis of how we converse, both on a personal and on a business level. This paper introduces the concepts of the communication process and then uses the aviation domain to exemplify how barriers to effective communication may manifest themselves. Two specific areas in aviation are discussed; barriers to effective communication between pilots, and, barriers to communication between pilots and air traffic controllers (ATC). The combination of case examples, empirical research, and studies of literature, is combined to give the reader a true picture of the effects of deficient communications processes in the aviation domain...

CRM From the Instructor/Facilitator Viewpoint: Observations we can all Learn From

By Robert Baron, Ph.D

In my years of being a flight, ground, and simulator instructor in high performance jets, I have had the pleasure of observing a plethora of behaviors in the area of Crew Resource Management. Additionally, as a CRM facilitator, I sometimes have access to the stories and confessions that some pilots are willing to share in a casual, relaxed setting. That said, I wanted to share some observations and recommendations for any person making an attempt to enhance their CRM skills...

Human Factors in Aviation Maintenance: A Look at the Fundamental Concepts

By Robert Baron, Ph.D

In 1988, Aloha Airlines Flight 243 had a large section of its fuselage separate from the aircraft at an altitude of 24,000 feet. While the aircraft did make a successful emergency landing, one flight attendant was fatally injured during the unfolding events. Aloha Flight 243 became the watershed event that would trigger the need to address human factors in aviation maintenance. This paper is intended to shed light on the fundamental concepts of human factors (HF). A brief history and overview is presented followed by a description of the elements that comprise an HF program...

Human Performance Limitations in Medicine: A Cognitive Focus

By Robert Baron, Ph.D

Medicine has traditionally been one of the most cognitively demanding occupations. This paper discusses the limitations of human performance in the hospital environment. Human Factors models are presented and used as an anchor for a randomly selected case study involving a potentially lethal medication error. The case study Root Cause Analysis showed five distinct factors that were causal to the error. The Human Factors models, in conjunction with an overview of basic human cognition, provide the reader with the tools to help understand all five findings of the case study. It is intended that this paper will provide a foundation for improving medical safety by creating an awareness of the factors that influence error in everyday procedures...

Pilots and Memory: A Study of a Fallible Human System

By Robert Baron, Ph.D

This paper looks at human memory with an emphasis on pilot performance in the cockpit. The basic biological processes of memory are discussed, including how memory is formed, stored, and retrieved, and how organic and non-organic influences may degrade or impede memory performance. Key findings in current research indicate that prospective memory failures may pose a significant threat to flight safety. Information derived from NASA's Aviation Safety Reporting System (ASRS), as well as NASA research that investigated concurrent and deferred task demands for pilots, provides valuable insight into the fallibilities of human memory as it applies to flight operations...

Monovision Contact Lens Use and the Crash of Delta Airlines Flight 554 at LaGuardia Airport, October 1996

By Robert Baron, Ph.D

October 19,1996. 1638 EDT: Delta Airlines Flight 554, a McDonnell Douglas MD-88, descended below the visual glidepath and collided with terrain on approach to New York’s LaGuardia Airport. There were 3 minor injuries and 60 uninjured. In its official investigation of the crash, the NTSB (National Transportation Safety Board) reached the following conclusions as to the probable cause...

Psychology of the Cockpit: The Pros and Cons of the MMPI in Pre-Employment Screening

By Robert Baron, Ph.D

The MMPI-2 has become one of the most widely used psychological assessments for the pre-employment screening of airline pilots. This paper looks at the development of the original MMPI through the revised version known as the MMPI-2. The test's psychometric properties and administration are discussed with a focus on threats to validity, such as faking, overreporting and underreporting, and defensive responses. Finally, an argument is presented that addresses whether the need for recurring psychological testing of airline pilots should be mandated based on past examples of in-flight pilot suicides. It appears that a one-time pre-employment screening may not be enough to adequately address the various innate, situational, and environmental factors that might cause psychological instability long after MMPI-2 administration...

Understanding the Role of Safety Culture in the Aviation Environment

By Robert Baron, Ph.D

Safety culture. A nebulous concept; one that by some is considered chaotic. Defining its meaning has been problematic. Yet we now know that a maladaptive safety culture can contribute to aircraft accidents. Organizational factors have been implied in a number of high-visibility accidents but it appears that safety culture in itself has been a concept either shunned or ignored for various reasons. Fortunately, this is changing. This paper addresses safety culture concepts by incorporating theoretical and actual case studies and concludes with this author's recommendations for human resource managers in high-risk industries. It is hoped that the information contained in this paper will be useful for organizations seeking to become proactive in the promotion of a healthy safety culture...

Safety Culture and Profit: Aviation's Continuing Organizational Dilemma

By Robert Baron, Ph.D

The safety vs. profit organizational dilemma has been a prominent trademark of the airline industry since its inception. This paper critically analyzes and compares two sets of management styles; one that propagates a pathogenic organizational and safety culture and another that exemplifies the proper balance of safety and profit while maintaining a high level of job satisfaction for its employees. Case examples are used to illustrate the consequential effects of both latent and overt management errors. A paradigm shift has begun to occur where the blame for accident causation is no longer pointing the guilt finger solely on the pilots; instead, the organizational culture itself is being defined as contributory to many of these accidents...

The Cockpit, the Cabin, and Social Psychology

By Robert Baron, Ph.D

All airline pilots are required to receive crew resource management (CRM) training, which augments technical flight and ground training with human factors subjects. There has also been an increase in this type of training for flight attendants. CRM training has been shown to be efficacious for both groups when viewed separately. Unfortunately, in real flight operations, there are cognitive and physical factors that cause these disparate groups to work less than efficiently between their groups, particularly when a cohesive environment is critical, such as in an emergency. This paper looks at the factors that influence the separation of these two groups and offers recommendations to address this critical issue...

Why On-Demand Jet Charter Needs CRM...Now!

By Robert Baron, Ph.D

On the basis of "the straw that broke the Camel’s back," the National Transportation Safety Board has finally reached a plateau in the form of operation-specific urgency. The NTSB wants the FAA to require Part 135 on-demand charter operators that conduct operations with aircraft requiring two or more pilots to establish a FAA-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. This, in light of the tragic Gulfstream III accident in Aspen Colorado in 2001, where there was such a breakdown in communications, responsibilities, and procedures between the crewmembers, that it was plainly obvious that Crew Resource Management training probably would have prevented the crash...