human errors that contribute to altitude deviations altitude busts: the view from atc & the...
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Human Errors that Contribute toHuman Errors that Contribute toAltitude DeviationsAltitude Deviations
Altitude Busts:Altitude Busts:
The View from ATC & the Flight DeckThe View from ATC & the Flight Deck
Royal Aeronautical SocietyRoyal Aeronautical Society
London Guildhall UniversityLondon Guildhall University
May 15, 1998May 15, 1998
Captain David A. Simmon (Ret)Captain David A. Simmon (Ret)
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OVERVIEWOVERVIEW
Human errorHuman error
Cali B-757 accidentCali B-757 accident
Error analysisError analysis
SummarySummary
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HUMAN ERRORHUMAN ERROR
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HUMAN ERRORHUMAN ERROR
““MAN - A creature that was created at the MAN - A creature that was created at the end of the week when God was very tired.”end of the week when God was very tired.”
Mark TwainMark Twain
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ARENAS OF POTENTIAL HUMAN ERRORARENAS OF POTENTIAL HUMAN ERROR.
Medi um Man
Machi ne
a
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HUMAN ERROR PRINCIPLESHUMAN ERROR PRINCIPLES
Applicable to everyoneApplicable to everyone
Separate error from consequences or blameSeparate error from consequences or blame
Develop a scientific understanding of errorDevelop a scientific understanding of error
Identify & adopt coping skills & strategiesIdentify & adopt coping skills & strategies
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TULUA
117.7 ULQ
115.5 CLOCALI
ROZO
274 R
6
AAL Flight 965AAL Flight 965Cali, ColombiaCali, ColombiaDecember 20, 1995December 20, 1995
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CALI ERRORSCALI ERRORS
1. Crew read back wrong transponder code1. Crew read back wrong transponder code
2. ATC did not pass on flight information to Cali2. ATC did not pass on flight information to Cali
3. Adequate approach review not accomplished3. Adequate approach review not accomplished
4. Adequate approach briefing not accomplished4. Adequate approach briefing not accomplished
5. Descent checklist not accomplished5. Descent checklist not accomplished
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CALI ERRORSCALI ERRORS
6. Tulua estimate not given to ATC6. Tulua estimate not given to ATC
7. ATC issued ambiguous clearance to Cali7. ATC issued ambiguous clearance to Cali
8. Route changed without PF concurrence8. Route changed without PF concurrence
9. Ambiguous clearance to Cali not clarified9. Ambiguous clearance to Cali not clarified
10. ATC gave incorrect clarifying response10. ATC gave incorrect clarifying response
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CALI ERRORSCALI ERRORS
11. Accepted rushed approach to runway 19 11. Accepted rushed approach to runway 19
12. ATC did not issue approach altitude12. ATC did not issue approach altitude
13. Ambiguous clearance altitude not clarified13. Ambiguous clearance altitude not clarified
14. Requested improper clearance to Rozo14. Requested improper clearance to Rozo
15. ATC’s response was incorrect15. ATC’s response was incorrect
16. Ambiguous clearance to Rozo not clarified16. Ambiguous clearance to Rozo not clarified
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CALI ERRORSCALI ERRORS
17. Select Desired WPT screen difficult to use17. Select Desired WPT screen difficult to use
18. Latitude/longitude not verified18. Latitude/longitude not verified
19. Charted & FMS data bases were different19. Charted & FMS data bases were different
20. New path to “R” not verified on map20. New path to “R” not verified on map
21. New path not confirmed by pilot-flying21. New path not confirmed by pilot-flying
22. Did not detect A/C deviation from course22. Did not detect A/C deviation from course
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CALI ERRORSCALI ERRORS
23. # 1 VHF NAV receiver was mistuned23. # 1 VHF NAV receiver was mistuned
24. Approach was not discontinued24. Approach was not discontinued
25. Left 15K before on approach segment25. Left 15K before on approach segment
26. Failed to report leaving 15,000 feet26. Failed to report leaving 15,000 feet
27. Autothrottle not disengaged after GPWS27. Autothrottle not disengaged after GPWS
28. Speedbrakes not retracted28. Speedbrakes not retracted
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ERROR ANALYSISERROR ANALYSIS
Flight Crew - 21/28 (75%)Flight Crew - 21/28 (75%)
ATC - 5/28 (18%)ATC - 5/28 (18%)
Design - 2/28 (7%)Design - 2/28 (7%)
Management - ?Management - ?
National Regulatory Authority - ?National Regulatory Authority - ?
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ERROR ANALYSISERROR ANALYSIS
Lapses - 5 ( 18%)Lapses - 5 ( 18%)
Slips - 3 ( 11%)Slips - 3 ( 11%)
Knowledge bases mistakes - 16 ( 57%)Knowledge bases mistakes - 16 ( 57%)
Rule based mistakes - 4 ( 14%)Rule based mistakes - 4 ( 14%)
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ELEMENTS OF EXPERT PERFORMANCEELEMENTS OF EXPERT PERFORMANCE
C o g n it iv e S k il ls
P s y c h o m o to r S k il ls
T e c h n ic a lK n o w le d g e &P ro c e d u re s
T e a m w o rk in g S k il ls
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PSYCHOLOGICAL PERSPECTIVESPSYCHOLOGICAL PERSPECTIVES
IntrapersonalIntrapersonal
InterpersonalInterpersonal
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CALI CREW ERRORSCALI CREW ERRORSActual Accident
Potential Accident
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SUMMARYSUMMARY
Cali accident was the result of numerous errors.Cali accident was the result of numerous errors.
Most of the errors were intrapersonal errors.Most of the errors were intrapersonal errors.
Most human factors training is interpersonal.Most human factors training is interpersonal.
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Reducing Altitude DeviationsReducing Altitude Deviations
with Intrapersonal with Intrapersonal
Human Factors TrainingHuman Factors Training
Captain David A. Simmon (Ret)Captain David A. Simmon (Ret)
Altitude Busts:Altitude Busts:
The Views from ATC & the Flight DeckThe Views from ATC & the Flight Deck
Royal Aeronautical SocietyRoyal Aeronautical Society
London Guildhall UniversityLondon Guildhall University
May 15, 1998May 15, 1998
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OVERVIEWOVERVIEW
Altitude change procedureAltitude change procedure
Cognitive skillsCognitive skills
Teamworking skillsTeamworking skills
ConclusionConclusion
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ELEMENTS OF EXPERT PERFORMANCEELEMENTS OF EXPERT PERFORMANCE
C o g n it iv e S k il ls
P s y c h o m o to r S k il ls
T e c h n ic a lK n o w le d g e &P ro c e d u re s
T e a m w o rk in g S k il ls
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ATC
PF PNF
MCP
2
3
1
31000
ALTITUDE CHANGE PROCEDUREALTITUDE CHANGE PROCEDURE
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INDIVIDUALINDIVIDUAL
COGNITIVE SKILLSCOGNITIVE SKILLS
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THOUGHT PATTERNSTHOUGHT PATTERNS
Macho
Impulsive
Invulnerable
Resigned
Anti-Authority
Wimp
Indecisive
Paranoid
Compulsive
Brainwashed
D
E
S
I
R
E
D
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Invulnerable - Paranoid ContinuumInvulnerable - Paranoid Continuum
11. InvulnerableInvulnerable
2. 2. SecureSecure
4. 4. WaryWary
5. 5. ParanoidParanoid
3. 3. ComfortableComfortable
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THOUGHT PATTERNSTHOUGHT PATTERNS
Pilots should consider ATC clearances with a Pilots should consider ATC clearances with a healthy degree of skepticism and controllers healthy degree of skepticism and controllers should listen to pilot readbacks with equal should listen to pilot readbacks with equal suspicion.suspicion.
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CFIT PRECURSORSCFIT PRECURSORS
Terrain-critical airportTerrain-critical airport
Night or IMC Night or IMC
No radarNo radar
Non-precision approachNon-precision approach
Non-English speaking pilots or controllersNon-English speaking pilots or controllers
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THOUGHT / ACTION PATTERNSTHOUGHT / ACTION PATTERNS
Conditional Vs. AbsoluteConditional Vs. Absolute
Mindful Vs. ComplacentMindful Vs. Complacent
Verify Vs. AssumeVerify Vs. Assume
Independent Perspective Vs. “Groupthink”Independent Perspective Vs. “Groupthink”
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TEMPORAL SKILLSTEMPORAL SKILLS
Accomplish actions in real timeAccomplish actions in real time
Defer low priority itemsDefer low priority items
Delegate actionsDelegate actions
Pre-accomplish future actionsPre-accomplish future actions
- Planning- Pre-decisions- Preparation- Priming
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REMEMBERING SKILLSREMEMBERING SKILLS
Rehearsal
Association
Visualization
Priming
Mnemonics
Heuristics
Chaining
Chunking
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ATTENTION MANAGEMENT SKILLSATTENTION MANAGEMENT SKILLS
Attention Hazards
Flexible Attention
Attention Tracking
Attention Steering
Monitoring Others
Time Projection
Memory Flagging
Attention Flagging
Pre-decisions
Priming
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REASONING & REASONING & PROBLEM-SOLVING SKILLSPROBLEM-SOLVING SKILLS
Problem-solving process
Individual perception checking
Verification
Conditional & lateral thinking
Knowledge of cognitive biases
Event managementEvent management
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IDEAL MENTAL STATEIDEAL MENTAL STATE
Stress Management
Fatigue Management
Mental Preparation
Diet & Nutrition
Rest
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TEAMWORKING SKILLSTEAMWORKING SKILLS
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TEAM-BUILDING SKILLSTEAM-BUILDING SKILLS
Social Validation
Universal Interaction
Briefing
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TEAM-PARTICIPATION SKILLSTEAM-PARTICIPATION SKILLS
Language Clarity
Active Listening
Perception Checking
Assertive Behavior
Conflict Management
Debriefing
Leadership
Followership
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BRIEFINGBRIEFING
PerspectivePerspectiveof theof the
PerformerPerformer
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The first step in an effective briefing is a The first step in an effective briefing is a thorough mental review and preparation for thorough mental review and preparation for the task-at-hand.the task-at-hand.
Briefings should be conducted for takeoffs, Briefings should be conducted for takeoffs, approaches and other mission-critical periods.approaches and other mission-critical periods.
Briefings are usually accomplished by the Briefings are usually accomplished by the most informed person - relative to a most informed person - relative to a particular task.particular task.
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The information should be relevant, precise, The information should be relevant, precise, and comprehensive.and comprehensive.
The briefing content should include both The briefing content should include both normal and non-normal situations. normal and non-normal situations.
The delivery has many of the characteristics The delivery has many of the characteristics of validating behavior.of validating behavior.
The briefer should explicitly invite feedback.The briefer should explicitly invite feedback.
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BRIEFINGBRIEFING
PerspectivePerspectiveof theof the
Other CrewmembersOther Crewmembers
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The listener perceives that he/she has been The listener perceives that he/she has been informed versus persuaded.informed versus persuaded.
The listener leaves the briefing with all The listener leaves the briefing with all critical questions answered.critical questions answered.
The listener feels armed for future problem The listener feels armed for future problem solving.solving.
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CONCLUSIONCONCLUSION
Intrapersonal skills can reduce altitude busts.Intrapersonal skills can reduce altitude busts.
Human factors training must emphasize Human factors training must emphasize
intrapersonal skills.intrapersonal skills.
Intrapersonal human factors training can also Intrapersonal human factors training can also reduce many other types of aviation accidents.reduce many other types of aviation accidents.
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ERROR REDUCTION METHODOLOGYERROR REDUCTION METHODOLOGY
PROCESSES PROBLEMS REMEDIESReasoning & Problem
SolvingReasoning & Problem
Solving Skills
BeliefFormation
Macho, Impulsive,Invulnerable, Resigned,
Anti-AuthorityThought Patterns
Effective ThoughtPatterns
Cooperative BehaviorSelf-sufficiency
Bystander ApathyGroupthink
Team Building SkillsTeam Participation
Skills
AttentionSlips of HabitMental Lapses,
Absorption, Distraction,Preoccupation
Attention ManagementSkills
Memory Mental Lapses Remembering Skills
Physical Functioning Stress & FatigueStress & Fatigue
Management, Diet,Nutrition, Rest
Biases, ComplacencyHaste, Mindlessness
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HUMAN FACTOR TRAINING NEEDSHUMAN FACTOR TRAINING NEEDS
Intrapersonal perspectiveIntrapersonal perspective
Cognitive & teamworking skillsCognitive & teamworking skills
Content at appropriate level of detailContent at appropriate level of detail
Operational contextOperational context