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At least 127 records · Page 7

"Oops, It didn't arm." - A Case Study of Two Automation Assisted Altitude Deviations

Altitude deviations are the most common pilot error reported to the Aviation Safety Reporting System. Last year, altitude deviations were reported to the ASRS at the rate of about one per hour. The reporting pilot's narrative is usually our only source of information about what happened in these incidents. In a recent line-oriented, simulator study, twenty-two airline crews flew a realistic, two-hour mission in a DC-9 and an MD-88 aircraft. This paper will describe and analyze two of the five altitude deviations that were observed during this study. The paper focuses on the flight crews' use (or misuse) of the autopilot and autothrottle during these incidents.

Plamer, Everett↗

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.↗

Operational problems experienced by single pilots in instrument meteorological conditions

The development and implementation of a search strategy to extract pertinent reports from the Aviation Safety Reporting System-2 (ASRS-2) database are described. For any particular occurence to be pertinent to the study, it must have satisfied the following conditions: the aircraft must be of the type usually flown by a single pilot; operation on an IFR flight plan in instrument meteorological conditions; pilot experienced an operational problem. The occurances consist of reports by the pilot about his own performance, by the pilot about the system performance, or by an air traffic controller about a pilot's performance.

Weislogel, S.↗

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.↗

Translating Research Into Airline Practice: Case Studies In Collaboration

Airline training departments are avid customers for research that will help them enhance the effectiveness of training and the safety of flight operations. However, various factors often make it difficult for training department managers to draw upon the large body of human factors research, e.g.: research may not address the specific questions facing the training departments, the research literature may not be in a form that training managers can readily interpret, researchers' recommendations may be too expensive or impractical to implement, etc. This panel will discuss ways in which researchers can work with training departments to design research and translate findings into products that airlines can use readily. This collaboration is most effective when it is an integral part of the study from its inception. To illustrate the process of collaboration we will use as a case study the recently completed LOFT (Line Oriented Flight Training) Debriefing research project. We will summarize the findings from that study and discuss how we translated those findings into two training tools: a manual on how to facilitate LOFT debriefings and a video that illustrates facilitation techniques in a realistically enacted debriefing. In some cases, instead of starting a new research project, training department needs can be addressed by reviewing the existing research literature and using expert opinion to develop products that specifically address those needs. To illustrate this approach we will discuss a recent informal working group of scientists and airline personnel that met to develop training material to enhance situation awareness. This group reviewed scientific literature and ASRS (Aviation Safety Reporting System) reports, analyzed contributing factors, and produced a model for managing situation awareness.

Dismukes, R. Key↗

Clustering and Recurring Anomaly Identification: Recurring Anomaly Detection System (ReADS)

This viewgraph presentation reviews the Recurring Anomaly Detection System (ReADS). The Recurring Anomaly Detection System is a tool to analyze text reports, such as aviation reports and maintenance records: (1) Text clustering algorithms group large quantities of reports and documents; Reduces human error and fatigue (2) Identifies interconnected reports; Automates the discovery of possible recurring anomalies; (3) Provides a visualization of the clusters and recurring anomalies We have illustrated our techniques on data from Shuttle and ISS discrepancy reports, as well as ASRS data. ReADS has been integrated with a secure online search

McIntosh, Dawn↗

SafeAeroBERT: Towards a Safety-Informed Aerospace-Specific Language Model

As aviation systems continue to operate with high traffic, large amounts of documents containing safety-relevant data continue to be generated via reporting systems such as the ASRS. Advanced natural language processing techniques, specifically pre-trained language models, have shown great success in domain-specific applications; however, the text in aviation safety reports is inundated with jargon and thus not fully utilized by general pre-trained models. In this research, we work towards developing a safety-informed aerospace-specific language model by pre-training a Bidirectional Encoder Representations from Transformer (BERT) model on reports from the Aviation Safety Reporting System and the National Transportation Safety Board. The resulting model, called SafeAeroBERT, is fine-tuned for the specific task of document classification, and can be further tuned for named-entity recognition, relation detection, information retrieval, and summarization. Results from the classification task are compared between SafeAeroBERT, the base BERT, and SciBERT models and show SafeAeroBERT outperforms the general BERT and SciBERT on classifying reports about human factors, aircraft, and procedure. SafeAeroBERT can be used on custom tasks, not limited to document classification, and is intended to aid an intelligent knowledge manager for safety report repositories.

Aviation↗

NASA Aviation Safety Reporting System

A comprehensive study of near midair collisions in terminal airspace, derived from the ASRS database is presented. A selection of controller and pilot reports on airport perimeter security, unauthorized takeoffs and landings, and on winter operations is presented. A sampling of typical Alert Bulletins and their responses is presented.

Source record↗

The NASA Aviation Safety Reporting System

This is the fourteenth in a series of reports based on safety-related incidents submitted to the NASA Aviation Safety Reporting System by pilots, controllers, and, occasionally, other participants in the National Aviation System (refs. 1-13). ASRS operates under a memorandum of agreement between the National Aviation and Space Administration and the Federal Aviation Administration. The report contains, first, a special study prepared by the ASRS Office Staff, of pilot- and controller-submitted reports related to the perceived operation of the ATC system since the 1981 walkout of the controllers' labor organization. Next is a research paper analyzing incidents occurring while single-pilot crews were conducting IFR flights. A third section presents a selection of Alert Bulletins issued by ASRS, with the responses they have elicited from FAA and others concerned. Finally, the report contains a list of publications produced by ASRS with instructions for obtaining them.

Source record↗

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.↗

A review of in-flight emergencies in the ASRS data base

A series of 154 in-flight emergencies as reported to the Aviation Safety Reporting System are described. The various types of emergencies are examined and an attempt is made to determine the human errors and other factors associated with each incident, as well as the measures taken to resolve the emergency. It is concluded that nearly one half of those emergencies reported were related to failure or malfunction of aircraft subsystems. Of all the emergencies, nearly one quarter were associated with power plant failure. Other frequently encountered emergency types are associated with operation in instrument meteorological conditions without appropriate clearance or qualification, and with low fuel state situations. Human error is prominently featured in many of the incidents, appearing in the actions of pilots and air traffic controllers.

Porter, R. F.↗

Simulation of the 1994 Charlotte Microburst with Look-Ahead Windshear Radar

A severe microburst occurred on 2 July 1994 at Charlotte, NC, and was associated with the crash of USAir Flight 1016 (FL-1016) (Salottolo 1994; Phillips 1994). The inbound DC-9 unexpectedly encountered a rapidly intensifying rainshaft just seconds before it was to touchdown on runway 18R. The aircraft crashed after encountering strong windshear, killing 37 of the 57 souls on board. The pilots did not recognize the windshear condition in time to prevent the accident and received no warning from the aircraft's Honeywell in-situ windshear detection system or from ground-based systems (Charlotte maintains both an ASR-9 weather radar and a Phase-2 LLWAS). Also two other aircraft landed ahead of FL-1016 without incident and reported smooth approaches to 18R. Section-2 of this paper reports briefly on the reconstruction of the event based on numerical results generated by the Terminal Area Simulation System (TASS) as presented at the National Transportation Safety Board (NTSB) public hearing (Proctor 1994). Section-3 discusses the simulation of this event with a look-ahead windshear radar.

Proctor, F. H.↗

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.↗