Prevent inadvertent slide deployment by learning from Japanese Bullet Train Drivers: mindFly

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Pointing and calling Flight Safety Australia

In 2014, the International Air Transportation Association estimated that inadvertent slide deployment costs the airline industry more than $20 million each year.

What can aviation learn from the bullet train driver.

With the horrible exception of the Amagasaki crash of 2005, which killed 107 people, Japanese railways are notably safe, with one passenger death per 51.4 billion passenger kilometres. The high-speed Shinkansen network, which is now six lines with trains running at up to 320 km/h (170 kt), has carried more than 10 billion passengers without a single passenger death from derailment or collision.

In 1994, the Japanese Railway Technical Research Institute assessed pointing and calling in an experiment that asked volunteers to complete a simple, but variable, task. When no special steps were taken to prevent errors, the volunteers made 2.38 errors per 100 actions. Calling or pointing cut this error rate significantly. But the greatest reduction in error to 0.38 errors per 100 actions happened when the volunteers both pointed and called their actions. This combination reduced mistakes by almost 85 per cent.

New York subway train conductors have been using point and call since 1996, when a system executive noticed the practice on a trip to Japan. A New York Metropolitan Transit Authority spokeswoman said that within two years of implementation, incidents of incorrectly berthed trains fell by 57 per cent.

CASA human factors and fatigue specialist, Robert Forsterlee, says pointing and calling improves operator responses by integrating physical and mental activity. ‘Your brain is more active when you point and speak than when you just think it. You are using more areas of your brain. It’s not just a memory thing, it’s a fatigue mediator. You’re making movements and if you do a little bit of exercise that’s refreshing.’

Writing in Aviation Week, James Albright outlined how adopting point and call could improve flight deck crosschecking. For altitude changes Albright suggests:

  • The PM acknowledges the altitude assignment on the radio while dialling in the new altitude (the ‘point’). While leaving a finger on the altitude selector is desirable, there are times when the PM has other immediate tasks.
  • The PM then announces the new altitude cross-cockpit (the ‘call’). Repeating the altitude between pilots reinforces the correct altitude in the PM’s mind.
  • The PF points to the primary flight display if that shows the primary flight guidance altitude, or to the altitude selector if that is primary to the avionics installation (the ‘point’). In some aircraft, the altitude selector may not accurately reflect the commanded altitude during metric altitude operations, for example.
  • The PF verbalises the new altitude assignment (the ‘call’). While having the PF also announce the altitude can seem to be more cockpit chatter than many crews would like, it gives both pilots another chance to mentally assimilate the instruction. It could, for example, cue the PM that something ‘isn’t right’.

Cabin crew incidents of slide deployments, ground incidents can be averted by this methodology.

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Looking without seeing is a contributory cause for the inadvertent slide deployment by the cabin crew. All checks and cross checks are performed by the crew member or a supporting crew member to ensure that the slide is disarmed by visually verifying the indications confirming the slide armed/disarmed state. When the mind is distracted , pre-occupied or in a rush, there is a tendency to call out the rehearsed confirmation by memory without verifying the actual position of the indications. By pointing and calling, all the attention is focused on the object/indication which is required to be checked and even under stress, rush or distracted state, a deliberate check is carried out and a safe outcome can be achieved.

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Being mindful and paying attention can be achieved by this deliberate methodology of pointing and calling. Learning from the success of the Japanese style of mindfulness is the way forward and is being used in many high risk industries.

1 Comment

  1. Spot ON Captain Amit. It is the lessons learnt from the similar occupation, that is the key. Cognitive Awareness is enhanced by calling & pointing. Very effectively brought the issue at hand about the inadvertent slide deployment. Thanks

    Like

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