Purpose and contents of the presentation • Introduction : Interruptions and distractions constitute an insidious threat • Analyzing mandatory and voluntary incident reports relative to distractions • A step-by-step analysis of databases with Excel filtering • Uncover and cluster factors related to distraction issues • Consequences and descriptors, operational and human factors markers • Discuss practical ways and means to take care of this • Using tactical countermeasures • Using prevention and recovery strategies • Using practical tips • Conclusion
Distractions and interruptions in ancient times Homer in the Odyssey described the devastating effects of distraction. His solution was to block his crew’s ears with wax. Nowadays, passengers are asked not to speak to bus drivers.
Distractions and interruptions in modern times • Interruptions and distractions result mainly from the following: • Pilot / Controller or inter / intra - cockpit communications • Head – down work • Responding to an abnormal condition or an unanticipated situation.
Factor % of Events Omission of action or inappropriate action 72 % Inadequate crew coordination, cross-check and back-up 63 % Insufficient horizontal or vertical situational awareness 52 % Inadequate or insufficient understanding of prevailing conditions 48 % Slow or delayed action 45 % Incorrect or incomplete pilot / controller communications 33 % Effects of distractions and interruptions in approach and landing accidents (ALA) according to the FSF ALA Task Force
Using incident reports for human factors evaluations • Lauber (1984) stated that an incident database “is a veritable gold mine of information waiting to be tapped.” • Rich source of information in aeronautical human factors • Use by policy makers, HF practitioners to improve safety. • The limitations of incident data in research • Bias factors: Who reports and what gets reported • To receive immunity pilots report some occurrences more. • No knowledge of actual number, only those reported • Temptation to attribute a coexistence of two factors to cause & effect • Multiple methods of looking at the data to uncover factors. After Sheryl L. Chappell (1994)
Using Databases: goldmines of information on distraction • BASIS • More than 72 ASR incidents relative to distraction screened, • AIRS • over 37 HF incidents relative to distraction screened, • SIE • only 5 incidents relative to distraction screened, • We now observe less HF’s in confidential reports, • We now observe more HF’s in mandatory reports, • ASR’s and HFR’s growing together, • SIE now migrating to IATA Steades, BASIS, AIRS, SIE excellent for health checks
SITUATION RECOGNITION / DIAGNOSIS PROCEDURE(S) ENVIRONMENT & CIRCUMSTANCES AIRCRAFT COCKPIT / WEATHER / PROCEDURE PROCEDURE CREW PROCEDURE HMI OPERATIONAL RUNWAY SYSTEMS CREW ORGANIZATIONAL ALERTS CABIN ENVIRONMENTAL TYPE ACCESS DIAGNOSIS CONTENTS ASPECTS ENVIRONMENT CONDITIONS CONDITION / FACTORS FACTORS EFFECTS CONDITIONS CONFIG CREW PERFORMANCE AIRCRAFT CREW ATTITUDE PROCEDURE CREW THREAT CREW ERROR AND EXECUTION ACTIONS MANAGEMENT COORDINATION MANAGEMENT FLIGHT PATH CONTROL OEAP : Involved Domains and Factors Warning: Do not attempt to read
Distraction caused by / resulting in the specific safety events • Air Traffic Control A/C communication & separation losses, • Cabin & Flight crew affection & incapacitation, • Flight Path Control (alt bust / dev,path dev,lat dev,vert dev,flare,taxi/rwy inc/exc,swerves,spd loss/drops,stall,…), • Non respect of Limitations (overspeeds,flap limit speeds…), • Threat for CFIT/ALAR (stabilization criteria not met, unstable/rushed/fast/slow approaches,…), • Go-around/IFTB/Delayed starts/diversions, • Loss of System Functions,
Themselves caused by / resulting in specific safety issues • Flight Control Difficulties (flaps not set,speed-brakes,gear not extended/retracted,delayed,configuration warnings), • Difficulties with automation (auto throttle,mode management,…), • Systems management (APU not shut down,parking brakes not set,anti-ice not selected,hot start…), • Fuel management (pump selections, limitations, quantities,imbalances,…), • Cabin pressurization difficulties, • Altimeter barometer setting, • TCAS/GPWS alerts,
Themselves caused by / resulting in specific safety issues • Ergonomics (plate/map holders,cockpit displays,sun visors), • Noises (engines,ATC buzzer,headset chatter,radio altitudecallout,warning,intercom,interference,mobiles,loudspeaker), • MEL/SOP’s,checklists,procedural difficulties (omission,item not completed / skipped / forgotten ), • Language confusion/difficulties,call sign misunderstandings, • Passenger / cabin distraction,cabin secure reports, • Hazard linked with kites,birds,wildlife,dogs, • Airport infrastructure (lighting,marking,…), • Burning smell/smoke,
Themselves caused by / resulting in specific safety issues • Navigation issues (FMS data introduction and databases,flying through localizer,flying past radio beacon,…) • Weather issues (lightning,fog,haze,hail,turbulence,waketurbulence,C/B’s,wind-shear) and avoidance thereof, • Technical system failures or system failures (preset altitude not acquired,descend through selected altitude), • Load-sheet figures not obtained/not introduced, suspicious items,fuel quantities,LMC’s not communicated), • Fatigue and Alertness issues, • Crew Resource Management issues, • Concurrent Task Management issues,
Situational Recognition / Diagnosis Difficulty in use of systems Automation not understood Condition not detected Noise False alert not identified Abnormal indication Late problem recognition Procedures Complex combination of procedures Procedure scope incomplete Entry in procedure unclear Procedure / A/C configuration mismatch ECAM warning As mediated / accompagnied by Ops/Human Factors Markers
Crew Performance Workload management Being unstabilized at approach gate Over-speed NATP SOP’s NATP C/L’s NATP Sterile Cockpit Degraded situational awareness Delayed action Cockpit/cabin comm’s Undetected/unchallengedcrew error Briefings Flight monitoring Environment & Circumstances Pilot/controller communication Operational stress In-flight failure Incomplete configuration Inadequate separation Inadequate ATC instruction Fatigue/vigilance Company policies As mediated /accompagnied by Ops/Human Factors Markers
Interruption / Distraction: Cause and / or Effect ? SAFETY EVENTS Situational Recognition/ Diagnosis Environment/ Circumstances Operational Factors Human Factors Crew Performance Procedures SAFETYISSUES
The essence of AIRS : modeling interactions within an event Interactions within the Human Factors Model ENVIRONMENT ORGANISATION CREW ACTIONS PERSONAL INFORMATION
First Party First Party First Party Third Party Third Party Third Party Concurrent Task Management as a cause of vulnerability T/O Config warning because pre-T/O checks not carried out Third Party COMPANY COMMUNICATIONS POST INCIDENT STRESS OPERATIONAL STRESS Third Party WORKLOAD MANAGEMENT AIRPORT FACILITIES DISTRACTION MEMORY LAPSE AIRS Treatment : modeling a Take-Off Configuration Event RTO
Concurrent Task Management as a cause of vulnerability NASA studies on distractions, distractions and Concurrent Task Management(by Loukopoulos,Dismukes and Barshi at NASA Ames) • Comparison of written materials with actual line operations : • Pilots often have to interleave two or more tasks concurrently to respond to operational demands, • written material can only prescribe serially and not frequentially, • Crews are sometimes unable to execute a procedural step at the point prescribed in written procedures, • information may be missing or the context can be inappropriate, • Crews are frequently interrupted especially by other personnel, • timing of interruptions / nature of response required unpredictable,
Concurrent Task Management as a cause of vulnerability NASA studies on distractions, distractions and Concurrent Task Management(by Loukopoulos,Dismukes and Barshi at NASA Ames) • Cognitive demands of concurrent task management : • Interleaving tasks and monitoring, • pilots are especially vulnerable to error if a task step unexpectedly requires an unusual amount of attention, • documentation provides little specific guidance on how frequently to monitor or how to divide attention between monitoring and rest, • Suspending and deferring tasks, • respond to the interruption + return to the interrupted task later or suitably halting the ongoing before responding to the interruption, • pilots like others are quite vulnerable to forget to perform deferred tasks, may overestimate the probability of remembering these,
Countermeasures for Concurrent Task Management Issues • Be aware of error proneness when performing routine tasksconcurrently or out of usual sequence / time scale, • Examine contents & timing of procedures & checklists with care, • Identify situations in which proc’s must be interleaved with frequent interruptions, • Design procedures to minimize concurrent task demands & interruptions, • Set salient traps and strict decision criteria that must be met before proceeding further, • Provide explicit guidance to crews on the importance of monitoring,what to monitor,and how to monitor,
Prevention and Recovery Strategies : Manage distractions • Recognize and Identify the disruption, • Re-establish Situational Awareness : • Identify : WHAT WAS I DOING? • Ask : WHERE WAS I INTERRUPTED? • Decide / Act : WHAT DECISION OR ACTION to get “ back on track”? • The following decision-making process to be applied : • Prioritize : FLY,NAVIGATE,COMMUNICATE and MANAGE! • Plan : TAKE TIME TO MAKE TIME! • Verify : THAT POSTPONED ACTIONS WERE FINALIZED! • Verbalize to mark interruptions and protect what you are doing,
Photo credit :TAKEOFF - The Swiss Professional Pilots’ Association Magazine Prevention and Recovery Strategies : Mutual Crosscheck • Each flight crewmember must actively cross-check the actions of each cockpit colleague, • These crew monitoring and cross-checking functions are the last line of defense : a detection may break the chain of events, • Monitoring and cross-checking accomplishes 3 VIP functions: • keeping the crew appraised of the current aircraft status, • helping the crew catch their own errors, • helping them detect evolving aspects.
Perceive Mitigate Situation Awareness Comprehend Trap Threat Management Project Avoid ESSAI : Enhanced Safety through Situation Awareness Integration in training (EEC program) Prevention and Recovery Strategies : Think & Trap Errors • Training for improved monitoring in the simulator will translate to better monitoring on the line and requires instructor patience. • Students should be allowed to make & catch their own mistakes. Errors that are not detected timely should be better debriefed. • LOSA found that crews failed to detect 42% of errors noted by cockpit observers. • Improving & sharpening crew monitoring skills through ESSAI by: • Minimising loss of Situation Awareness (SA) • Increasing Threat Management (TM) skills
Prevention and Recovery Strategies : Monitoring Skills • Traditional CRM has excelled in training to challenge or speak up when something seems unsafe or unwise, • To challenge something, one must first detect it, and detection requires effective monitoring, • Traditionally monitoring has not been held as a primary task. • Pilot-not-flying duties typically include tasks such as handling radio comm’s, operating gear and flaps, and keeping a flight log. • Monitoring is typically not listed, leading to the erroneous conclusion that it is more or less a secondary duty to be performed when crewmembers are not busy with other tasks.
Prevention and Recovery Strategies : SOP’s (AC 120-71A ) • The FAA recently solicited industry input to develop a template that airlines can adopt to support enhanced monitoring which led to a revised AC on “ Standard Operating Procedures ", • This Advisory Circular notes that several operators have changed the title of Pilot Not Flying to Pilot Monitoring, • PM better defines this pilot's role, and is more descriptive because it really states what this pilot should be doing, • This also appears to be an excellent Risk Management Tactic,
Prevention and Recovery Strategies : Manage Fatigue & Alertness • How does your body manifest being tired? • What effect does being tired or being less alert have on your monitoring behavior ? • How does diminished alertness affect your performance in flight ? • How did you cope with poor alertness in the past ?
Practical Tips for avoiding lapses in Monitoring (from NASA) • Manage Workload : rearrange sequence, divide responsibilities, put limits, • Recognize multi-task demands and dividing attention: • Identify specific things to monitor + periodically switch attention, • Divided attention between tasks + avoid preoccupation with either, • Break concurrent tasks into subtasks + pause/monitor in between, • Review task in advance to identify crucial junctures to monitor: • Brief departure procedure ahead and review PF/PNF action plan, • Raise red flag in vulnerable situations and increase vigilance: • PNF announcing going head-down,PF intensifies when PNF off, • Assign neglected task higher priority : e.g. collision avoidance, • Create salient visual, auditory or tactile reminders : • PNF calling out progress so PF can monitor while doing other tasks, Questionnaire studies based on ten incident scenario’s from ASRS study on distractions (by Loukopoulos,Dismukes and Barshi at NASA Ames)
Practical Tips for avoiding lapses in Memory (from NASA) Questionnaire studies based on ten incident scenario’s from ASRS study on distractions (by Loukopoulos,Dismukes and Barshi at NASA Ames) • Create a habit linking memory item to habitual actions : • e.g. add landing clearance to final C/L as personal technique, • Manage workload within acceptable limits : • Divide responsibilities + stick to it, F/O as PF so Capt manages, • Create salient visual, auditory or tactile reminders : • Hold C/L, keep hand on radio, write down ATC, C/L for baro set, • Execute task immediately : • Call tower early , set PNF altimeter or standby altimeter asap, then PF at appropriate transition altitude, • Miscellaneous : enhance encoding of intentions in memory by repeating aloud, adhere to SOP’s, restart checklists if uncertain,
Conclusion : HF Analysis for Distraction Related Events • Interruptions and Distractions constitute an insidious Threat that mandate operational protection tips, • We need to integrate the language of Human Factors into our SOP’s andTraining and Operations Manuals : crew awareness, monitoring,etc… • We need to integrate the voluntary and the mandatory sides of reportingand encourage pilots talking human factors to capture the why’s, • We definitely need to develop a Human Factors Toolkit to make usunderstand why this can improve aviation safety for all system actors , • practical briefings, training material and safety initiatives on human factors subjects for use by the widest range of people for eye-opening, What really matters is what pilots need to have on their plate