faa research briefing

7/30/2019 FAA Research Briefing

1/30

University of Texas

FAA Research Briefing

Robert HelmreichJames Klinect

Michelle Harper

Department of Psychology

The University of Texas at Austin

Washington, 3 March 2004


2/30

UT Human Factors Research Project

Studies individual / crew performance in demandingprofessions; influence of system and organizational factors

The research team: Robert Helmreich, PhD, FRAeSProject Director

James Klinect

LOSA Project Coordinator

Michelle Harper, MSASAP Project Coordinator

Ashleigh Merritt, PhDResearch Scientist

Chris Henry - Researcher

Lou Montgomery - Research Assistant


3/30

Aviation Safety EnvelopeAccidents

Incidents

Normal Operations

Accident Investigation

LOSA

FOQA

ASAP

Good News

1. All areas of the envelope can beinvestigated

2. Strong airline buy-in

Bad News

1. Airlines overwhelmed with data

2. Lessons learned kept within each airline

3. Multiple data sources not integrated


4/30

Bad News: Issues and Solutions

Airlines overwhelmed with data Solution: Airlines need help collecting / analyzing data

Lessons learned kept within each airline Solution: Third party conducts industry level analyses

Multiple data sources not integrated Solution: A common conceptual framework


5/30

Threat and Error Management (TEM)

TEM providesa common frameworkfor studying flight crewperformance and the operating environment

Multiple uses of TEM

Data collection, analysis and feedback

LOSA

ASAP

Incident / Accident analysis (IATA)

Pilot training and evaluation

Curriculum development

Line checks

Licensing (ICAO)


6/30

Threat and Error Management Model

Threat Management

Successful(Inconsequential)

Incident orAccident

Error Management

UndesiredAircraft States

Error(Threat Induced)

Error(Spontaneous)

Undesired AircraftState Management

Latent Threats Active Threats


7/30

Line Operations Safety Audit(LOSA)


8/30

Aviation Safety Envelope: LOSAAccidents

Incidents

Normal Operations

LOSA


9/30

LOSA Archive

AeroMexico

Alaska Airlines

Air New Zealand 98, 03

Braathens ASA

Cathay Pacific

China Airlines

Continental 96, 98, 00, 04 Continental Express

Continental Micronesia

Delta Airlines

EVA AIR

Frontier Airlines

QANTAS

Singapore Airlines

Silk Air

UNI AIR US Airways

Since 1996 - 21 LOSAs, all TEM-based; Archive now has3000+ observations

Most foreign carriers code share with US airlines


10/30

LOSA Data

% of flights with one ormore threats % of threats that weremismanaged

All Threats 92% 12%

ATC Threats 47% 28%

% of flights% of errors / UAS

mismanaged

Errors 71% 28%


29% 3%


11/30

LOSA Drivers

1) UTHFs reputation in the industry2) TEMs intuitive appeal

3) Airline success stories (Continental 1996-2000)

4) ICAO Formalized LOSA as best practice Sponsored LOSA weeks (Hong Kong, Panama, Dubai and

Dublin)

ICAO Document 9803 (LOSA)

5) Pilot association endorsements ALPA and IFALPA

6) The LOSA Collaborative


12/30

LOSA: Research Plan 2004-2007

1) Concepts: Refine and expand the role of TEM

2) Method: Disseminate LOSA tools and techniques to industry

3) Research: Conduct industry level analyses of the LOSA data archive

4) Communication: Distribute findings to airlines, regulators and industry

5) Data Sharing: Develop a proof of concept for LOSA / ASAP integration


13/30

Aviation Safety Action Program(ASAP)


14/30

Aviation Safety Envelope: ASAPAccidents

Incidents

Normal Operations

Accidents

Incidents

Normal Operations

ASAP


15/30

UTHF/ASAP Demonstration ProgramASAP Support Tools Development

Developing a set of tools to aid airlines in the collection,categorization and analysis of ASAP data

1) Pilot reporting form

2) ASAP manager tool kit

3) Event Review Committee (ERC) review forms

All tools internet based

Tools based on TEM Tools feed into internal airline-housed database


16/30

UTHF / ASAP Demonstration ProgramMethodology

Participating airlines Continental Frontier Northwest

In return for support UTHF given access to airline housed ASAP data

UTHF server to airline server communication

High-speed, encrypted, intranet access

Benefits of UTHF server to Airline server access

Data Protection - Data confidentiality protected Data Sharing Ability to query data from multiple ASAP databases

Cost Sharing - Tools developed by UTHF / Maintained and supported by

airline


17/30

1) Method: Develop ASAP data collection, categorization and analysistools

2) Research: Complete industry-level analyses of threat and error

profiles, high risk events, system level factors, and intervention

strategies

3) Communication: Distribute findings to airlines, regulators and

industry

4) Data Sharing: Develop a proof of concept for LOSA / ASAP

integration

ASAP: Research Plan 2004-2007


18/30

Summary


19/30

Issues and UTHF Strategies

Airlines overwhelmed with data

Provide LOSA and UTHF ASAP implementation andanalysis tools to industry

Lessons learned kept within each airline

UTHFs unique access to LOSA and ASAP data willenable industry level analysis and feedback

Multiple data sources not integrated Apply TEM as a framework for linking normal

operations, incident and accident data


20/30

The University of Texas

Human Factors Research Project

www.psy.utexas.edu/HumanFactors
http://www.psy.utexas.edu/HumanFactorshttp://www.psy.utexas.edu/HumanFactors


21/30

Supplementary Slides

Threat and Error ManagementDefinitions and Example


22/30

Threat and Error Management Model

Threat Management

Successful(Inconsequential) Incident orAccident

Error Management


Error(Threat Induced)

Error(Spontaneous)

Undesired AircraftState Management

Latent Threats Active Threats


23/30

Latent Threats

Aspects of the system that predispose the commission oferrors or can lead to undesired aircraft states

ATC practices

Organizational, national, professional culture

Aircraft characteristics Qualification standards

Regulatory practices and oversight

Flawed procedures

Scheduling and rostering practices


24/30

Active Threats

1. Environmental Threats

Adverse WX

Terrain

Airport Conditions Heavy traffic / TCAS events

2. ATC Threats

Command events / errors

Language difficulties

3. Aircraft Threats

Malfunctions

Automation events

4. Crew Support Threats

Dispatch events / errors

Ground events / errors

MX events / errors

5. Operational Threats Time Pressures

Irregular Operations

Radio congestion / poor

reception

6. Cabin Threats Cabin events / FA errors

Events or errors that originate outside the influence of the flight

crew but require their attention to maintain safety


25/30

Errors

Intentional Noncompliance intentional deviations from SOP

Ex) Performing a checklist from memory

Procedural Followed procedures with incorrect executionEx) Wrong attitude setting dialed

Communication Missing information or misinterpretation

Ex) Miscommunication with ATC

Decision Crew decision unbounded by procedures thatunnecessarily increased risk

Ex) Unnecessary navigation through adverse weather

A threat-induced or spontaneous deviation from organizational

or flight crew expectations


26/30

Undesired Aircraft States

Lateral deviation

Vertical deviation

Speed too high

Speed too low

Incorrect aircraft configurations

Flight controls Systems

Fuel

Automation

Unstable approach

Abrupt aircraft control

Long landing

Firm landing

Wrong taxiway / ramp

Wrong runway

Runway incursion

A threat or error-induced state in which the aircraft is placed in

a compromised situation that increases risk to safety


27/30

Sample TEM Exercise

Takeoff / ClimbDuring climb, the crew discovered that a fuel

pump low pressure light was illuminated. All crewmembers were

working the problem when ATC instructed them climb to FL350. The

First Officer (PNF) read back FL350 but failed to make the change in

the MCP. The crew also failed to cross-verify the altitude change in

the MCP. After a few moments, ATC noticed that the aircraft

remained at FL270 and called the crew to correct the problem.


28/30

Example: Threats

Threat Aircraft Fuel pump low pressure light

Threat management Mismanaged because the crew got distracted and

failed to set the correct altitude led to a verticaldeviation


29/30

Example: Errors

Error #1 Procedural Crew failed to dial the correct altitude in

the MCP as requested by ATC.

Error #2 Procedural Crew failed to cross-verify the altitude

change per altitude awareness SOP.

Error management Mismanaged because the crew failed to detect their

errors due to be being distracted by the fuel pumplow pressure light issue


30/30

Example: Undesired Aircraft States

Undesired Aircraft State Vertical deviation aircraft remained level after ATC

instructed the crew to climb

Undesired Aircraft State Management Mismanaged by the crew since the errors that led to

the vertical deviation were undetected

Managed by ATC with a callback to the crew

instructing them to climb

faa research briefing

Documents