Investigations of Carrier Flight Team Blunder Administration

Presentation Transcript



Explorations of Airline Flight Crew Error Management The University of Texas at Austin March 4, 1999

Line Operations Safety Audit Systematic perceptions of group execution Team of spectators from the carrier and U.T. Non-peril Union upheld Measures: CRM - behavioral markers and group execution Threat - outside dangers Error - cockpit blunders SOP - consistence Interview - Informal criticism from the teams about flight operations and preparing

The LOSA Error Database 1. Universal Major - 59 groups on 91 flights International and local flights - South Pacific and Pacific Rim 2. U.S. Major - 65 groups on 102 flights Only universal flights - Central and South America 3. U.S. Local - 60 groups on 121 flights Experienced Captains with unpracticed First Officers (under 4 years in flying and short of what one year in position)

Expected Events and Risks Unexpected Events and Risks External Error External Threats Crew-Based Errors Internal Threats Threat Recognition and Error Avoidance Behaviors CRM Behaviors Error Detection and Response Behaviors A Safer Flight Recovery to A Safer Flight Additional Error Outcomes Incidents/Accident

Threat Management

External Events External Errors System Defenses Crew Threat Recognition and Error Avoidance Behaviors Crew Error Detection and Management Behaviors Incident/Accident The Rain of Threats

External Events Adverse climate ATC summon Terrain Aircraft frameworks glitch Maintenance occasion Dispatch occasion Ground taking care of occasion Cabin occasion Airport conditions Operational pressure External Errors Maintenance mistake Dispatch blunder ATC mistake Ground team mistake Cabin group blunder Threats increment the level of hazard to security

A Heavy Rain of Threat On one flight perception, 1. Late arriving air ship 2. Conflicting fuel slips 3. Weight limitation on takeoff 4. Climate and substantial activity on departure 5. Toilet smoke caution amid voyage 6. Climate and substantial movement on landing 7. ATC trained a runway change in late last

Threat Results 72% of the flights had at least one dangers From 0 to 10 outer dangers for every flight Average of 2 dangers for each flight

Threats by Phase of Flight Threats most oftentimes happen amid preflight and approach

Most Common Threats 1. Antagonistic climate - 20% of all flights 2. Air ship breakdowns - 12% 3. ATC occasion - 10% 4. Outer mistakes (ATC, Maintenance, Cabin, Dispatch, and Ground Crew) - 8% 5. Operational weights - 8%

Threats Profile Airlines and Fleets - An Example from One Airline Narrow body operations were undermined more by climate/twist 69% of flight portions versus 49% of wide body flights were debilitated more by landscape 23% of flight sections versus 2% of wide body flights were less debilitated via flying machine abnormals 18% of flight fragments versus 67% of wide body flights

Threat Recognition and Error Avoidance Behaviors that groups used to perceive dangers and maintain a strategic distance from mistake 1. Dynamic Captain authority 2. Cautiousness 3. Operational arranges plainly expressed and recognized 4. Remaining on the ball 5. Taking after SOP

Error Management

External Events External Errors System Defenses Crew Threat Recognition and Error Avoidance Behaviors Flightcrew Errors Crew Error Detection and Management Behaviors Incident/Accident The Other Piece: Flightcrew Errors

Flightcrew Errors Can be activated by an outside risk or happen in detachment Flightcrew blunder definition - an activity or inaction that prompts to a deviation from group or authoritative aims or desires

A Model of Error Management

Intentional Noncompliance Procedural Communication Proficiency Operational Decision Error Types

Error Types 1. Purposeful Noncompliance - infringement ex.) Omitted required briefings Performing agendas from memory Failure to cross-confirm settings 2. Procedural - took after strategies however wrong execution ex.) Lever and switch settings Wrong elevation dialed Wrong MCP mode executed

Error Types 3. Correspondence - Misinterpretation or missing data amid a trade ex.) Wrong readbacks to ATC Missed ATC calls Wrong runway conveyed 4. Capability - absence of information or expertise mistake ex.) Lack of stick and rudder capability Lack of learning with mechanization Lack of information with techniques

Error Types 5. Operational Decision - optional choice not secured by methodology that pointlessly expanded hazard ex.) Over-dependence on robotization Unnecessary low move on approach Unnecessary route through unfavorable climate

Intentional Noncompliance Procedural Communication Proficiency Operational Decision Error Types Trap Exacerbate Fail to Respond Error Responses

Error Responses Trap - mistake is recognized and oversaw before it gets to be noteworthy (undesired state or extra blunder) Exacerbate - blunder is identified however the group's activity or inaction gets to be weighty Fail to Respond - absence of a reaction to a blunder (undetected or disregarded) that can either wind up being irrelevant or important

Intentional Noncompliance Procedural Communication Proficiency Operational Decision Error Types Trap Exacerbate Fail to Respond Error Responses Error Outcomes Inconsequential Undesired State Additional Error

Lateral deviation - heading Vertical deviation - elevation Speed to high or low Unstable approach Near miss Fuel level underneath essentials Vertical deviation on the G.S. Long landing Hard Landing off centerline Wrong runway or incline Wrong runway Wrong airplane terminal Wrong nation Undesired States Undesired air ship states are deviations from ordinary flight that superfluously bargains security

Crew-Based Accident Intentional Noncompliance Procedural Communication Proficiency Operational Decision Error Types Trap Exacerbate Fail to Respond Error Responses Error Outcomes Inconsequential Undesired State Additional Error Undesired State Responses Mitigate Additional Error

Flightcrew Error Results 72% of the teams submitted no less than one blunder 65% of the flights had at least one mistakes From 0 to 14 blunders for every flight Averaged 2 mistakes for each flight There were between and inside armada contrasts

Consequential means prompting to an undesired state or extra blunder Errors by Phase of Flight

Error Frequencies and Consequences

Most Common Errors 1. Computerized frameworks blunders (MCP and FMC) - 21% of all flights Failure to cross-check settings Wrong MCP or FMC settings Other Intentional resistance mistakes 2. Agenda blunders - 20% Checklist performed from memory Nonstandard agenda utilization Self-performed agenda Procedural agenda mistakes

Most Common Errors 3. Sterile cockpit infringement - 10% 4. ATC mistakes - 6% Missed ATC calls Omitted data (readbacks or call signs) Accepting ATC guidelines that pointlessly expanded hazard Procedural ATC blunders 5. Instructions blunders (excluded or deficient) - 5%

Proficiency and Operational Decision mistakes are the most hard to oversee Error Management Results

Undesired State Results Responses to Undesired States 75% are relieved 9% prompt to extra mistakes 16% required no team reaction

Error Detection and Management Behaviors that groups used to recognize and oversee mistakes 1. Dynamic chief administration 2. Environment set for open correspondences 3. Group individuals making inquiries and talking up 4. Cautiousness 5. Prioritization of errands to oversee workload 6. Screen and Cross-Check 7. Registration teach

Between-Airline Differences

Average Number of Errors Per Flight Segment

Types of team mistakes profile armadas - case from one aircraft

Violations matter 40% of mishaps in worldwide deadly mischance database had infringement Flight Safety Foundation: Approach and Landing Accident Reduction Task Force Report R. Khatwa & R. Helmreich November, 1998

Culture and infringement Cross-social research demonstrates that American pilots are minimum tolerating of the need to agree to SOPs. Helmreich & Merritt (1998)

Violations as the Norm One spectator noticed the accompanying amid the U.S. Provincial review on an IOE ride, " The Check Airman ran the whole taxi agenda by memory ." Organizations can't permit infringement to standardize Why? - Crews that confer no less than one deliberate rebelliousness mistake will probably submit different sorts of blunder than those without a purposeful resistance mistake

CRM Countermeasures to Error Bryan's most recent investigations

CRM educational modules - recurrent Basic CRM issues are general The Devil is in the detail Enormous hierarchical and armada contrasts in blunder and danger Recurrent preparing ought to be exceedingly particular to association with concentrate on armada or operation issues, for example, global flying Risk of institutionalized educational programs is to disregard neighborhood issues

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