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A Glimpse at Archie: The LOSA Archive Ashleigh Merritt, Ph.D. The University of Texas Human Factors Research Project (UT) Third ICAO/IATA LOSA/TEM Conference.

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Presentation on theme: "A Glimpse at Archie: The LOSA Archive Ashleigh Merritt, Ph.D. The University of Texas Human Factors Research Project (UT) Third ICAO/IATA LOSA/TEM Conference."— Presentation transcript:

1 A Glimpse at Archie: The LOSA Archive Ashleigh Merritt, Ph.D. The University of Texas Human Factors Research Project (UT) Third ICAO/IATA LOSA/TEM Conference September 13-14, 2005, Kuala Lumpur

2 What is Archie? Archie is the LOSA Archive Archie is the LOSA Archive A database of de-identified airline data which is maintained and updated by UT A database of de-identified airline data which is maintained and updated by UT Airlines that do a LOSA with The LOSA Collaborative contribute their data to Archie for research purposes Airlines that do a LOSA with The LOSA Collaborative contribute their data to Archie for research purposes

3 How big is Archie? As of October 2004, Archie had data from As of October 2004, Archie had data from 15 airlines 15 airlines 3,309 flights 3,309 flights 11,000+ threats 11,000+ threats 7,000+ errors 7,000+ errors 1,500+ undesired aircraft states 1,500+ undesired aircraft states

4 How old is Archie? Five LOSAs in five years to develop the methodology Five LOSAs in five years to develop the methodology Data in the Archive starts in 2000 Data in the Archive starts in 2000 Had to wait for Archie to grow before doing any industry-wide analyses. Had to wait for Archie to grow before doing any industry-wide analyses. If we think of Archie as a dog, he would be a young bloodhound If we think of Archie as a dog, he would be a young bloodhound

5 How big is Archie? As of August 2005, Archie has data from As of August 2005, Archie has data from 20 airlines (including 3 repeat LOSAs) 20 airlines (including 3 repeat LOSAs) 4800 flights 4800 flights 4800 flight narratives written by trained observers 4800 flight narratives written by trained observers 4800 ratings of TEM countermeasure performance 4800 ratings of TEM countermeasure performance 17,500+ threats 17,500+ threats 12,500+ errors 12,500+ errors 2,400+ undesired aircraft states 2,400+ undesired aircraft states

6 Archies Attributes Archie is loyal and faithful 2. Archie alerts of danger 3. Archie is a tracker 4. Archie plays well with others

7 2005 Update on Archie Archie has remained loyal and faithful to its aviation master No airline has been publicly identified No airline has been publicly identified No individual pilots can be or ever have been identified No individual pilots can be or ever have been identified

8 Archie continues to play well with others Queries from / data-sharing with: NOSS (ATC group) NOSS (ATC group) IATA/ICAO (ITA) IATA/ICAO (ITA) Boeing Boeing Airlines Airlines ASAP ASAP ATSB ATSB

9 2005: Archie is learning to track Airline threats Airline threats ATC threats ATC threats Intentional Noncompliance Intentional Noncompliance

10 Airline threats: Simple Tracking Airline threats include aircraft malfunctions, time pressure, errors/distractions/interruptions from Cabin, Dispatch, Maintenance, Ground, Ramp. Airline threats occur on 2/3 of all flights, adding to overall workload. Airline threats occur on 2/3 of all flights, adding to overall workload. Range: 55% - 81% across different airlines Range: 55% - 81% across different airlines Three-quarters of airline threats occur before the aircraft has even left the gate (predeparture). Three-quarters of airline threats occur before the aircraft has even left the gate (predeparture). TARGETS FOR ENHANCEMENT?

11 ATC threat chains: Complex tracking 10 LOSAs – 2426 Flights – 9450 threats 2350 ATC threats = ¼ of all threats = about 1 per flight 236 mismanaged ATC threats = 30% of all mismanaged threats 10% of all ATC threats were mismanaged

12 Mismanaged ATC threats 2426 Flights – 9450 threats 236 mismanaged ATC threats Challenging clearances (53%) Runway Changes (14%) Language difficulty (8%) Similar call signs (5%) ATC error (7%)

13 ATC threats -> Errors 2426 Flights – 9450 threats 236 mismanaged ATC threats 280 errors Automation errors (20%) – wrong MCP/FCU altitude setting dialed Communication errors (27%) - misinterpret ATC instructions Aircraft handling (24%) – unintentional speed, lateral, vertical deviations Cross-verification errors (7%) Ground navigation errors (6%)

14 ATC threats -> Errors -> UAS 2426 Flights – 9450 threats 236 mismanaged ATC threats 280 errors 56 Automation errors 76 Communication errors 67 Aircraft handling errors 19 Cross-verification errors 16 Ground navigation errors 2 UAS 58 UAS 5 UAS 9 UAS 21 UAS

15 ATC threats -> UAS 2426 Flights – 9450 threats 236 mismanaged ATC threats 280 errors 106 UAS Lateral deviation 17% Speed too high 14% Vertical deviation 10% Unstable Approach 10% Continued Landing 9% Incorrect Automation configuration 9% Taxiway/runway incursion 6% Speed too low 6% Incorrect Aircraft configuration 5% Other 14% Bottom line: 4% of flights had a UAS arising from an ATC threat that was mismanaged. ¾ occurred during descent/approach/land

16 Archie tracks intentional noncompliance Across 22 LOSAs, the average is 40% of flights have one or more noncompliance errors Across 22 LOSAs, the average is 40% of flights have one or more noncompliance errors Range: 23% of flights at one airline to 90% (!!) at another Range: 23% of flights at one airline to 90% (!!) at another Most common noncompliance errors: Most common noncompliance errors: checklist performed from memory / nonstandard checklist use checklist performed from memory / nonstandard checklist use failure to cross-verify MCP/FCU altitude alerter changes failure to cross-verify MCP/FCU altitude alerter changes PF makes own MCP/FCU changes PF makes own MCP/FCU changes

17 Noncompliance correlates with.. Based on 22 LOSAs (4800 flts), airlines that have more flights with intentional noncompliance errors also have more flights with: Mismanaged threats (r =.7) Mismanaged threats (r =.7) Mismanaged handling errors (r =.9) Mismanaged handling errors (r =.9) Undesired aircraft states (r =.9) Undesired aircraft states (r =.9) Mismanaged UASs (r =.8) Mismanaged UASs (r =.8) Archie was shocked…

18 Archies Future Archie is maturing and getting smarter – more LOSAs allow for more analyses at the airline level, which is where the greatest differences are emerging. Soon a sub- Archive for regional airlines Archie is getting involved in more industry projects If LOSA and ASAP overlap, then focusing on LOSA targets should reduce ASAP incidents… ATC is a big threat to pilots, are pilots a big threat to ATC?

19 Archie is recognizing his strength LOSA is a macro approach for Safety Management Systems LOSA is a macro approach for Safety Management Systems LOSA detects gross effects – strengths and weaknesses in the system LOSA detects gross effects – strengths and weaknesses in the system Management uses the information Management uses the information Self-corrections, training, procedural changes, … Self-corrections, training, procedural changes, … If and when certain problems persist, micro approaches can investigate more closely…

20 The University of Texas Human Factors Research Project


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