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		<title>Per page discussions (new posts)</title>
		<link>http://aviationknowledge.wikidot.com/forum/c-61121/per-page-discussions</link>
		<description>Posts in the forum category &quot;Per page discussions&quot; - This category groups discussions related to particular pages within this site.</description>
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				<guid>http://aviationknowledge.wikidot.com/forum/t-123445#post-891795</guid>
				<title>Hazardous Attitudes: Hazardous Attitudes</title>
				<link>http://aviationknowledge.wikidot.com/forum/t-123445/hazardous-attitudes#post-891795</link>
				<description></description>
				<pubDate>Fri, 08 Oct 2010 10:31:29 +0000</pubDate>
				<wikidot:authorName>robere</wikidot:authorName>				<wikidot:authorUserId>508422</wikidot:authorUserId>				<content:encoded>
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						 <p>I would just like to make one comment about the subject article on attitudes with respect to unusual attitudes. In the unlikely event that a reader uses the article as a SOP, my recommendation for coping with an unusual attitude in a descending turn is:</p> <ul> <li>Check airspeed - if rapidly increasing reduce power</li> <li>roll wings level - this bit is important!</li> <li>pitch to the horizon</li> <li>etc</li> </ul> 
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				<guid>http://aviationknowledge.wikidot.com/forum/t-186267#post-600263</guid>
				<title>Accident Causation Model: The one-man war on error- Tony Kern</title>
				<link>http://aviationknowledge.wikidot.com/forum/t-186267/accident-causation-model#post-600263</link>
				<description></description>
				<pubDate>Sat, 03 Oct 2009 15:03:36 +0000</pubDate>
				<wikidot:authorName>Kiwi Fighter</wikidot:authorName>				<wikidot:authorUserId>233621</wikidot:authorUserId>				<content:encoded>
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						 <p>Hi I would like to share with you an article I found in the Flight Safety Australia Magazine. It summarizes an Australian Wide Error Management Conference lead by Tony Kern a well known pilot for his work on airmanship. I felt that it would be best contributed to the bottom of this page as it provides an alternative view on the effectiveness of systematic approaches in human error management such as James Reason’s Swiss Cheese Model in the industry today.<br /> Tony states that effective error control requires a greater consideration of the role of individual performance, arguing until now, the focus of error management in aviation has been on a systematic approach. These Safety Management Systems (SMS) deal with the issues at a systems level, and Crew Resource Management and Threat and Error Management (TEM) focus at a team level, and no one according to Kern is dealing with the root cause that ‘Safety Management begins with personal accountability.’ Tony believes the current CRM and TEM are polished antiques, and to which people are bored of the recurring training that has no effect on reducing error. Tony’s experience as a US Defence Force Flight Instructor helped to lead him on this road to personal accountability. Deeply affected by high accident rates and numerous fatalities in the defence force (13 in 18 months) he was lead to question the accepted systems approach. He now believes ‘Individual improvement will trump organisational fixes, things must be at a personal level but personal accountability is not intuitive. It is a learnt skill, but not a taught skill.’ He now pushes for individuals to adopt a daily regime of personal error control, beginning with complacency because in an emergency situation we will all perform worse than our average, so our goal must be towards perfect performance and not to be comfortable with the average. Human error should be seen as no more apart of being human than cancer is. Each individual should develop a personal code in the 3Ds- ‘attention to detail, diligence- every time, all the time and discipline- the ability to self check and resist temptation to deviate.’ By practicing these habits of professional discipline, the individual makes them permanent. As for SMS Kern believes they disintegrate from within and for future effective error control in the industry it is required for aviation professionals to set uncompromising standards in their daily lives, refusing to allow the ‘crushing grip of mediocrity’ to take hold, then these disciplinary skills will progress into the cockpit and workshop.<br /> I find this a very interesting article that leads me to think of how much we focus on SMS in Human Factors and how personal accountability (active errors) is just component of the larger system. I see how arguments could be thrown both ways and would be interested to here other peoples views on the subject.</p> <p>Reference<br /> <strong>Flight Safety Australia (Sep-Oct 2009).</strong> <em>The one-man war on error.</em> Flight Safety Australia Magazine Issue No. 70 (p.42-43). IPMG (Independant Print Media Group), Canberra.</p> 
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				<guid>http://aviationknowledge.wikidot.com/forum/t-123445#post-587381</guid>
				<title>Hazardous Attitudes: Re: Get Home-it-is</title>
				<link>http://aviationknowledge.wikidot.com/forum/t-123445/hazardous-attitudes#post-587381</link>
				<description></description>
				<pubDate>Fri, 18 Sep 2009 02:56:07 +0000</pubDate>
				<wikidot:authorName>Zash</wikidot:authorName>								<content:encoded>
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						 <p>Thank you for your input and references.</p> <p>Indeed sometimes automation does cause complacency and affects the pilot's SA.<br /> Another point I thought i share about automation is when a pilot is new to a particular system. Its difficult to ignore previous system knowledge and accept new operating philosophy. For example, converting to an Airbus aircraft after flying a Boeing aircraft for a period of time, or vice versa.</p> <p>To illustrate an example of the differences in the design and use of automation, is the Auto-pilot system between the two types of aircraft.<br /> In a decent for an approach to land, the Boeing and the Airbus auto-pilot system usually take reference for its navigation from a system that follows the planned lateral and vertical route from the Flight Management System (FMS). Whatever that is programmed by the pilot, the aircraft auto-pilot system will fly (even if its rubbish) to maintain the vertical and the lateral profile as accurately possible. Ideally, having this system will allow a continuos decent to land with the engines operating at almost ilde power, thus increasing fuel efficiency, reducing noise and environmental pollution. But at most international airports the ability to fly the aircraft on a standard arrival route (STAR) is sometimes impossible without constant Air Traffic Controller's (ATC) instructions changes on the track and height to accommodate other traffic.</p> <p>The Airbus aircraft flies the planned lateral route in an auto -pilot mode called NAV (navigation) and the vertical profile in DES (decent) mode. All height and lateral constraints impossed in the STAR will be complied with for as long as ATC does not intervene. The Boeing aircraft, does it similarly but calls it partly different. The lateral route mode, NAV (navigation) and vertical profile, VNAV PTH ( decent).</p> <p>Now when ATC instructs a change in heading of the aircraft, the Boeing pilot will select the HDG (heading) mode and the aircraft takes reference of the changes from the pilot's inputs and ignore the lateral routing from the FMS but still maintain the vertical profile of the planned route in the FMS. Airbus pilots, on the other hand will also select the HDG mode but the automation logic design will also disengage the planned vertical profile and change the decent mode to V/S (vertical speed) and maintain the aircraft's current decent vertical speed, which must be controlled by the pilot too.</p> <p>If pilots do not realize the differences quick enough, then they lose situational awareness. The height of the aircraft will be too high or too low for the approach, causing undesirable reactions. Thus the differences in the designs of automation also contributes to the negative effects in crew perception and reactions.</p> <p>For more information on the auto-pilot automation, visit the website below:</p> <p><a href="http://www.airbus.com/en/corporate/ethics/safety_lib/">http://www.airbus.com/en/corporate/ethics/safety_lib/</a></p> <p>Shahrin Hashim</p> 
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				<guid>http://aviationknowledge.wikidot.com/forum/t-123445#post-586506</guid>
				<title>Hazardous Attitudes: Re: Get Home-it-is</title>
				<link>http://aviationknowledge.wikidot.com/forum/t-123445/hazardous-attitudes#post-586506</link>
				<description></description>
				<pubDate>Thu, 17 Sep 2009 01:00:59 +0000</pubDate>
				<wikidot:authorName>Pilotpete</wikidot:authorName>				<wikidot:authorUserId>354603</wikidot:authorUserId>				<content:encoded>
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						 <p>Very interesting article and valuable insight into a syndrome known to many pilots. It is certainly something that has been stressed to me throughout my training and i have continued to pass on my own words of caution to my students as a flight instructor. As you say there are other contributory factors that could be taken into consideration which add to the 'get home-it-is' to compound the problem. I was just reading an article by Endsley (1999) Situation Awareness in Aviation Systems. I thought it worth mention because it highlights the detrimental effects of being too reliant on automated systems and subsequent reduction in SA levels as a result of being &quot;out of the loop&quot;. I can imagine after flying many hours along the same route, there may be a tendency to be slightly complacent about certain factors pertaining to the repetitive nature of scheduled flights. In the article it says that automation of systems can be useful to reduce the workload, however being to reliant on automated systems will have the negative effect in that crew may perceive, process and react slower to any change of state due to;</p> <p>a) &quot;a loss of vigilance and increase in complacency associated becoming a monitor with implementation of automation&quot;<br /> b) &quot;being a passive recipient of information rather than an active processor of information, and a loss of or change in the type of feedback provided to the aircrew concerning the state of the system being automated (Endsley &amp; Kiris, 1995)</p> <p>It was fortunate in your situation that you were able to react quickly to the audible warning system. However i can imagine that with the amount of information that is presented to you and the level of automated technology available on commercial aircraft it maybe possible to become experience a reduction in situation awareness.</p> <p>For further information and reading on situation awareness the reference below is provided.</p> <p>Reference<br /> ENDSLEY Mica R (1999). Situation awareness in aviation systems. In Daniel J Garland, John A Wise &amp; David HOPKIN (1999). Handbook of aviation human factors, Laurence Erlbaum Associates (New Jersey, USA), 1999, chapter 11, pp.257-276. ISBN: 9780805816808.</p> 
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				<guid>http://aviationknowledge.wikidot.com/forum/t-122256#post-575242</guid>
				<title>Managing pilot&#039;s fatigue: Potential Changes to FAA attitude and rules</title>
				<link>http://aviationknowledge.wikidot.com/forum/t-122256/managing-pilot-s-fatigue#post-575242</link>
				<description></description>
				<pubDate>Thu, 03 Sep 2009 03:16:39 +0000</pubDate>
				<wikidot:authorName>laserflyer</wikidot:authorName>				<wikidot:authorUserId>353395</wikidot:authorUserId>				<content:encoded>
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						 <p>While the NTSB has held a strong line on fatigue issues for some time, the FAA (Federal Aviation Administration) in the US has often paid only lip service to issues and concerns. This has changed recently with a commuter aircraft crash near Buffalo Airport in Newark, New Jersey. The Continental Connection Flight 3407 crash resulted in the deaths of the 49 people on board and one on the ground (Associated Press, 2009). While the immediate cause was loss of control in icing conditions reports identified fatigue as a likely contributing factor. In response the FAA has announced plans to review fatigue and rest rules (Karp, 2009).</p> <p>Concerns include the way in which commuter operators roster staff, the fact that bases are often temporary and change frequently, without the airline contributing to moving costs, meaning that crew often have to commute long distances form domicile to work and home again with minimum or no actual rest prior to commencing duty. Further issues raised include the fact that junior crew are often paid minimally, which means many cannot afford to live on their own but rather stay at home with their families or in dormitory style accommodation with other crew, resulting in poor rest patterns and habits.</p> <p>References:</p> <p>Associated Press. (2009, February 13). <em>NTSB: Crew reported ice build up before crash</em>. Retrieved September 3, 2009 from <a href="http://www.msnbc.msn.com/id/29173163/">http://www.msnbc.msn.com/id/29173163/</a></p> <p>Karp, A. (2009, June 25). <em>FAA starts 'expedited review' of pilot rest rules, plans 'rapidly' to develop new rule</em>.Retrieved September 3, 2009 from <a href="http://www.atwonline.com/news/story.html?storyID=17032">http://www.atwonline.com/news/story.html?storyID=17032</a></p> 
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				<guid>http://aviationknowledge.wikidot.com/forum/t-123445#post-573524</guid>
				<title>Hazardous Attitudes: Get Home-it-is</title>
				<link>http://aviationknowledge.wikidot.com/forum/t-123445/hazardous-attitudes#post-573524</link>
				<description></description>
				<pubDate>Tue, 01 Sep 2009 03:09:20 +0000</pubDate>
				<wikidot:authorName>zash</wikidot:authorName>				<wikidot:authorUserId>351982</wikidot:authorUserId>				<content:encoded>
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						 <p>Get Home-it-is<br /> I have always seen this phrase used in some articles (non-aviation) but did not stop to wonder how it feels to be a victim of it. So what is it?</p> <p>I experienced it during a long day at work, flying a six-sector domestic flight schedule. The standard operating procedures in one sector involves the pre-flight, taxi, take-off, short cruise of less than 20 minutes, decent, approach and landing. Of course all the necessary checks and procedures are squeezed in between them. On that day, we did 6 of these. The day started at 0700hrs in the morning and lasted almost till 1800hrs.</p> <p>As you have guess it, the phrase describes “I had enough of this, just quickly do whatever there is to do and get on with going home!”, feeling. It’s a syndrome whereby pilot’s try to reach their destination at all cost, even deciding to land the aircraft without confirming that the wheels have been extended and locked in the landing position!</p> <p>That happened to me, on the approach to land on the 6th sector of the day. Embarrassing as it sounds but at the end of the day, the incident was down right dangerous and ignorant of the consequences that may have followed. That day the aircraft automation saved the day (me as well). At the sound of a loud human synthetic voice to “PULL UP! PUL UP! GEAR”, I remembered talking to myself, “that can’t be me, I’m already few hundred feet away from home.” Next thing I knew, the instinctive reaction to that warning was to increase the power of the engines to climb setting and abort the landing. I was lucky. Unfortunately there have been reports of incidents involving pilots continuing the approach to land, ultimately ending in tragic accidents.</p> <p>One example is quoted from an article by (Berman &amp; Dismukes, 2006)</p> <p>June1, 1999 – American Airlines Flight 1420 was seconds from landing at little rock, Arkansas, U.S., when the captain’s view of the runway was obscured by heavy rain lashing the windshield. “ I can’t see it,” he said, but the runway quickly reappeared. From 200 ft to the ground, he struggled against the thunderstorm’s crosswinds to align the McDonnell Douglas MD-82 with the centreline, and the ground proximity warning system (GPWS) produced two warnings of excessive sink rate. The first officer thought about telling the captain to go around, but if he spoke, his voice was too sift to be heard. Saturated with high workload during the last stages of the approach, the crew had forgotten to arm the jet’s ground spoilers for automatic deployment and had not completed the last steps of the landing checklist, which included verification of the spoilers; consequently, braking performance was greatly degraded. During the landing rollout, the airplane veered left and right by as much as 16 degrees before departing the left side of the runway at high speed. The crash into the approach light stanchions at the end of runway destroyed the airplane and killed 11 people, including the captain!</p> <p>The U.S. National Transportation Safety Board (NTSB) concluded that the crew caused the accident.</p> <p>So what caused us, pilots, to make similar decisions and errors? According to U.S. National Aeronautics and Space Administration (NASA) study, the skilled performance of experts, such as airline pilots, is driven by the interaction of moment-to-moment task demands, the availability of information and social/organizational factors with the inherent characteristics and limitations of human cognitive processes. Whether a particular crew in a given situation makes errors depends as much, or more, on this somewhat random interaction of factors as it does on the individual characteristics of the pilots.</p> <p>Among the two most common causes are:</p> <p>1. plan continuation bias – a deeply rooted tendency of individuals to continue their original plan of action even when changing circumstances required a new plan.</p> <p>2. snowballing workload – workload that builds on itself and increases at an accelerating rate.</p> <p>Although other factors not discussed here played roles in these accidents, the problems encountered by the crew and myself seem to have centered on these two factors.<br /> These findings were quoted from the article found from the website:</p> <p>[<a href="http://www.flightsafety.org/asw/dec06/asw_dec06_p28-33.pdf">http://www.flightsafety.org/asw/dec06/asw_dec06_p28-33.pdf</a>]</p> <p>Other interesting reads:</p> <p>The Get-Home-It-Is Syndrome:<br /> [<a href="http://www.bea-fr.org/etudes/gethomeitis/gethomeitis.html">http://www.bea-fr.org/etudes/gethomeitis/gethomeitis.html</a>]</p> <p>Plan continuation Bias:<br /> [<a href="http://www.avweb.com/news/pilotlounge/193599-1.html">http://www.avweb.com/news/pilotlounge/193599-1.html</a>]</p> <p>Reference</p> <p>B. A. Berman, &amp; R. K. Dismukes (2006) Pressing the Approach: A NASA Study of 19 Recent Accidents Yields a New Perspective on Pilot Error, Berman, B. A. &amp; Dismukes, R. K. (2006) Pressing the Approach: A NASA Study of 19 Recent Accidents Yields a New Perspective on Pilot Error. Aviation Safety World, December 2006, 28-33.</p> 
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				<guid>http://aviationknowledge.wikidot.com/forum/t-122328#post-370030</guid>
				<title>The dirty dozen: Posters</title>
				<link>http://aviationknowledge.wikidot.com/forum/t-122328/the-dirty-dozen#post-370030</link>
				<description></description>
				<pubDate>Thu, 29 Jan 2009 15:36:59 +0000</pubDate>
				<wikidot:authorName>CXWX</wikidot:authorName>								<content:encoded>
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						 <p>oh i found this site too. you can check out many aviation posters there . There is also one on the dirty dozen.<br /> <a href="http://www.tc.gc.ca/civilaviation/systemsafety/posters/menu.htm">http://www.tc.gc.ca/civilaviation/systemsafety/posters/menu.htm</a></p> 
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				<guid>http://aviationknowledge.wikidot.com/forum/t-122328#post-370019</guid>
				<title>The dirty dozen: Re: A very valuable lesson</title>
				<link>http://aviationknowledge.wikidot.com/forum/t-122328/the-dirty-dozen#post-370019</link>
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				<pubDate>Thu, 29 Jan 2009 15:28:51 +0000</pubDate>
				<wikidot:authorName>CXWX</wikidot:authorName>								<content:encoded>
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						 <p>Sure thing. The dirty dozen affects us all even in the errors we make in daily life. Do introduce it to more people, especially those in this industry.</p> 
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				<guid>http://aviationknowledge.wikidot.com/forum/t-122328#post-369533</guid>
				<title>The dirty dozen: A very valuable lesson</title>
				<link>http://aviationknowledge.wikidot.com/forum/t-122328/the-dirty-dozen#post-369533</link>
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				<pubDate>Thu, 29 Jan 2009 00:31:39 +0000</pubDate>
				<wikidot:authorName>tcl01</wikidot:authorName>				<wikidot:authorUserId>239871</wikidot:authorUserId>				<content:encoded>
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						 <p>Hello,<br /> I just have to say I am so impressed with your DIRTY DOZEN lesson that I would like to be able to submit it to my Flight Safety Advisor for inclusion in our next company in-house safety newsletter. He had asked me if I would put something in maybe along the lines of James Reason's Swiss Cheese model, and this fits it perfectly. It is a good lesson to us all and I am sure the pilots in the company will appreciate its message. We are currently operating our busy season, and we are constantly on the go, pushed for time, working in hot conditions. This lesson would be a timely reminder for all to just watch out, and make sure we watch out for each other and speak up if we see the signs. If you are ok with me submitting this to our newsletter, I will also suggest to the pilots that they check out this forum - I am sure they would find it very valuable.<br /> Thanks.</p> 
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				<guid>http://aviationknowledge.wikidot.com/forum/t-118338#post-364540</guid>
				<title>I.M.S.A.F.E.: The Notorious Five</title>
				<link>http://aviationknowledge.wikidot.com/forum/t-118338/i-m-s-a-f-e#post-364540</link>
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				<pubDate>Fri, 23 Jan 2009 11:16:08 +0000</pubDate>
				<wikidot:authorName>edmarlo</wikidot:authorName>				<wikidot:authorUserId>238454</wikidot:authorUserId>				<content:encoded>
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						 <p>Complementing the I.M.S.A.F.E checklist, are the notorious 5 hazardous attitudes. See more <a href="http://aviationknowledge.wikidot.com/pilot:hazardous-attitudes">here</a>.</p> 
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