By Captain Chris Nutter and Thomas Anthony USC Aviation Safety and Security Program IHTAR Current situation well developed training for specific emergency scenarios No training for scenarios where the nature of the event is unclear ID: 1045532
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1. IHTAR An Event Management StrategyBy: Captain Chris Nutter and Thomas AnthonyUSC Aviation Safety and Security Program
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3. IHTARCurrent situation – well developed training for specific emergency scenarios. No training for scenarios where the nature of the event is unclear.No training in managing events.IHTAR is a protocol to fill that gap.
4. IHTARThe “Startle Effect”An Event Management Strategy for –Any event/ situation where there is a lack of clarity as to the nature of the problem or how to proceed.–
5. An event management strategy for any event that can absorb pilot attention, narrow focus, and severely reduce Situational AwarenessNon- linear problem solving and identification
6. MotivationWhy?If you don’t know what the problem is, difficult to solve it
7. IHTARProtocol to crew to utilize the maximum resources available to the crew AND avoid over-concentration on the anomalous event.Why ? Because over-concentration causes loss of Situational Awareness which may result in an Undesired Aircraft State
8. PrecedentsAir France 447American Airlines 965, Cali, ColombiaEastern Airlines 401, Everglades, West of Miami, FloridaUnited 173, Portland, Oregon
9. Air France 447
10. American Airlines Flight 965
11. Eastern Airlines Flight 401
12. EvolutionNot some thing completely newCRMTEMPilot MonitoringIHTAR gives us a protocol, a context in which to employ these successfully.Introduces a fourth element – Dynamic Maneuver Monitoring – DM2
13. A Disconnect Between Aircraft State and Pilot Awareness“I wonder what that is..?“Why is the aircraft doing that?”“Why did we lose the ______?”
14. Anomalous situations present a hazard that goes beyond loss of Situational AwarenessDraw in and absorb the pilots –downward spiral of Situational AwarenessNot just “heads down” but “minds scoped down.”Mythology – Odysseus and the Sirens, The Lorelei
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16. Is it needed?Is it needed? Recent Study of 1,020 FAA Part 121 and Part 135 accidents from1990-2002: Overall, nearly 70% were associated with some manner of aircrew or supervisory error. Approximately 50% associated with skill- based error, and 36.7% contained decision errors. Human Error and Commercial Aviation Accident: A Fine Grained Analysis Using HFACS, Shappell, Detwiler, Boquet, Weigmann, July 2006 . Human Error and Commercial Aviation Accident: A Fine Grained Analysis Using HFACS, Shappell, Detwiler, Boquet, Weigmann, July 2006
17. IHTAR- What is it?Three step processLike 3 waypoints that lead to a successful solution of an anomalous event or situation
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19. IHTARThe Three Waypoints are:IHTARHITSIWAYFI
20. The First Step
21. IHTARIHTAR“I have the aircraft and radios, you have everything else.”Ensures 1st priority – maintain aircraft in a safe operating stateAviateNavigate
22. IHTARIHTARAlso, begins an identified processClearly assigns rolesMaintains authority of CaptainAssures command integrity of entire crew and aircraft controlStarts a specific communication – DIALOG
23. IHTARPF maintains focus on aircraft state, fly the aircraft, AVIATE, awareness of outside environment, communication with ATCAvoid the “Two Heads Down” phenomenonCommunicate with ATC, tell them what you need and WHY. Make them part of the solution.Could be UHTAR
24. The Second Step
25. HITSI – The Second StepHITSI“Here is the way I see it”Directly builds upon CRM Continues the crew communication processEstablishes a common basis of understandingSeeks second view – Creates the environment for next step
26. HITSIKipling’s story of the elephant and the blind menSextant navigation- fix your position before setting out on a course
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29. The Third Step
30. WAYFIWAYFI – Third Step“What are you finding?”Continues the communication process – dialogSeeks independent assessmentDialog – synergy, a process of discovery, hueristicAn important process redundancy
31. WAYFI / DIALOGDialogDisciplined verbal communicationRequires sharing, listening, and attentionTrainingPracticeNot informal conversation.
32. WAYFIMaintains overall situational awarenessEach pilot performs Monitoring function for the otherAllows PF to listen and evaluate reports PF maintains distance –Notices “Does this make sense?
33. WAYFICreates specific roles and communication that avoids both pilots from missing the gorilla in the basketball gameAvoids task over-concentration causing us to miss other important information – hazard information – subsequent threat and error mgt.
34. WAYFI“What are you finding?”As information is reported the PF is in the position to notice anomaliesAnomalies are things that don’t make senseCali, Colombia “That can’t be right”How important are anomalies?Compass needle pointing to the problem
35. WAYFIInstead of discarding anomalous information – “What if it is true?”“What could this be telling us?”Maybe, doesn’t make sense because it doesn’t fit our mental model BUT we did NOTICE it.
36. NOTICINGNoticing is a primary mental mechanism that makes the IHTAR process workNoticing is an important threat detection function
37. How does Noticing work?
38. NOTICINGProduct of interest, knowledge, and experienceHappens automaticallySubconscious processing of informationSubconscious processing –remembering of namesNoticing is the result of cognitive integration – visual, memory, cognitive and intellect
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40. NOTICINGMechanism that makes SCANNING work.It is probably the reason why it is easier for us to scan analog rate and trend displays rather than digital.
41. NOTICING“Huh” is the verbalization of noticingTwo usages of “Huh”Don’t ignore the “Huh”Recognition of a relationship at the subconscious levelBecause product of our interest, knowledge, experience it should not be ignored
42. B 737 NG Unsecured Panel
43. IHTAR / NOTICING“Huh. I wonder why that panel is open in the first place.”“The Little Voice”
44. THE ENEMIES OF NOTICINGIHTAR recognizes the natural reaction to over-concentrate in emergency situationsFight or flight physiologyIHTAR maintains one pilot with ability to NOTICE – maintain peripherality (S/A)Notice things that don’t make sense and can lead to a solution of the situation
45. Emergency SituationsFight or FlightIncreased heart rate Apollo 11 Armstrong 156Blood flow to musclesTunnel visionAuditory exclusionIt is time we teach pilots about stress, stress response, behavior and performance under stress
46. Ability to NoticeThe more we know, the more we can notice.Novelty is the most attractive type of input for our brainsMemory not a photo but a survival toolSully - opportunity to learnIHTAR – implies personal and organizational responsibilities.We need to ensure that our policies and procedures are designed to mitigate stress effects
47. IHTAR goes beyond a challenge and reply or cockpit event resolutionPersonal / Professional responsibilityOrganizational responsibilityCaptain as mentor – a responsibility of commandRespect on-going learningProfessional curiosityLearning Culture
48. Dynamic Maneuver MonitoringDynamic Maneuver Monitoring – DM2When the PF executes any dynamic maneuver of the aircraft The PNF exclusively monitorsAvoids any extraneous conversationAvoids doing checklists in turnsDoubles the NOTICING ability Avoids causing any distractions
49. IHTAR RecapIHTAR SUMMARYCommunication protocol Managing situations where the nature of the event/problem is unknown or uncertainManaging beyond “Startle” events
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51. Establishes first priority – fly the aircraftAssigns roles Initiates dialog – mechanism of discoveryMaintains one crew member with ability to NOTICE – maintain peripherality and SA
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54. IHTARRecognizes that subconscious processing is real and is a valuable tool in identifying problems
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56. HMS Gloustershire, USS Missouri, The Silkworm Incident
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58. IHTAR Implementation Step 1 – IHTAR training for simulator instructorsStep 2 - Optional training protocol for crews displaying difficultyStep 3 - Collect data from crews and instructorsStep 4 - Analyze dataStep 5 - Expand training to pilot cadre based upon resultsStep 6 – Continue data collection and refinement of IHTAR procedureStep 7 – Tailoring – If you tailor it; share that.
59. IHTAR ImplementationGuidelines availableDocumentIHTAR Implementation – Rationale and ProceduresUniversity of Southern California, Viterbi School of Engineering, Aviation Safety and Security Programby Captain Chris Nutter and Thomas AnthonyRequest digital or print: Avsafe@usc.edu
60. Thank You from USC