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Key Dismukes Chief Scientist for Aerospace Human Factors Human Factors Research and Technology Division NASA-Ames Research Center ATA AQP Annual Conference.

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Presentation on theme: "Key Dismukes Chief Scientist for Aerospace Human Factors Human Factors Research and Technology Division NASA-Ames Research Center ATA AQP Annual Conference."— Presentation transcript:

1 Key Dismukes Chief Scientist for Aerospace Human Factors Human Factors Research and Technology Division NASA-Ames Research Center ATA AQP Annual Conference October 2003 Managing Interruptions, Distractions and Concurrent Task Demands

2 Our Research Team Immanuel Barshi LaQuisha Beckum Sean Belcher Rahul Dodhia Jon Holbrook Kim Jobe Tri Li Loukia Loukopoulos Jessica Lange Nowinski Mark Staal

3 Consequences of Inadvertent Procedural Omissions LaGuardia (1994): MD-82 ran off runway end after high-speed rejected take-off –NTSB: Anomalous airspeed indications caused by failure to turn on pitot heat Detroit (1987): DC-9 crashed shortly after take-off –NTSB: Flaps/slats not set to take-off position Dallas (1988): B-727 crashed shortly after take-off –NTSB: Flaps/slats not set to take-off position Houston (1996): DC-9 landed gear-up –NTSB: Hydraulic pump not set to high position

4 Were These Accidents Unique? Rejected take-offs –Anomalous airspeed indications (pitot heat not on) –Configuration warning (flaps or trim not set) Other consequences of overlooked procedural steps –Runway incursions –Broken tow-bars –Taxi into ditch –Engine flame-out –Overtemp engine –Flew wrong departure route –Go-around Unnecessary costs and delays But for luck any of these incidents might have become accidents Not according to recent ASRS reports: –Departed with inadequate fuel –APU left running during takeoff -- fire –Packs failed in cruise –Took off without PDC –Deviated from speed or altitude restriction –Nose gear failed to retract –etc.

5 Why? Why would experienced crews forget a procedural step they normally perform day in and day out? Why fail to catch omissions with checklists?

6 An Ongoing NASA Research Project “Carelessness” not an adequate explanation Crews vulnerable to omissions when: –Interrupted or preoccupied with one of several concurrent tasks (Young, Dismukes, & Sumwalt, 1998). –Deferring tasks out of normal sequence (Loukopoulos, Dismukes, & Barshi, 2003). Vulnerability to error among experienced pilots largely driven by: –Characteristics of tasks performed –Demands tasks place on human cognitive processes –Operating environment –Norms for actual line operations

7 Jumpseat Observation Study (Loukopoulos, Dismukes, & Barshi, 2003) Reviewed FOMs, observed line operations, analyzed ASRS, NTSB reports –All phases of flight — focus today on preflight and taxi Discovered disconnect between FOM/training and actual line operations in depiction of task management

8 CAPTAIN FIRST OFFICER Preflight - In theory (FOM) Obtain ATIS Obtain clearance Review paperwork Prepare/review charts (Passenger count) (Load Sheet) Program FMC Begin checklist Checklist complete Begin checklist Checklist complete ENGINE START & PUSHBACK Review paperwork Sign flight release Prepare/review charts Review Load Schedule Review FMC Takeoff brief Ask for checklist CLEARANCE procedure checklist Cabin Attendant Gate Agent ACARs / OPC Interphone Ground/ Company/ Dispatch Frequencies

9 Depiction of Cockpit Task Management in FOM/Training Tasks are serial and linear: task A  task B  task C in a fixed sequence.

10 CAPTAIN FIRST OFFICER Preflight - In theory (FOM) Obtain ATIS Obtain clearance Review paperwork Prepare/review charts (Passenger count) (Load Sheet) Program FMC Begin checklist Checklist complete Begin checklist Checklist complete ENGINE START & PUSHBACK Review paperwork Sign flight release Prepare/review charts Review Load Schedule Review FMC Takeoff brief Ask for checklist CLEARANCE procedure checklist Cabin Attendant Gate Agent ACARs / OPC Interphone Ground/ Company/ Dispatch Frequencies

11 Depiction of Cockpit Task Management in FOM/Training Linear: task A  task B  task C in a fixed sequence. Controllable: tasks are initiated by crew at their discretion. Predictable: –Information available to crew when needed. –Individuals can communicate as needed.

12 CAPTAIN FIRST OFFICER First Officer Receive taxi clearance Start checklist Checklist complete Receive takeoff clearance Start checklist Checklist complete Captain Start taxiing Ask for checklist Receive takeoff clearance Ask for checklist Line up with runway Taxi Clearance MONITOR Ground Company Takeoff Clearance MONITOR Ground Company/Dispatch MONITOR Captain taxiing TAKEOFF Taxi-out - In theory (FOM)

13 Depiction of Cockpit Task Management in FOM/Training Linear: task A  task B  task C in a fixed sequence. Controllable: tasks are initiated by crew at their discretion. Predictable: –Information available to crew when needed. –Individuals can communicate as needed. Overall picture: flight operations are pilot- driven and under moment-to-moment control of crew.

14 Obtain ATIS Obtain clearance Review paperwork Prepare/review charts (Passenger count) (Load Sheet) Program FMC Begin checklist Checklist complete Begin checklist Checklist complete ENGINE START & PUSHBACK Review paperwork Sign flight release Prepare/review charts Review Load Schedule Review FMC Takeoff brief Ask for checklist CAPTAIN FIRST OFFICER CLEARANCE procedure Cabin Attendant Gate Agent ACARs / OPC Interphone Ground/ Company/ Dispatch Frequencies Preflight - the reality Interruption FO busy Interruption busy frequency Keep trying Ask for checklist Resume flow Inoperative item Time pressure Inoperative item Flight release still not picked up no time, familiarity Interruption Delay at gate Ramp and/or Ground? Flight plan/ Departure runway change Conduct exterior walk-around no time, familiarity New PDC Still refueling Data unavailable Passenger count unavailable Call maintenance Look for ops/gate agent Double-check charts Resume checklist Confirm Mx responded Confirm Mx departed Confirm resolution Confirm logbook on board Check charts Defer programming FMC Communicate with company Compute new performance #s Re-program FMS Re-program FMC Check fuel quantity and pumps Re-brief Re-flow trim & other settings New flight release/PDC? Re-set MCP Takeoff brief Request passenger count procedure checklist

15 Obtain ATIS Obtain clearance Review paperwork Prepare/review charts (Passenger count) (Load Sheet) Program FMC Begin checklist Checklist complete Begin checklist Checklist complete ENGINE START & PUSHBACK Review paperwork Sign flight release Prepare/review charts Review Load Schedule Review FMC Takeoff brief Ask for checklist CAPTAIN FIRST OFFICER CLEARANCE procedure Cabin Attendant Gate Agent ACARs / OPC Interphone Ground/ Company/ Dispatch Frequencies Preflight - the reality Interruption FO busy Interruption busy frequency Keep trying Ask for checklist Resume flow Inoperative item Time pressure Inoperative item Flight release still not picked up no time, familiarity Interruption Delay at gate Ramp and/or Ground? Flight plan/ Departure runway change Conduct exterior walk-around no time, familiarity New PDC Still refueling Data unavailable Passenger count unavailable Call maintenance Look for ops/gate agent Double-check charts Resume checklist Confirm Mx responded Confirm Mx departed Confirm resolution Confirm logbook on board Check charts Defer programming FMC Communicate with company Compute new performance #s Re-program FMS Re-program FMC Check fuel quantity and pumps Re-brief Re-flow trim & other settings New flight release/PDC? Re-set MCP Takeoff brief Request passenger count procedure checklist

16 –Each pilot must juggle several tasks concurrently. –Crews are frequently interrupted. –External demands arrive at unpredictable moments. –Conditions sometimes force task elements to be performed out of normal sequence. Line Observations Reveal a Different Story Normal line operations are quite dynamic:

17 –Each pilot must juggle several tasks concurrently. –Crews are frequently interrupted. –External demands arrive at unpredictable moments. –Conditions sometimes force task elements to be performed out of normal sequence. Line Observations Reveal a Different Story Normal line operations are quite dynamic: Crews must at times struggle to maintain control of the timing and sequence of their work tasks. – Lack of guidance

18 Conflict Between Theory and Reality FOM is a powerful tool for safety by providing: Operational reality disrupts ideal execution of procedures – Explicit description of how each task is to be performed – Standardization across crews – Checklists and checking procedures

19 So What? Pilots become accustomed to concurrent task demands, interruptions, distractions and disruptions. However these situations substantially increase vulnerability to error, especially omission of critical procedural steps.

20 ERRORS attributed to concurrent task demands, interruptions, and disruptions (ASRS reports) Omitted review of charts - distractions - speed violation on departure Entered wrong weight in FMS - tail strike at takeoff Omitted flow and checklist items - interruptions; delay; change in departure runway - discover insufficient fuel at ft Skipped over checklist item - fuel pumps deferred during preflight because refueling - engine starvation in flight Improper setting of pressurization during preflight flow - interruptions - cabin altitude warning light in cruise Read but not verify checklist item - distractions - pushback with throttles open, damage to aircraft Forgot logbook at ramp - kept deferring to check it; distractions; busy with preflight - discovered en route Neglected to set flaps -preoccupied with new departure clearance and packs-off operation - aborted takeoff FO failed to monitor CA -runway change; busy reprogramming FMC - taxied past intended taxiway Omitted setting flap - busy with delayed engine start; rushed to accept takeoff clearance - aborted takeoff Started taxi without clearance - crew discussing taxi instructions - struck pushback tug FO failed to monitor CA – busy with flow; night taxi – taxi in wrong direction Failed to verify new clearance - monitoring convective activity on radar - flew wrong heading Omitted climb checklist - busy copying hold instructions - missed setting altimeter and overshot altitude Failed to reset bleeds on - complex departure; multiple ATC calls; traffic - altitude warning and 0 2 mask deployment Did not notice wind - preoccupied with annunciator light; handling radios - track deviation Unstabilized approach - accepted runway change right before FAF; did not review charts or make callouts - tailstrike Did not complete checklist - TCAS alerts; parallel runways in use; GPWS alert - did not extend gear for landing Did not extend gear; checklist interrupted; TCAS alerts; parallel runways in use; GPWS alert - struck ground on go-around Forgot to reset altimeters - distracted by FA in cockpit - TCAS RA and overshot arrival fix Failed to monitor PF - busy reprogramming FMS; weather changes - go around Failed to verify FMC settings - PNF giving IOE to PF; multiple ATC calls; hold instruction - flew pattern in wrong direction ATC instructions too close to turn fix - busy slowing aircraft; approach checklist; radios - failed to make published turn Vectored too close - busy catching up with glideslope; not instructed to switch to Tower - landed without clearance Forgot to switch to Tower at FAF - last minute runway change; busy reconfiguring aircraft - landed without clearance PREFLIGHT > PUSHBACK > TAXI > TAEKOFF > CLIMB > CRUISE > DESCEND > LAND

21 Why So Vulnerable to These Errors?

22 Brain has two ways of processing information to perform tasks: Cockpit tasks vary from requiring mainly controlled processing to being largely automatic. Why So Vulnerable to These Errors? 1) “Controlled” processing –Corresponds to conscious attention –Slow, serial, and effortful: low capacity –Required for tasks with novel aspects 2) Automatic processing –Fast, minimal effort, high capacity –Develops with extensive practice of habitual procedure –Requires minimal conscious supervision

23 Automatic processing has enormous advantages but also has serious vulnerabilities

24 Aft Overhead Logbook/Gear Pins PREFLIGHT Flow (B as trained) (checklist items are marked *) * * * * * * * * * * * * * * * * * * Aft Electronic Center Instrument Mode Control Panel Captain Instrument First Officer Instrument Forward Overhead Forward Electronic Control Stand Logbook/Gear Pins * * * * * * * * * * * * * Aft Overhead First Officer Instrument ATIS Slakfj aslkfj890 Slkdfj Slkafj f095j 019 Sa;lskdfjl Lskd LOAD Slakfj aslkfj890 Slkdfj Slkafj f095j 019 Sa;lskdfjl Lskd Slkf9 9oy99 Slkdfj A;slkg eri kgj skj 9 FLIGHT PLAN Slakfj aslkfj890 Slkdfj Slkafj f095j 019 Sa;lskdfjl Lskd SFAS ALSKFJ XLKAF ALKDFJJ;AL PAX CT 107, 22, 5 3 WH FUEL 107, 22, 5 3 WH PDC Slakfj aslkfj890 Slkdfj Slkafj f095j 019 Sa;lskdfjl Lskd Slkf9 9oy99 Slkdfj A;slkg eri kgj skj 9 JEPP 107, 22, 5 x Forward Overhead Captain Instrument Center Instrument Forward Electronic Control Stand Aft Electronic Mode Control Panel

25 Vulnerabilities of Automatic Processing If procedural flow is interrupted, chain is broken. –Pause prevents one step from triggering the next. Initiation of automatic process depends on receiving signal or noticing a cue in the cockpit environment. –If signal does not occur, individual is not prompted to initiate procedure.

26 Vulnerabilities of Automatic Processing If procedural flow is interrupted, chain is broken. –Pause prevents one step from triggering the next. Initiation of automatic process depends on receiving signal or noticing a cue in the cockpit environment. –If signal does not occur, individual is not prompted to initiate procedure. Highly practiced procedures and checklists tend to develop “look without seeing” automatic responses. High workload and/or rushing prevent conscious supervision of automatic processes--exacerbates vulnerability

27 Vulnerability to Errors of Omission Can Be Reduced 1) Actions airline operations and training departments can take 2) Actions individual pilots can take

28 Ways Airlines Can Reduce Vulnerabilities Analyze actual line opswrite procedures to minimize opportunities for disruptions. Avoid “floating” procedural items allowed to be performed at varying times. –Anchor critical items (e.g., setting takeoff flaps) to distinct step that cannot be forgotten (e.g., before start of taxi).

29 Ways Airlines Can Reduce Vulnerabilities Analyze actual line opswrite procedures to minimize opportunities for disruptions. Avoid “floating” procedural items allowed to be performed at varying times. –Anchor critical items (e.g., setting takeoff flaps) to distinct step that cannot be forgotten (e.g., before start of taxi). Analyze actual fleet “norms” for how checklists are executed and bottom-lines observed. –LOSA Train with realistic concurrent task demands.

30 Ways Pilots Can Reduce Vulnerability Being aware of vulnerability reduces threat. –Especially vulnerable when head-down, communicating, searching for traffic, or managing abnormals. When interrupted or deferring a task: –Pause to encode intention to resume –Create conspicuous cue as reminder (e.g. checklist in throttle quadrant) Develop habit of deliberate execution of procedures and checklists to allow controlled supervision of habitual responses. Avoid rushing.

31 Ways Pilots Can Reduce Vulnerability Being aware of vulnerability reduces threat. –Especially vulnerable when head-down, communicating, searching for traffic, or managing abnormals. When interrupted or deferring a task: –Pause to encode intention to resume –Create conspicuous cue as reminder (e.g. checklist in throttle quadrant) Develop habit of deliberate execution of procedures and checklists to allow controlled supervision of habitual responses. Avoid rushing. Pause at critical junctures to review. Schedule/reschedule activities to minimize concurrent task demands (e.g., brief before TOD). Treat monitoring as essential task (Sumwalt).

32 For further information: This work is supported by NASA’s Airspace Systems Program and by the FAA (AFS-230), Dr. Eleana Edens, program manager.


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