Human factors - Error management in Aviation

Error Management

Failure to follow procedures is not uncommon in incidents and accidents related to both flight operations and maintenance procedures. However, the industry lacks insight into why such errors occur. To date, the industry has not had a systematic and consistent tool for investigating such incidents. To improve this situation, Boeing has developed human factors tools to help understand why the errors occur and develop suggestions for systematic improvements.
Two of the tools operate on the philosophy that when airline personnel (either flight crews or mechanics) make errors, contributing factors in the work environment are part of the causal chain. To prevent such errors in the future, those contributing factors must be identified and, where possible, eliminated or mitigated.

The tools are

Procedural Event Analysis Tool.
Maintenance Error Decision Aid.

Procedural Event Analysis Tool (PEAT)

This tool, for which training began in mid-1999, is an analytic tool created to help the airline industry effectively manage the risks associated with flight crew procedural deviations. PEAT assumes that there are reasons why the flight crew member failed to follow a procedure or made an error and that the error was not intentional. Based on this assumption, a trained investigator interviews the flight crew to collect detailed information about the procedural deviation and the contributing factors associated with it. This detailed information is then entered into a database for further analysis. PEAT is the first industry tool to focus on procedurally related incident investigations in a consistent and structured manner so that effective remedies can be developed.

Maintenance Error Decision Aid (MEDA)

This tool began as an effort to collect more information about maintenance errors. It developed into a project to provide maintenance organizations with a standardized process for analyzing contributing factors to errors and developing possible corrective actions (see “Boeing Introduces MEDA” in Airliner magazine, April–June 1996, and “Human Factors Process for Reducing Maintenance Errors” in Aero no. 3, October 1998). MEDA is intended to help airlines shift from blaming maintenance personnel for making errors to systematically investigating and understanding contributing causes. As with PEAT, MEDA is based on the philosophy that errors result from a series of related factors. In maintenance practices, those factors typically include misleading or incorrect information, design issues, inadequate communication, and time pressure. Boeing maintenance human factors experts worked with industry maintenance personnel to develop the MEDA process. Once developed, the process was tested with eight operators under a contract with the U.S. Federal Aviation Administration. Since the inception of MEDA in 1996, the Boeing maintenance human factors group has provided on-site implementation support to more than 100 organizations around the world. A variety of operators have witnessed substantial safety improvements, and some have also experienced significant economic benefits because of reduced maintenance errors.

Three other tools that assist in managing error are
• Crew information requirements analysis.
• Training aids.
• Improved use of automation

Crew information requirements analysis (CIRA)

Boeing developed the CIRA process to better understand how flight crews use the data and cues they are given. It provides a way to analyze how crews acquire, interpret, and integrate data into information upon which to base their actions. CIRA helps Boeing understand how the crew arrived or failed to arrive at an understanding of events. Since it was developed in the mid-1990s, CIRA has been applied internally in safety analyses supporting airplane design, accident and incident analyses, and research.

Training aids

Boeing has applied its human factors expertise to help develop training aids to improve flight safety. An example is the company’s participation with the aviation industry on a takeoff safety training aid to address rejected takeoff runway accidents and incidents. Boeing proposed and led a training tool effort with participation from line pilots in the industry. The team designed and conducted scientifically based simulator studies to determine whether the proposed training aid would be effective in helping crews cope with this safety issue. Similarly, the controlled flight into terrain training aid resulted from a joint effort by flight crew training instructor pilots, human factors engineering, and aerodynamics engineering.

Improved use of automation

Both human factors scientists and flight crews have reported that flight crews can become confused about the state of advanced automation, such as the autopilot, auto throttle, and flight management computer. This condition is often referred to as decreased mode awareness. It is a fact not only in aviation but also in today’s computerized offices, where personal computers sometimes respond to a human input in an unexpected manner. The Boeing Human Factors organization is involved in a number of activities to further reduce or eliminate automation surprises and to ensure more complete mode awareness by flight crews. The primary approach is to better communicate the automated system principles, better understand flight crew use of automated systems, and systematically document skilled flight crew strategies for using automation. Boeing is conducting these activities in cooperation with scientists from the U.S. National Aeronautics and Space Administration. When complete, Boeing will use the results to improve future designs of the crewmember-automation interface and to make flight crew training more effective and efficient.

References

1. DEITZ S R, THOMAS W E & QUORUM (1991). Pilots, Personality and Performance: Human behavior & Stress in the Skies.

2. ORLADY H W & ORLADY L W (1999). Human factors in Multi-crew flight operations.

3. FSA (1999). Propulsion System Malfunction and Inappropriate Crew Response. Retrieved from Flight safety foundation on 28 October 2011.

4. TROLLIP S R & JENSEN R S (1991). Human factors in general aviation.