NZHPA Safety taskforce summary - #6 HUMAN FACTORS & #7 REPORTING

#6 HUMAN FACTORS IN FREE FLYING 

Human factors (HF) are poorly researched and infrequently (if at all) discussed in free flying literature internationally. There is some useful information coming from other adventure sports including skydiving (studies linking personality to risk-taking and accidents) and back-country skiing (situation awareness and decision making error through contextually false mental models, particularly around avalanche avoidance). Parallels can be drawn from these and from general/commercial aviation to our sports as, despite the lack of specific mention of HF by name, human error and poor decision making are implicated in much of the international free flying accident research and consistently in our own AIRS database. 
Incident report excerpts below show occurrences involving human factors, including decision making, judgement, situation awareness, emotions (such as fear), incentives, confusion, functioning under pressure, stress, and fatigue: 

• “Retrospectively, fatigue was a key factor that led to poor decision making.” 
• “It is often reported that incidents are a culmination of intersecting decisions.” 
• “After a lovely flight in smooth conditions, I was determined to top-land and made some poor decisions close to the ground, [which resulted in me] landing in a bush.” 
• “Root cause: The decision not to abort a launch of a glider with a line problem.” 
• “The problem was several poor decisions made by me.” 
• “My glider was new (it was my second flight on it)”
• “Pilot landed hard and fast due to misjudgement of height and speed of final approach.” 
• “Misjudgement of one of the turns towards the ridge caused loss of valuable few metres.” 
• “Due to a number of factors including deteriorating conditions, time pressure, intense fatigue and stress I chose to continue the launch.” 

The adventure sports factor 
It is worth remembering that many free flying pilots see themselves as much (if not more) as adventure sports people than ‘aviators’. There is an idea among some that free flying has a surfing style cultural feel to it, that carries a sense of uniqueness, exhilaration and escape. However, such an ‘adventure ethos’ is also a stereotype that, if left unchecked, may contribute to a culture of accepting accidents as being ‘part of the game’. It also likely includes a lack of true appreciation of the risks that are involved and that many can be mitigated without losing much of the adventure feel. 

Recommendations 

• Consider how ‘non-technical’ HF aspects can and do lead to unintentional unsafe acts in your flying - and that learning about them and implementing deliberate practices can help manage risk. 
• Build a culture of reporting all near misses, incidents, and accidents (see more in the reporting section below). 

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#7 REPORTING


In order to understand, learn from, and prevent incidents and accidents happening again, they must first be accurately and openly reported. While the CAA and the NZHGPA have mandatory reporting for accidents and serious incidents, both organisations strongly encourage reporting of any and all occurrences relating to safety. The CAA defines an ‘occurrence’ as including any incident, accident, or hazard that you would not want to happen again in the future. 

It is estimated that more than 50% of free flying accidents (let alone other non-accident incidents and occurrences) in NZ go unreported. Anecdotally, there seems to be a number of common situations and/or groups within our community that routinely fail to report occurrences that would benefit the free flying community if reported and well-communicated. This culture is not necessarily ‘anti-safety’ but it does not add any value to the community either. 

Willingness to report accidents has been well researched in aviation and lessons are likely to be relevant to free flying here in NZ too. The research shows across aviation disciplines that the following are the main reasons for low reporting rates: 

• fear of disciplinary action 
• risk acceptance 
• practical reasons 
• belief that reporting is useless 

“A point raised by several safety officers was a culture of unwillingness by pilots to file accident or incident reports. Reasons for this could include embarrassment, fear of ‘punishment’ or negative consequences from their local club or the NZHGPA, and unfamiliarity with the AIRS system.” 

Recommendations 

• Reporting is a big contributor to safety learning, but it must be easy and well-understood by pilots so that they are able and motivated to use the reporting system effectively. 
• Understand that learning about incidents can only come through transparent reporting and that by contributing to this knowledge you may help prevent more serious incidents in the future. 
• Build a habit of reporting all near misses, incidents, and accidents no matter how big or small. Things may seem embarrassing or trivial, but the contribution to the flying community is significant.