slide1 l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Key Dismukes Chief Scientist for Aerospace Human Factors Human Factors Research and Technology Division NASA-Ames Resear PowerPoint Presentation
Download Presentation
Key Dismukes Chief Scientist for Aerospace Human Factors Human Factors Research and Technology Division NASA-Ames Resear

Loading in 2 Seconds...

play fullscreen
1 / 32

Key Dismukes Chief Scientist for Aerospace Human Factors Human Factors Research and Technology Division NASA-Ames Resear - PowerPoint PPT Presentation


  • 201 Views
  • Uploaded on

Managing Interruptions, Distractions and Concurrent Task Demands. Key Dismukes Chief Scientist for Aerospace Human Factors Human Factors Research and Technology Division NASA-Ames Research Center ATA AQP Annual Conference October 2003. Our Research Team. Immanuel Barshi LaQuisha Beckum

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

Key Dismukes Chief Scientist for Aerospace Human Factors Human Factors Research and Technology Division NASA-Ames Resear


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Managing Interruptions, Distractions and Concurrent Task Demands

Key Dismukes

Chief Scientist for Aerospace Human Factors

Human Factors Research and Technology Division

NASA-Ames Research Center

ATA AQP Annual Conference

October 2003

our research team
Our Research Team
  • Immanuel Barshi
  • LaQuisha Beckum
  • Sean Belcher
  • Rahul Dodhia
  • Jon Holbrook
  • Kim Jobe
  • Tri Li
  • Loukia Loukopoulos
  • Jessica Lange Nowinski
  • Mark Staal
consequences of inadvertent procedural omissions
Consequences of Inadvertent Procedural Omissions
  • LaGuardia (1994): MD-82 ran off runway end after high-speed rejected take-off
    • NTSB: Anomalous airspeed indications caused by failure to turn on pitot heat
  • Detroit (1987): DC-9 crashed shortly after take-off
    • NTSB: Flaps/slats not set to take-off position
  • Dallas (1988): B-727 crashed shortly after take-off
    • NTSB: Flaps/slats not set to take-off position
  • Houston (1996): DC-9 landed gear-up
    • NTSB:Hydraulic pump not set to high position
were these accidents unique
Were These Accidents Unique?

Not according to recent ASRS reports:

  • Rejected take-offs
    • Anomalous airspeed indications (pitot heat not on)
    • Configuration warning (flaps or trim not set)
  • Other consequences of overlooked procedural steps
    • Runway incursions
    • Broken tow-bars
    • Taxi into ditch
    • Engine flame-out
    • Overtemp engine
    • Flew wrong departure route
    • Go-around
  • Unnecessary costs and delays
  • But for luck any of these incidents might have become accidents
  • Departed with inadequate fuel
  • APU left running during takeoff -- fire
  • Packs failed in cruise
  • Took off without PDC
  • Deviated from speed or altitude restriction
  • Nose gear failed to retract
  • etc.
slide5
Why?
  • Why would experienced crews forget a procedural step they normally perform day in and day out?
  • Why fail to catch omissions with checklists?
an ongoing nasa research project
An Ongoing NASA Research Project
  • “Carelessness” not an adequate explanation
  • Crews vulnerable to omissions when:
    • Interrupted or preoccupied with one of several concurrent tasks (Young, Dismukes, & Sumwalt, 1998).
    • Deferring tasks out of normal sequence (Loukopoulos, Dismukes, & Barshi, 2003).
  • Vulnerability to error among experienced pilots largely driven by:
    • Characteristics of tasks performed
    • Demands tasks place on human cognitive processes
    • Operating environment
    • Norms for actual line operations
jumpseat observation study loukopoulos dismukes barshi 2003
Jumpseat Observation Study(Loukopoulos, Dismukes, & Barshi, 2003)
  • Reviewed FOMs, observed line operations, analyzed ASRS, NTSB reports
    • All phases of flight — focus today on preflight and taxi
  • Discovered disconnect between FOM/training and actual line operations in depiction of task management
slide8

Preflight - In theory (FOM)

Ground/

Company/

Dispatch

Frequencies

Interphone

Cabin Attendant

Gate Agent

ACARs / OPC

CAPTAIN FIRST OFFICER

Review paperwork

Sign flight release

Prepare/review charts

Review Load Schedule

Review FMC

Takeoff brief

Ask for checklist

  • Ask for checklist

Obtain ATIS

Obtain clearance

Review paperwork

Prepare/review charts

(Passenger count)

(Load Sheet)

Program FMC

Begin checklist

Checklist complete

Begin checklist

Checklist complete

procedure

procedure

checklist

CLEARANCE

checklist

ENGINE START & PUSHBACK

depiction of cockpit task management in fom training
Depiction of Cockpit Task Management in FOM/Training
  • Tasks are serial and linear: task A task B  task C in a fixed sequence.
slide10

Preflight - In theory (FOM)

Ground/

Company/

Dispatch

Frequencies

Interphone

Cabin Attendant

Gate Agent

ACARs / OPC

CAPTAIN FIRST OFFICER

Review paperwork

Sign flight release

Prepare/review charts

Review Load Schedule

Review FMC

Takeoff brief

Ask for checklist

  • Ask for checklist

Obtain ATIS

Obtain clearance

Review paperwork

Prepare/review charts

(Passenger count)

(Load Sheet)

Program FMC

Begin checklist

Checklist complete

Begin checklist

Checklist complete

procedure

procedure

checklist

CLEARANCE

checklist

ENGINE START & PUSHBACK

depiction of cockpit task management in fom training11
Depiction of Cockpit Task Management in FOM/Training
  • Linear: task A task B  task C in a fixed sequence.
  • Controllable: tasks are initiated by crew at their discretion.
  • Predictable:
    • Information available to crew when needed.
    • Individuals can communicate as needed.
slide12

Taxi-out - In theory (FOM)

CAPTAIN FIRST OFFICER

Captain

Start taxiing

Ask for checklist

Receive takeoff clearance

Ask for checklist

Line up with runway

First Officer

Receive taxi clearance

Start checklist

Checklist complete

Receive takeoff clearance

Start checklist

Checklist complete

MONITOR

Ground

Company/Dispatch

MONITOR

Ground

Company

TaxiClearance

MONITOR

Captain taxiing

Takeoff Clearance

TAKEOFF

depiction of cockpit task management in fom training13
Depiction of Cockpit Task Management in FOM/Training
  • Linear: task A task B  task C in a fixed sequence.
  • Controllable: tasks are initiated by crew at their discretion.
  • Predictable:
    • Information available to crew when needed.
    • Individuals can communicate as needed.
  • Overall picture: flight operations are pilot- driven and under moment-to-moment control of crew.
slide14

Review paperwork

Sign flight release

Prepare/review charts

Review Load Schedule

Review FMC

Takeoff brief

Ask for checklist

Ask for checklist

Preflight - the reality

Conduct exterior walk-around

no time, familiarity

Ramp and/or Ground?

Check charts

busy frequency

Keep trying

Double-check charts

no time, familiarity

Interruption

Interruption

Resume flow

Still refueling

Check fuel quantity

and pumps

Inoperative item

Inoperative item

Call maintenance

Confirm Mx responded

Passenger count unavailable

Confirm resolution

Request passenger count

Confirm Mx departed

Data unavailable

Confirm logbook on board

Defer programming FMC

Flight release still not picked up

Look for ops/gate agent

New PDC

Delay at gate

Re-program FMC

New flight release/PDC?

Re-set MCP

Time pressure

FO busy

Re-flow trim & other settings

Ask for checklist

Takeoff brief

Flight plan/

Departure runway change

Interruption

Resume checklist

Communicate with company

Compute new performance #s

Re-program FMS

Re-brief

CAPTAIN FIRST OFFICER

Obtain ATIS

Obtain clearance

Review paperwork

Prepare/review charts

(Passenger count)

(Load Sheet)

Program FMC

Begin checklist

Checklist complete

Begin checklist

Checklist complete

Ground/

Company/

Dispatch

Frequencies

Interphone

Cabin Attendant

procedure

Gate Agent

ACARs / OPC

procedure

procedure

checklist

CLEARANCE

checklist

ENGINE START & PUSHBACK

slide15

Review paperwork

Sign flight release

Prepare/review charts

Review Load Schedule

Review FMC

Takeoff brief

Ask for checklist

Ask for checklist

Preflight - the reality

Conduct exterior walk-around

no time, familiarity

Ramp and/or Ground?

Check charts

busy frequency

Keep trying

Double-check charts

no time, familiarity

Interruption

Interruption

Resume flow

Still refueling

Check fuel quantity

and pumps

Inoperative item

Inoperative item

Call maintenance

Confirm Mx responded

Passenger count unavailable

Confirm resolution

Request passenger count

Confirm Mx departed

Data unavailable

Confirm logbook on board

Defer programming FMC

Flight release still not picked up

Look for ops/gate agent

New PDC

Delay at gate

Re-program FMC

New flight release/PDC?

Re-set MCP

Time pressure

FO busy

Re-flow trim & other settings

Ask for checklist

Takeoff brief

Flight plan/

Departure runway change

Interruption

Resume checklist

Communicate with company

Compute new performance #s

Re-program FMS

Re-brief

CAPTAIN FIRST OFFICER

Obtain ATIS

Obtain clearance

Review paperwork

Prepare/review charts

(Passenger count)

(Load Sheet)

Program FMC

Begin checklist

Checklist complete

Begin checklist

Checklist complete

Ground/

Company/

Dispatch

Frequencies

Interphone

Cabin Attendant

procedure

Gate Agent

ACARs / OPC

procedure

procedure

checklist

CLEARANCE

checklist

ENGINE START & PUSHBACK

line observations reveal a different story
Line Observations Reveal a Different Story
  • Normal line operations are quite dynamic:
  • Each pilot must juggle several tasks concurrently.
  • Crews are frequently interrupted.
  • External demands arrive at unpredictable moments.
  • Conditions sometimes force task elements to be performed out of normal sequence.
line observations reveal a different story17
Line Observations Reveal a Different Story
  • Each pilot must juggle several tasks concurrently.
  • Crews are frequently interrupted.
  • External demands arrive at unpredictable moments.
  • Conditions sometimes force task elements to be performed out of normal sequence.
  • Normal line operations are quite dynamic:
  • Crews must at times struggle to maintain control of the timing and sequence of their work tasks.
  • Lack of guidance
slide18

Conflict Between Theory and Reality

  • FOM is a powerful tool for safety by providing:
  • Operational reality disrupts ideal execution of procedures
  • Explicit description of how each task is to     be performed
  • Standardization across crews
  • Checklists and checking procedures
so what
So What?
  • Pilots become accustomed to concurrent task demands, interruptions, distractions and disruptions.
  • However these situations substantially increase vulnerability to error, especially omission of critical procedural steps.
slide20

ERRORS

attributed to concurrent task demands, interruptions, and disruptions (ASRS reports)

Forgot logbook at ramp - kept deferring to check it; distractions; busy with preflight - discovered en route

Skipped over checklist item - fuel pumps deferred during preflight because refueling - engine starvation in flight

Omitted review of charts - distractions - speed violation on departure

Entered wrong weight in FMS - tail strike at takeoff

Improper setting of pressurization during preflight flow - interruptions - cabin altitude warning light in cruise

Omitted flow and checklist items - interruptions; delay; change in departure runway - discover insufficient fuel at 12000 ft

Read but not verify checklist item - distractions - pushback with throttles open, damage to aircraft

Started taxi without clearance - crew discussing taxi instructions - struck pushback tug

Neglected to set flaps -preoccupied with new departure clearance and packs-off operation - aborted takeoff

FO failed to monitor CA – busy with flow; night taxi – taxi in wrong direction

FO failed to monitor CA -runway change; busy reprogramming FMC - taxied past intended taxiway

Omitted setting flap - busy with delayed engine start; rushed to accept takeoff clearance - aborted takeoff

Failed to verify new clearance - monitoring convective activity on radar - flew wrong heading

PREFLIGHT > PUSHBACK > TAXI > TAEKOFF > CLIMB > CRUISE > DESCEND > LAND

Omitted climb checklist - busy copying hold instructions - missed setting altimeter and overshot altitude

Failed to reset bleeds on - complex departure; multiple ATC calls; traffic - altitude warning and 02 mask deployment

Did not notice wind - preoccupied with annunciator light; handling radios - track deviation

Forgot to reset altimeters - distracted by FA in cockpit - TCAS RA and overshot arrival fix

Failed to monitor PF - busy reprogramming FMS; weather changes - go around

Failed to verify FMC settings - PNF giving IOE to PF; multiple ATC calls; hold instruction - flew pattern in wrong direction

ATC instructions too close to turn fix - busy slowing aircraft; approach checklist; radios - failed to make published turn

Vectored too close - busy catching up with glideslope; not instructed to switch to Tower - landed without clearance

Forgot to switch to Tower at FAF - last minute runway change; busy reconfiguring aircraft - landed without clearance

Unstabilized approach - accepted runway change right before FAF; did not review charts or make callouts - tailstrike

Did not complete checklist - TCAS alerts; parallel runways in use; GPWS alert - did not extend gear for landing

Did not extend gear; checklist interrupted; TCAS alerts; parallel runways in use; GPWS alert - struck ground on go-around

why so vulnerable to these errors22
1) “Controlled” processing

Corresponds to conscious attention

Slow, serial, and effortful: low capacity

Required for tasks with novel aspects

2) Automatic processing

Fast, minimal effort, high capacity

Develops with extensive practice of habitual procedure

Requires minimal conscious supervision

Why So Vulnerable to These Errors?
  • Brain has two ways of processing information to perform tasks:
  • Cockpit tasks vary from requiring mainly controlled processing to being largely automatic.
slide24

PAX CT

107, 22, 5

3 WH

ATIS

Slakfj aslkfj890

Slkdfj 3409589

Slkafj f095j 019

Sa;lskdfjl

Lskd

LOAD

Slakfj aslkfj890

Slkdfj 3409589

Slkafj f095j 019

Sa;lskdfjl

Lskd

Slkf9 9oy99

Slkdfj

A;slkg eri kgj skj 9

FLIGHT

PLAN

Slakfj aslkfj890

Slkdfj 3409589

Slkafj f095j 019

Sa;lskdfjl

Lskd SFAS ALSKFJ

XLKAF ALKDFJJ;AL

FUEL

107, 22, 5

3 WH

PDC

Slakfj aslkfj890

Slkdfj 3409589

Slkafj f095j 019

Sa;lskdfjl

Lskd

Slkf9 9oy99

Slkdfj

A;slkg eri kgj skj 9

JEPP

107, 22, 5

• •x

Aft Overhead

Aft Overhead

*

*

PREFLIGHT Flow (B73-300 - as trained)

(checklist items are marked*)

*

*

Forward Overhead

Forward Overhead

*

*

*

*

*

Mode Control Panel

*

*

Mode Control Panel

*

*

*

First Officer

Instrument

Captain

Instrument

*

Center Instrument

Center Instrument

*

*

Captain

Instrument

First Officer

Instrument

*

*

*

*

Forward Electronic

Forward Electronic

*

*

Control

Stand

Control

Stand

*

*

*

*

Aft

Electronic

*

Aft

Electronic

*

*

*

Logbook/Gear Pins

Logbook/Gear Pins

vulnerabilities of automatic processing
Vulnerabilities of Automatic Processing
  • If procedural flow is interrupted, chain is broken.
    • Pause prevents one step from triggering the next.
  • Initiation of automatic process depends on receiving signal or noticing a cue in the cockpit environment.
    • If signal does not occur, individual is not prompted to initiate procedure.
vulnerabilities of automatic processing26
Vulnerabilities of Automatic Processing
  • If procedural flow is interrupted, chain is broken.
    • Pause prevents one step from triggering the next.
  • Initiation of automatic process depends on receiving signal or noticing a cue in the cockpit environment.
    • If signal does not occur, individual is not prompted to initiate procedure.
  • Highly practiced procedures and checklists tend to develop “look without seeing” automatic responses.
  • High workload and/or rushing prevent conscious supervision of automatic processes--exacerbates vulnerability
vulnerability to errors of omission can be reduced
Vulnerability to Errors of Omission Can Be Reduced

1) Actions airline operations and training  departments can take

2) Actions individual pilots can take

ways airlines can reduce vulnerabilities
Ways Airlines Can Reduce Vulnerabilities
  • Analyze actual line ops write procedures to minimize opportunities for disruptions.
  • Avoid “floating” procedural items allowed to be performed at varying times.
    • Anchor critical items (e.g., setting takeoff flaps) to distinct step that cannot be forgotten (e.g., before start of taxi).
ways airlines can reduce vulnerabilities29
Ways Airlines Can Reduce Vulnerabilities
  • Analyze actual line ops write procedures to minimize opportunities for disruptions.
  • Avoid “floating” procedural items allowed to be performed at varying times.
    • Anchor critical items (e.g., setting takeoff flaps) to distinct step that cannot be forgotten (e.g., before start of taxi).
  • Analyze actual fleet “norms” for how checklists are executed and bottom-lines observed.
    • LOSA
  • Train with realistic concurrent task demands.
ways pilots can reduce vulnerability
Ways Pilots Can Reduce Vulnerability
  • Being aware of vulnerability reduces threat.
    • Especially vulnerable when head-down, communicating, searching for traffic, or managing abnormals.
  • When interrupted or deferring a task:
    • Pause to encode intention to resume
    • Create conspicuous cue as reminder (e.g. checklist in throttle quadrant)
  • Develop habit of deliberate execution of procedures and checklists to allow controlled supervision of habitual responses.
  • Avoid rushing.
ways pilots can reduce vulnerability31
Ways Pilots Can Reduce Vulnerability
  • Being aware of vulnerability reduces threat.
    • Especially vulnerable when head-down, communicating, searching for traffic, or managing abnormals.
  • When interrupted or deferring a task:
    • Pause to encode intention to resume
    • Create conspicuous cue as reminder (e.g. checklist in throttle quadrant)
  • Develop habit of deliberate execution of procedures and checklists to allow controlled supervision of habitual responses.
  • Avoid rushing.
  • Pause at critical junctures to review.
  • Schedule/reschedule activities to minimize concurrent task demands (e.g., brief before TOD).
  • Treat monitoring as essential task (Sumwalt).
slide32
For further information:

http://human-factors.arc.nasa.gov/ihs/flightcognition/

This work is supported by NASA’s Airspace Systems Program and by the FAA (AFS-230), Dr. Eleana Edens, program manager.