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At least 163 records · Page 9
All sourcesNASA NTRSDOE OSTI
NASA NTRS1989

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.↗
NASA NTRS1989

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.↗
NASA NTRS1985

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.↗
NASA NTRS1993

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.↗
NASA NTRS1993

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.↗
NASA NTRS1993

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.↗
NASA NTRS1995

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↗
NASA NTRS1996

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.↗
NASA NTRS1996

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↗
NASA NTRS1998

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↗
NASA NTRS2001

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↗
NASA NTRS1995

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.↗
NASA NTRS1995

Cross-Cultural Barriers to Effective Communication in Aviation

Recent research on communication and performance in airline flight crews has led to a concept of shared mental models that is associated with effective, efficient team coordination in problem solving and decision making situations. Elements that characterize efficient communication have been identified. This research, however, was based strictly on US crews. More recent studies supported by NASA have identified cultural factors that influence communication among team members who vary in their status and roles. Research is just beginning to identify commonalities and culturally distinct strategies for accomplishing joint tasks. ASRS incident reports have been analyzed to identify language barriers in flight that have safety consequences. Implications of these concepts and findings for multi-cultural command and control will be explored.

Orasanu, Judith↗
NASA NTRS1995

"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↗
NASA NTRS1996

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↗
NASA NTRS1997

Identification of Error Patterns in Terminal-Area ATC Communications

Advancing air traffic management technologies have enabled a greater number of aircraft to use the same airspace more effectively. As aircraft separations are reduced and final approaches are more finely timed, there is less room for error. The present study examined 122 terminal-area, loss-of-separation and procedure violation incidents reported to the Aviation Safety Reporting System (ASRS) by air traffic controllers. Narrative description codes were used for the incidents for type of violation, contributing factors, recovery strategies, and consequences. Usually multiple errors occurred prior to the violation. Error sequences were analyzed and common patterns of errors were identified. In half of the incidents, errors were noticed in time to correct mistakes. Of these, almost 43% committed additional errors during the recovery attempt. This analysis shows that redundancies in the present air traffic control system may not be sufficient to support large increases in traffic density. Error prevention and design considerations for air traffic management systems are discussed.

Quinn, Cheryl↗
NASA NTRS1997

Alternative Perspectives on Risk: Individual Differences in Problem Structuring

Team decision making involves contributions of multiple players toward a common goal. While much has been written about the importance of developing shared mental models in order for teams to work together effectively, little has been done to determine the value of alternative perspectives on problem solving and decision making. Early studies of expertise contrasted experts with novices and noted that the two groups differ in the way they structure problems and in their selection of information as salient. Little attention has been given to differences among experts who differ in their specializations. A series of experiments was conducted to determine: (1) what dimensions of flight-related problem situations pilots judge to be most important when making flight-relevant decisions; and (2) whether pilots in different crew positions differ in the way they interpret problems relating to flight decisions. A sorting task was used to identify underlying dimensions judged as salient to individual pilots. Captains, first officers, and flight engineers from two major carriers participated in the study. Twenty-two flight scenarios were developed based on ASRS reports. Pilots were required to make judgments about how they would respond in each case and to sort the scenarios on the basis of similarity of decision factors. They were also asked to provide a verbal label that described each of their sorted categories. A second study required a different group of pilots (also captains, first officers and flight engineers) to sort on predetermined bases.

Orasanu, Judith↗
NASA NTRS1995

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.↗