Decision Errors in the Cockpit

In flight operations, pilots are confronted with many problems that occur in continually changing situations that create a level of stress and lead to accidents. To make rapid decisions, pilots make decisions using a holistic process involving situation recognition and pattern matching. This research investigated 157 pilots from a B747 fleet to find out how pilots make in-flight decision in such stressful situations. The research method is based upon evaluating the situational awareness, risk management, response time and applicability of four different decision-making mnemonics in six in-flight scenarios. The data obtained in this research suggests that the FOR-DEC may be suitable as a basis for providing training which will be applicable for covering all basic types of decision. FOR-DEC was evaluated as the most applicable mnemonic-based decision making process across the six different scenarios used. It also had significantly superior performance compared with the other three mnemonic-based methods evaluated (SHOR, PASS & DESIDE) when making recognition-primed decisions, response selection decisions, non-diagnostic procedural decisions, and problem-solving decisions.

1979

Journal of aeronautics, astronautics and aviation, Series A, 2014

Operating a high-technology commercial airliner is not only an issue in psychomotor skill performance but also of a real-time decision-making involving situation awareness and risk management within a limited-time condition. The number of aircraft accidents attributable solely to mechanical failures has decreased markedly in recent years, but the contribution of human error has declined at a much slower rate. Previous research demonstrated a belief rule-based decision support system has provided more reliable and informative performance after training. The purpose of this research was to identify the best mnemonic-based method of decision support systems for improving commercial pilot's performance in the advanced cockpit. A total of 157 airline pilots, all qualified on the Boeing 747-400 evaluated the suitability of four different ADM methods: SHOR (Stimuli, Hypotheses, Options, Response); PASS (Problem identification, Acquire information, Survey strategy, Select strategy); FOR...

2015

The objective of this study is to analyse pilots' decision-making behaviour in terms of naturalistic decision-making. In line with the highly experienced group of pilots (n = 120), recognition-primed decisions are expected to dominate. In a full-flight simulator experiment, with two groups of pilots (short-haul and long-haul pilots) with different levels of practice and training, we were able to show that only about one-third of the pilots make recognition-primed decisions. Results may indicate that the current training practice helps pilots to handle foreseeable problems very well, yet does not support pilots in ambivalent and new decision-making situations. Based on these findings, we recommend the incorporation of more unforeseen events in recurrent training simulator missions to train pilots in handling unknown situations.

2010

Aeronautical decision-making (ADM) is defined by the FAA (1991) as 'a systematic approach to the mental process used by aircraft pilots to consistently determine the best course of action in response to a given set of circumstances'. found that decision errors contributed to 35% of all nonfatal and 52% of all fatal general aviation accidents in the United States. proposed that decision errors contributed to 56% of airline accidents and 53% of military accidents. This research analyzes 51 accident reports obtained from ROC Aviation Safety Council (ASC) published between 1999 and 2008. Each accident report was independently analyzed using the Human Factors Analysis and Classification System (HFACS) framework (Weigmann and Shappell, 2003). The presence or the absence of each HFACS category was evaluated from the narrative of each accident report. Statistical relationships linking fallible decisions in upper management were found to directly affect supervisory practices, thereby creating the psychological preconditions for unsafe acts and hence indirectly impairing the performance of pilots' decision-making. It was observed that 68% of accidents in this sample included a decision error. The results show clearly defined, statistically-described paths with pre-cursors to decision errors at both the immediately adjacent and also higher levels in the organization. This study provides an understanding, based upon empirical evidence, of how actions and decisions at higher managerial levels in the operation of commercial aircraft result in decision errors on the flight deck and subsequent accidents. To reduce the accident rate resulting from decision errors in flight operations the 'paths to failure' relating to these organizational and human factors issues must be addressed.

Digital Avionics Systems Conference, …, 2002

Cognitive theory is presented that has relevance for the definition and assessment of situational awareness in the cockpit. The theory asserts that maintenance of situation awareness is a constructive process that demands mental resources in competition with ongoing task performance. Implications of this perspective for assessing and improving situational awareness are discussed.

2015

The majority of aviation accidents are still attributed to human error, with flight crew actions accounting for the majority of these mishaps. The Federal Aviation Administration (FAA) has identified 12 behavioral traps that can ensnare even experienced pilots. This study examined the FAA-defined behavioral traps and the regularity with which they occurred in flight crew related accidents. The top three traps were Neglect of Flight Planning, Preflight Inspection, and Checklists; Loss of Positional or Situational Awareness; and Getting Behind the Aircraft, which were found in 72%, 61%, and 48% of aviation accidents, respectively. The results showed the contributing factors of training inadequacies/lack of Crew Resource Management, night, and low ceiling and/or visibility compounded the effects of the unsafe attitudes. These conditions were found in 48%, 46%, and 42% of accidents, respectively. Approximately three out of four aviation accidents result from human error (FAA, 2009). The FAA uses studies in human behavior in an effort to reduce human error in aviation accidents. Flying consists of decision making activities, some of which are routine, others more complex. Effective aeronautical decision making (ADM) is essential to flight safety. The first two steps of ADM are "(1) identifying personal attitudes hazardous to safe flight and (2) learning behavior modification techniques" (FAA, 2009, p. 5-3).

Applied Ergonomics

In this article, we analyse flight crew response to an in-flight powerplant system malfunction (PSM) using control task analysis. We demonstrate the application of the decision ladder template and the skills, rules, and knowledge (SRK) framework to this new area of inquiry. Despite the high reliability of turbofan engines, accidents and incidents involving PSM still occur. During these unusual events, flight crew have not always responded appropriately, leading to a reduction in safety margins or disruption of operations. This article proposes recommendations for technological and information system that can support flight crew in responding safely and appropriately to a PSM. These recommendations focus on new ways in which information from engine health monitoring system and other sources of data can be utilised and displayed. Firstly, we conducted knowledge elicitation using Critical Decision Method (CDM) interviews with airline pilots who have experienced real or simulated PSM events. We then developed generic decision ladders using the interview data, operations manual, training manual, and other guideline documents. The generic decision ladders characterise the different stages of responding to PSM identified as part of the research. These stages include: regaining and maintaining control of aircraft, identifying PSM and selecting appropriate checklists to secure the engine, and modifying the flight plan. Using the decision ladders and insights from the CDM interviews, we were able to identify cognitive processes and states that are more prone to error and therefore more likely to generate an inappropriate response. Using the SRK framework, we propose design recommendations for technological and information systems to minimise the likelihood of such inappropriate response. We conclude that this combination of methods provides a structured and reliable approach to identifying system improvements in complex and dynamic work situations. Our specific contributions are the application of these techniques in the unrepresented area of flight operations, and the development of evidence-based design recommendations to improve flight crew response to in-flight powerplant system malfunctions.

Lecture Notes in Computer Science, 2010

This paper presents a cognitive modelling approach to predict pilot errors and error recovery during the interaction with aircraft cockpit systems. The model allows execution of flight procedures in a virtual simulation environment and production of simulation traces. We present traces for the interaction with a future Flight Management System that show in detail the dependencies of two cognitive error production mechanisms that are integrated in the model: Learned Carelessness and Cognitive Lockup. The traces provide a basis for later comparison with human data in order to validate the model. The ultimate goal of the work is to apply the model within a method for the analysis of human errors to support human centred design of cockpit systems. As an example we analyze the perception of automatic flight mode changes.

Aircrew decision making is one central element of the CRM-training course for cockpit crews which was developed recently by the DLR-Department of Aviation and Space Psychology in cooperation with Lufthansa German Airlines and Condor. Examples of the course contents and methods are illustrated. As a framework for the training units of aircrew decision making the FOR-DEC model is proposed. FOR-DEC is an acronym which stands for six different phases of the decision making process: Facts, Options, Risks & Benefits, Decision, Execution and Check. The paper describes how this model is integrated into the training units on team problem solving and decision making. First evaluation results of the course are shown which are based on the seminar critiques of 750 participants. These feedbacks are very positive in regard to the overall relevance of the course contents and methods. However, they also indicate the importance of authentic in-house scenarios for the effectiveness of the seminar processes.