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At least 127 records · Page 7

A summary and integration of research concerning single pilot IFR operational problems

A review of seven research studies pertaining to Single Pilot IFR (SPIFR) operations was performed. Two studies were based on questionnaire surveys, two were based on National Transportation Safety Board (NTSB) reports, two were based on Aviation Safety Reporting System (ASRS) incident reports, and one report used event analysis and statistics to forecast problems. The results obtained in each study were extracted and integrated. Results were synthesized and key issues pertaining to SPIFR operations problems were identified. The research that was recommended by the studies and that addressed the key issues is cataloged for each key issue.

Chapman, G. C.↗

Addressee Errors in ATC Communications: The Call Sign Problem

Communication errors involving aircraft call signs were portrayed in reports of 462 hazardous incidents voluntarily submitted to the ASRS during an approximate four-year period. These errors resulted in confusion, disorder, and uncoordinated traffic conditions and produced the following types of operational anomalies: altitude deviations, wrong-way headings, aborted takeoffs, go arounds, runway incursions, missed crossing altitude restrictions, descents toward high terrain, and traffic conflicts in flight and on the ground. Analysis of the report set resulted in identification of five categories of errors involving call signs: (1) faulty radio usage techniques, (2) call sign loss or smearing due to frequency congestion, (3) confusion resulting from similar sounding call signs, (4) airmen misses of call signs leading to failures to acknowledge or readback, and (5) controller failures regarding confirmation of acknowledgements or readbacks. These error categories are described in detail and several associated hazard mitigating measures that might be aken are considered.

Monan, W. P.↗

Cleared for the visual approach: Human factor problems in air carrier operations

The study described herein, a set of 353 ASRS reports of unique aviation occurrences significantly involving visual approaches was examined to identify hazards and pitfalls embedded in the visual approach procedure and to consider operational practices that might help avoid future mishaps. Analysis of the report set identified nine aspects of the visual approach procedure that appeared to be predisposing conditions for inducing or exacerbating the effects of operational errors by flight crew members or controllers. Predisposing conditions, errors, and operational consequences of the errors are discussed. In a summary, operational policies that might mitigate the problems are examined.

Monan, W. P.↗

Flight crew performance when pilot-flying and pilot-not-flying duties are exchanged

This study compares reports from the ASRS database depicting operational anomalies related to flight crew performance when pilot-flying and pilot-not-flying duties were exchanged. A greater number of near midair collisions, takeoff anomalies, and crossing altitude deviations were reported when the Captain was flying. More altitude deviations, near midair collisions during approach, and landing incidents occurred when the First Officer was flying. There were differences in monitoring effectiveness and in the type and distribution of information transfer problems associated with the anomalies. In addition, a number of crew performance factors were noted that were not affected by the exchange of duties. Several of these were deemed important enough to be included as matter of general interest.

Orlady, H. W.↗

Investigation of hypersonic rarefied flow on a spherical nose of the AOTV

The Navier-Stokes (NS) equations were integrated numerically for investigating the flow characteristics on the forepart of the spherical nose of a space vehicle such as the AOTV or AFE by a modified Accelerated Successive Replacement (ASR) scheme under hypersonic rarefied conditions. Technical feasibility of the mathematical approach was demonstrated by computing the flowfield on a spherical nose under conditions that the AFE encounters at times t = 15 and 20 seconds after its reentry into the atmosphere. Local similar solutions for the merged layer flow along the stagnation line of the sphere were developed. These are correct to the same degree of accuracy as the NS equations. These solutions provided stagnation line boundary conditions for the domain of integration on the spherical noise. Also, a parametric study of the stagnation line solution was made with a view to understand the flow characteristics in tunnels with different ambient fluids. Analytical expressions for surface slip temperature, jump conditions, and concentration level in the presence of the real gas effects at the top of the Knudsen layer were derived and used to calculate the stagnation line flowfield with nonequilibrium dissociation and ionization. A number of graphics were drawn to illustrate the basic physics of the flowfields. The present analysis can be extended to include real gas effects and to bodies of arbitrary shapes. It can further provide boundary conditions for integrating the NS equations in the near wake region.

Jain, Amolak C.↗

Human factors in aviation operations: The hearback problem

This report covers a study of ASRS reports wherein ATC controllers failed to monitor adequately (hearback) incorrect readbacks of ATC clearances. A total of 417 reports received over a period of 29 months from April 1981 through July 1983 comprised the study data set. Factors examined were: the reasons for a flight crew's getting clearances incorrectly, the operating factors that caused controllers to mishear or not hear the correct readbacks, and consequences of the various types of hearback misses. The principle conclusion of the study takes the form of a precaution to flight crews that a controller's not challenging a readback does not necessariliy mean the readback is correct and that flight crews must explicitly question any doubtful or unusual aspects of clearances rather than depending on controllers to detect readback errors.

Monan, William P.↗

Classification and reduction of pilot error

Human error is a primary or contributing factor in about two-thirds of commercial aviation accidents worldwide. With the ultimate goal of reducing pilot error accidents, this contract effort is aimed at understanding the factors underlying error events and reducing the probability of certain types of errors by modifying underlying factors such as flight deck design and procedures. A review of the literature relevant to error classification was conducted. Classification includes categorizing types of errors, the information processing mechanisms and factors underlying them, and identifying factor-mechanism-error relationships. The classification scheme developed by Jens Rasmussen was adopted because it provided a comprehensive yet basic error classification shell or structure that could easily accommodate addition of details on domain-specific factors. For these purposes, factors specific to the aviation environment were incorporated. Hypotheses concerning the relationship of a small number of underlying factors, information processing mechanisms, and error types types identified in the classification scheme were formulated. ASRS data were reviewed and a simulation experiment was performed to evaluate and quantify the hypotheses.

Rogers, W. H.↗

Fatigue, pilot deviations and time of day

The relationships between pilot fatigue, pilot deviations, reported incidents, and time of day are examined. A sample of 200 Aviation Safety Reporting System (ASRS) reports were analyzed from 1985 and 200 reports from 1987, plus 100 reports from late 1987 and early 1988 that were selected because of possible association with fatigue. The FAA pilot deviation data and incident data were analyzed in relation to denominator data that summarized the hourly operations (landings and takeoffs of scheduled flights) at major U.S. airports. Using as numerators FAA data on pilot deviations and incidents reported to the FAA, the rates by time of day were calculated. Pilot age was also analyzed in relation to the time of day, phase of flight, and type of incident.

Baker, Susan P.↗

Non-airborne conflicts: The causes and effects of runway transgressions

The 1210 ASRS runway transgression reports are studied and expanded to yield descriptive statistics. Additionally, a one of three subset was studied in detail for purposes of evaluating the causes, risks, and consequences behind trangression events. Occurrences are subdivided by enabling factor and flight phase designations. It is concluded that a larger risk of collision is associated with controller enabled departure transgressions over all other categories. The influence of this type is especially evident during the period following the air traffic controllers' strike of 1981. Causal analysis indicates that, coincidentally, controller enabled departure transgressions also, show the strongest correlations between causal factors. It shows that departure errors occur more often when visibility is reduced, and when multiple takeoff runways or intersection takeoffs are employed. In general, runway transgressions attributable to both pilot and controller errors arise from three problem areas: information transfer, awareness, and spatial judgement. Enhanced awareness by controllers will probably reduce controller enabled incidents.

Tarrel, Richard J.↗

Altitude deviations: Breakdowns of an error-tolerant system

Pilot reports of aviation incidents to the Aviation Safety Reporting System (ASRS) provide a window on the problems occurring in today's airline cockpits. The narratives of 10 pilot reports of errors made in the automation-assisted altitude-change task are used to illustrate some of the issues of pilots interacting with automatic systems. These narratives are then used to construct a description of the cockpit as an information processing system. The analysis concentrates on the error-tolerant properties of the system and on how breakdowns can occasionally occur. An error-tolerant system can detect and correct its internal processing errors. The cockpit system consists of two or three pilots supported by autoflight, flight-management, and alerting systems. These humans and machines have distributed access to clearance information and perform redundant processing of information. Errors can be detected as deviations from either expected behavior or as deviations from expected information. Breakdowns in this system can occur when the checking and cross-checking tasks that give the system its error-tolerant properties are not performed because of distractions or other task demands. Recommendations based on the analysis for improving the error tolerance of the cockpit system are given.

Palmer, Everett A.↗

A taxonomy of decision problems on the flight deck

Examining cases of real crews making decisions in full-mission simulators or through Aviation Safety Reporting System (ASRS) reports shows that there are many different types of decisions that crews must make. Features of the situation determine the type of decision that must be made. The paper identifies six types of decisions that require different types of cognitive work and are also subject to different types of error or failure. These different requirements, along with descriptions of effective crew strategies, can serve as a basis for developing training practices and for evaluating crews.

Orasanu, Judith M.↗

EMS helicopter incidents reported to the NASA Aviation Safety Reporting System

The objectives of this evaluation were to: Identify the types of safety-related incidents reported to the Aviation Safety Reporting System (ASRS) in Emergency Medical Service (EMS) helicopter operations; Describe the operational conditions surrounding these incidents, such as weather, airspace, flight phase, time of day; and Assess the contribution to these incidents of selected human factors considerations, such as communication, distraction, time pressure, workload, and flight/duty impact.

Connell, Linda J.↗

Airport ramp safety and crew performance issues

This study examined 182 ramp operations incident reports from the Aviation Safety Reporting System (ASRS) database, to determine which factors influence ramp operation incidents. It was found that incidents occurred more often during aircraft arrival operations than during departure operations; incidents occurred most often at the gate stop area, less so at the gate entry/exit areas, and least on the ramp fringe areas; and reporters cited fewer incidents when more ground crew were present. The authors offer suggestions for both airline management and flight crews to reduce the rate of ramp incidents.

Chamberlin, Roy↗

Reporter Concerns in 300 Mode-Related Incident Reports from NASA's Aviation Safety Reporting System

A model has been developed which represents prominent reporter concerns expressed in the narratives of 300 mode-related incident reports from NASA's Aviation Safety Reporting System (ASRS). The model objectively quantifies the structure of concerns which persist across situations and reporters. These concerns are described and illustrated using verbatim sentences from the original narratives. Report accession numbers are included with each sentence so that concerns can be traced back to the original reports. The results also include an inventory of mode names mentioned in the narratives, and a comparison of individual and joint concerns. The method is based on a proximity-weighted co-occurrence metric and object-oriented complexity reduction.

McGreevy, Michael W.↗

Loss of Situation Awareness in Pilots: Analysis of Incident Reports

Approximately 75% of all aviation accidents and incidents are attributable to human failures in monitoring, managing, and operating system. Tactical decision errors were found to be a factor in 25 of 37 major US air transport accidents between 1978 and 1990. These two facts demonstrate the inability of some pilots to maintain situation awareness. Situation awareness (SA) is defined as 'the perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future". Thus, when a pilot loses SA, he or she is unable to ether perceive, comprehend, or project the status of the aircraft. In pilots terms, he or she has 'fallen behind the airplane'. Our study this summer involved an analysis of 190 NASA Aviation Safety Reporting System (ASRS) reports.

Eric B. Villeda↗

Safety Analysis of FMS/CTAS Interactions During Aircraft Arrivals

This grant funded research on human-computer interaction design and analysis techniques, using future ATC environments as a testbed. The basic approach was to model the nominal behavior of both the automated and human procedures and then to apply safety analysis techniques to these models. Our previous modeling language, RSML, had been used to specify the system requirements for TCAS II for the FAA. Using the lessons learned from this experience, we designed a new modeling language that (among other things) incorporates features to assist in designing less error-prone human-computer interactions and interfaces and in detecting potential HCI problems, such as mode confusion. The new language, SpecTRM-RL, uses "intent" abstractions, based on Rasmussen's abstraction hierarchy, and includes both informal (English and graphical) specifications and formal, executable models for specifying various aspects of the system. One of the goals for our language was to highlight the system modes and mode changes to assist in identifying the potential for mode confusion. Three published papers resulted from this research. The first builds on the work of Degani on mode confusion to identify aspects of the system design that could lead to potential hazards. We defined and modeled modes differently than Degani and also defined design criteria for SpecTRM-RL models. Our design criteria include the Degani criteria but extend them to include more potential problems. In a second paper, Leveson and Palmer showed how the criteria for indirect mode transitions could be applied to a mode confusion problem found in several ASRS reports for the MD-88. In addition, we defined a visual task modeling language that can be used by system designers to model human-computer interaction. The visual models can be translated into SpecTRM-RL models, and then the SpecTRM-RL suite of analysis tools can be used to perform formal and informal safety analyses on the task model in isolation or integrated with the rest of the modeled system. We had hoped to be able to apply these modeling languages and analysis tools to a TAP air/ground trajectory negotiation scenario, but the development of the tools took more time than we anticipated.

Nancy G. Leveson↗

Personal Electronic Devices and Their Interference with Aircraft Systems

A compilation of data on personal electronic devices (PEDs) attributed to having created anomalies with aircraft systems. Charts and tables display 14 years of incidents reported by pilots to the Aviation Safety Reporting System (ASRS). Affected systems, incident severity, sources of anomaly detection, and the most frequently identified PEDs are some of the more significant data. Several reports contain incidents of aircraft off course when all systems indicated on course and of critical events that occurred during landings and takeoffs. Additionally, PEDs that should receive priority in testing are identified.

Ross, Elden↗

Alaska Humans Factors Safety Study: The Southern Coastal Area

At the request of the Alaska Air Carriers Association, researchers from the NASA Aviation Safety Reporting System, at NASA Ames Research Center, conducted a study on aspects of safety in Alaskan Part 135 air taxi operations. An interview form on human factors safety issues was created by a representative team from the FAA-Alaska, NTSB-Alaska, NASA-ASRS, and representatives of the Alaska Air Carriers Association which was subsequently used in the interviews of pilots and managers. Because of the climate and operational differences, the study was broken into two geographical areas, the southern coastal areas and the northern portion of the state. This presentation addresses the southern coastal areas, specifically: Anchorage, Dillingham, King Salmon, Kodiak, Cold Bay, Juneau, and Ketchikan. The interview questions dealt with many of the potential pressures on pilots and managers associated with the daily air taxi operations in Alaska. The impact of the environmental factors such as the lack of available communication, navigation and weather information systems was evaluated. The results of this study will be used by government and industry working in Alaska. These findings will contribute important information on specific Alaska safety issues for eventual incorporation into training materials and policies that will help to assure the safe conduct of air taxi flights in Alaska.

Chappell, Sheryl L.↗