Taming Human Error with a Systems Approach

1
Taming Human Errorwith a Systems Approach

• Hazel Courteney
• UK CAA

2
The Pilot connects different elements of the
aviation system
3
This represents dis-integration
4
(No Transcript)
5
ATC - Operations

• Controllers need to understand the increase in
  workload that is placed on a 2-man crew using an
  FMC when giving restrictions and holding
  instructions off of a fix not on their route.
  FAA

6
ATC - Operations

• I do not believe that ATC controllers understand
  the operation of computer driven aircraft. We
  are plagued with late clearances, frequent
  changesAlso it would be nice if the center used
  the enroute waypoints instead of giving us
  mileage points these simple changes to procedure
  would help cut out workload so we could keep our
  heads out of the cockpit and still use the
  computer FAA

7
Design - ATC

• In busy ATC environments, especially in the USA,
  the anticipated arrival/descent routing is very
  often changed. This results in several
  reprogramming operations, often at a time of high
  crew workload which can distract from the main
  task of flying the aircraft safely.
•  

8
Design - ATC

• If a height restriction is programmed in for a
  descent and the aircraft is subsequently cleared
  to a more distant waypoint, even if abeam
  waypoint is selected, the height restriction
  falls out. This is incredibly irritating and
  very time consuming. It also destroys the VNAV
  profile as a whole load of power comes on as the
  aircraft thinks it is now low and by the time the
  restriction is re-programmed the VNAV profile is
  irrecoverable.
•  

9
Design - Operations

• Lack of appreciation of relationship between
  company supplied profile and LEGS set up.
   Also.During set up, the scratch pad often
  gives prompts at the wrong time.
• Training limited. I believe that most
  individuals learn from their mistakes online.
• Many of the irritations of FMS could be solved
  with a higher speed processor - a 10 second
  standby one allows the aircraft to travel in
  excess of 1 mile!

10
Design - Operations

• Switching from one runway to its parallel
  partner very close in. Once the aircraft has
  acquired LOC G/S, this can only be achieved at
  the expense of disengaging the autopilot and
  switching off the flight directors. This is a
  real design fault, especially at somewhere like
  LAX (4 // runways) (Not unknown to have been
  switched across all 4!).

11
Number of Problems per Accident
12
Conclusions

• Direct Human Factors issues affecting crew
  performance include aircraft design, CRM, FTL,
  ATM procedures, airports
• Meta Human Factors refers to the level of
  integration between general areas of the aviation
  system
• Dis-integration of the overall aviation
  environment can strain all human elements
  including pilots.