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Explorations of Airline Flight Crew Error Management. The University of Texas at Austin March 4, 1999. Line Operations Safety Audit. Systematic observations of crew performance Team of observers from the airline and U.T. Non-jeopardy Union supported Measures:

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Explorations of airline flight crew error management l.jpg

Explorations of Airline Flight Crew Error Management

The University of Texas at Austin

March 4, 1999


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Line Operations Safety Audit

  • Systematic observations of crew performance

    • Team of observers from the airline and U.T.

    • Non-jeopardy

    • Union supported

  • Measures:

    • CRM - behavioral markers and crew performance

    • Threat - external threats

    • Error - cockpit errors

    • SOP - compliance

    • Interview - Informal feedback from the crews about flight operations and training


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    The LOSA Error Database

    1. International Major - 59 crews on 91 flights

    • International and domestic flights - South Pacific and Pacific Rim

      2. U.S. Major - 65 crews on 102 flights

    • Only international flights - Central and South America

      3. U.S. Regional - 60 crews on 121 flights

    • Experienced Captains with inexperienced First Officers (less than 4 years in aviation and less than one year in position)


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    Expected

    Events and Risks

    Unexpected Events and Risks

    External Error

    External Threats

    Crew-Based

    Errors

    Internal Threats

    Threat Recognition and Error Avoidance

    Behaviors

    CRM Behaviors

    Error Detection

    and Response

    Behaviors

    A Safer Flight

    Recovery to

    A Safer Flight

    Additional

    Error

    Outcomes

    Incidents / Accident



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    External Events

    External Errors

    System Defenses

    Crew Threat Recognition

    and Error Avoidance Behaviors

    Crew Error Detection and Management Behaviors

    Incident / Accident

    The Rain of Threats


    Threats l.jpg

    External Events

    Adverse weather

    ATC command

    Terrain

    Aircraft systems malfunction

    Maintenance event

    Dispatch event

    Ground handling event

    Cabin event

    Airport conditions

    Operational pressure

    External Errors

    Maintenance error

    Dispatch error

    ATC error

    Ground crew error

    Cabin crew error

    Threats

    Threats increase the level of risk to safety


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    A Heavy Rain of Threat

    On one flight observation,

    1. Late arriving aircraft

    2. Inconsistent fuel slips

    3. Weight restriction on departure

    4. Weather and heavy traffic on takeoff

    5. Lavatory smoke alarm during cruise

    6. Weather and heavy traffic on arrival

    7. ATC instructed a runway change in late final


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    Threat Results

    • 72% of the flights had one or more threats

    • From 0 to 10 external threats per flight

    • Average of 2 threats per flight


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    Threats by Phase of Flight

    Threats most frequently occur during preflight and approach


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    Most Common Threats

    1. Adverse weather - 20% of all flights

    2. Aircraft malfunctions - 12%

    3. ATC event - 10%

    4. External errors (ATC, Maintenance, Cabin, Dispatch, and Ground Crew) - 8%

    5. Operational pressures - 8%


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    Threats Profile Airlines and Fleets - An Example from One Airline

    • Narrow body operations

      • were threatened more by weather / wind

        • 69% of flight segments vs 49% of wide body flights

      • were threatened more by terrain

        • 23% of flight segments vs 2% of wide body flights

      • were less threatened by aircraft abnormals

        • 18% of flight segments vs 67% of wide body flights


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    Threat Recognition and Error Avoidance Behaviors

    • Behaviors that crews used to recognize threats and avoid error

      1. Active Captain leadership

      2. Vigilance

      3. Operational plans clearly stated and acknowledged

      4. Staying ahead of the curve

      5. Following SOP



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    External Events

    External Errors

    System Defenses

    Crew Threat Recognition

    and Error Avoidance Behaviors

    Flightcrew Errors

    Crew Error Detection and Management Behaviors

    Incident / Accident

    The Other Piece: Flightcrew Errors


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    Flightcrew Errors

    • Can be triggered by an external threat or occur in isolation

    • Flightcrew error definition - an action or inaction that leads to a deviation from crew or organizational intentions or expectations



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    Intentional Noncompliance

    Procedural

    Communication

    Proficiency

    Operational Decision

    Error Types


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    Error Types

    1. Intentional Noncompliance - violations

    ex.) Omitted required briefings

    Performing checklists from memory

    Failure to cross-verify settings

    2. Procedural - followed procedures but wrong execution

    ex.) Lever and switch settings

    Wrong altitude dialed

    Wrong MCP mode executed


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    Error Types

    3. Communication - Misinterpretation or missing information during an exchange

    ex.) Wrong readbacks to ATC

    Missed ATC calls

    Wrong runway communicated

    4. Proficiency - lack of knowledge or skill error

    ex.) Lack of stick and rudder proficiency

    Lack of knowledge with automation

    Lack of knowledge with procedures


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    Error Types

    5. Operational Decision - discretionary decision not covered by procedures that unnecessarily increased risk

    ex.) Over-reliance on automation

    Unnecessary low maneuver on approach

    Unnecessary navigation through adverse weather


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    Intentional Noncompliance

    Procedural

    Communication

    Proficiency

    Operational Decision

    Error Types

    Trap

    Exacerbate

    Fail to Respond

    Error Responses


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    Error Responses

    • Trap - error is detected and managed before it becomes consequential (undesired state or additional error)

    • Exacerbate- error is detected but the crew’s action or inaction becomes consequential

    • Fail to Respond - lack of a response to an error (undetected or ignored) that can either end up being inconsequential or consequential


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    Intentional Noncompliance

    Procedural

    Communication

    Proficiency

    Operational Decision

    Error Types

    Trap

    Exacerbate

    Fail to Respond

    Error Responses

    Error Outcomes

    Inconsequential

    Undesired State

    Additional Error


    Undesired states l.jpg

    Lateral deviation - heading

    Vertical deviation - altitude

    Speed to high or low

    Unstable approach

    Near miss

    Fuel level below minimums

    Vertical deviation on the G.S.

    Long landing

    Hard landing

    Landing off centerline

    Wrong taxiway or ramp

    Wrong runway

    Wrong airport

    Wrong country

    Undesired States

    Undesired aircraft states are deviations from normal

    flight that unnecessarily compromises safety


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    Crew-Based

    Accident

    Intentional Noncompliance

    Procedural

    Communication

    Proficiency

    Operational Decision

    Error Types

    Trap

    Exacerbate

    Fail to Respond

    Error Responses

    Error Outcomes

    Inconsequential

    Undesired State

    Additional Error

    Undesired State Responses

    Mitigate

    Additional Error


    Flightcrew error results l.jpg
    Flightcrew Error Results

    • 72% of the crews committed at least one error

    • 65% of the flights had one or more errors

    • From 0 to 14 errors per flight

    • Averaged 2 errors per flight

    • There were between and within-fleet differences


    Errors by phase of flight l.jpg

    Consequential means leading to an undesired state or additional error

    Errors by Phase of Flight



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    Most Common Errors additional error

    1. Automated systems errors (MCP and FMC) - 21% of all flights

    • Failure to cross-verify settings

    • Wrong MCP or FMC settings

    • Other Intentional noncompliance errors

      2. Checklist errors - 20%

    • Checklist performed from memory

    • Nonstandard checklist usage

    • Self-performed checklist

    • Procedural checklist errors


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    Most Common Errors additional error

    3. Sterile cockpit violations - 10%

    4. ATC errors - 6%

    • Missed ATC calls

    • Omitted information (readbacks or call signs)

    • Accepting ATC instructions that unnecessarily

      increased risk

    • Procedural ATC errors

      5. Briefing errors (omitted or incomplete) - 5%


    Error management results l.jpg

    Proficiency and Operational Decision errors are the most difficult to manage

    Error Management Results


    Undesired state results l.jpg
    Undesired State Results difficult to manage

    • Responses to Undesired States

      • 75% are mitigated

      • 9% lead to additional errors

      • 16% required no crew response


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    Error Detection and Management Behaviors difficult to manage

    • Behaviors that crews used to detect and manage errors

      1. Active captain leadership

      2. Environment set for open communications

      3. Crew members asking questions and speaking up

      4. Vigilance

      5. Prioritization of tasks to manage workload

      6. Monitor and Cross-Check

      7. Check-list discipline


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    Between-Airline Differences difficult to manage


    Average number of errors per flight segment l.jpg
    Average Number of Errors difficult to managePer Flight Segment



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    Violations matter airline

    • 40% of accidents in global fatal accident database had violations

    Flight Safety Foundation: Approach and Landing

    Accident Reduction Task Force Report

    R. Khatwa & R. Helmreich

    November, 1998


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    Culture and violation airline

    Cross-cultural research shows that American pilots are least accepting of the need to comply with SOPs.

    Helmreich & Merritt (1998)


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    Violations as the Norm airline

    • One observer noted the following during the U.S. Regional audit on an IOE ride,

      “The Check Airman ran the entire taxi checklist by memory.”

    • Organizations cannot allow violations to normalize

    • Why? - Crews that commit at least one intentional noncompliance error are more likely to commit other types of error than those without an intentional noncompliance error


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    CRM Countermeasures to Error airline

    • Bryan’s latest analyses


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    CRM curriculum - recurrent airline

    • Basic CRM issues are general

    • The Devil is in the detail

      • Enormous organizational and fleet differences in error and threat

      • Recurrent training should be highly specific to organization with focus on fleet or operation issues such as international flying

    • Risk of standardized curriculum is to ignore local issues


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    Our Website airline

    www.psy.utexas.edu/psy/helmreich/nasaut.htm


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