Transcript Human Factors in Aviation Where we are, Where we go

Training Situation
Assessment and Decision Making
A rule making approach
Rene Amalberti, MD, PhD
Professor of Medicine, Physiology and ergonomics,
Head Cognitive Science Department, IMASSA,
Test-flight center, Brétigny-sur-Orge
[email protected]
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Outline of the presentation
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Basic Assumptions on Training and
Decision Making in Aviation
The Reality gap
Tactical and strategic options for rule
making
The JAA approach
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Basic Assumptions
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Situation assessment and decision making
are priorities for flight safety (CAST, JSSI,
ALAR)
Specific training is needed
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Situation Assessment and Decision Making
are priorities for Safety (CAST, JSSI, ALAR
Fatalities by Accident Categories Fatal Accidents, Worldwide Commercial Jet Fleet (1990-1999)
Approach &
Landing
Accident
Reduction
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Approach &
Landing
Accident
Reduction
ATC
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Challenge or refuse ATC instructions when they are not clearly
understood, are questionable or conflict with your assessment
of aircraft position relative to the terrain.
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Exercise good radio communication discipline.
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Know the height of the highest terrain or obstacle in the
operating area.
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Know your aircraft’s position in relation to the surrounding
high terrain.
Approach &
Landing
Accident
Reduction
Autoflight
System
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Monitor the autoflight system for desired operation.
Use the best available mode for current flight conditions.
Follow procedures.
Monitor navigation performance.
CRM, SOPs and Training
Factors Involved in ALAs
Approach &
Landing
Accident
Reduction
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74% - Inadequate crew decision making
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72% - Inadvertent non adherence to procedures
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63% - Failure in CRM (cross-check/coordination)
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46% - Failures in company management
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40% - Deliberate non adherence to procedures
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37% - Inadequate training
CRM = Crew resource management
SOPs = Standard operating procedures
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The reality gap
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Training time costs money, and tends to
remain as short as possible
Consistent plan for integrated human
factors training, conceptually and practically
hard to design
 Persistent false believes on cognition,
 human behaviour, and human error
Training evaluation for human factors
related aspects hard to accept
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Reduction time in training courses
Feedback from the FAA/JAA report on The Interfaces Between Flight crews and Modern
Flight Deck Systems, June 1996
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Reduction time
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3
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Back to the minimum
Ambiguities for decision
making
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Strong belief (evidence?)
that learning cognitive
skills needs a shorter
time compared to
learning motor skills
Training time (weeks)
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Persistent false belief on Human
behaviour and human error
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Training priorities not necessary the ones
identified
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False belief regarding « back to manual »
Remaining language problems aggravating situation
awareness
Effects of complexity on pilots’ expertise
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Poor situation awareness and false
expectation on crew behaviour
•10 crews experiencing rare software failures
•Modification of Flight Simulator Capacities
•LOFT scenario: LYON - MADRID
Simul A320
micro
Speed corruption
Caméra
Enregistrement
micro
Mach corruption
Teléphone
Salle déportée
INSTRUCTEUR
Emulation
ATC
J.P. Mesure
Jeuen pilote
Altitude corruption
Etudiante
Altitude
ineffective
Liaison fonctionnelle
preset
Automatic reversion
of
descent
mode
between
HeadingVertical Speed (HdgVs) and Track-Flightpath angle (TK-FPA)
and versus.
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Experimental crew training to deal
with automation surprises (Results 1)
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All crews landed safely
Only four crews went back to manual
All crews showed a tendency to cycle the failing system several
times to test the failure before trying to reset the system in order
to recover it (resetting fuse, proceeding the global function reset,
e.g. resetting FMGS)
A thorough analysis of crews’ mental representation and situation
awareness via verbal protocols analysis show a series of
unexpected ‘magic’ thinking on sub-systems organisation and
inter-relations.
Crews gave priority to the situation management, not to optimal
error or failure management. HE rate increases to 50%, error
detection rate going down to 30%, only 10% of HE properly
recovered.
No causal reasoning, search for comprehension collectively
refrained
First priorities for safe situation management : control the very
short term, and search for solutions compliant with the goal.
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Complexity, and Expertise
Glass-cockpit a/c, Amalberti, 1996, 2000
Virtual space of total system knowledge
Knowledge at the end of A/C type-rated
Initial phase
Routines
Exploration phase
Cognition in the wild
Retraction phase
Core of routines
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New Technologies and Associated Cultural
Problems
APPR PROC:
STATUS
-L/G……………ON
-APPR NAVAID….ON RMP1
APPR SPD: VREF +10KT
LDG DIST…………X 1.55
ENG 1 APPR IDLE ONLY
ENG 2 APPR IDLE ONLY
ALTN LAW: PROST LOST
WHENL/G ON:DIRECT LAW
CTR TK FUEL UNUSABLE
PACKS AT FIXED TEMP
INCREASED FUEL CONSUPP
SLATS/FLAPS SLOW
CAT 1 ONLY
TAT +28°C
SAT +16°C
11H05
INOP SYS
WINDSHEAR DET
ATT LIMIT
OVSPD LIMIT
ADR2+
RA1+2
SPLR 1+2+5
ELAC 2
SEC 2+3
ILS 2
FAC 1+2
A/CALL OUT
VHF 2
ACP 3
CAPT STAT
CAPT TAT
WSHLD HEAT
GW XX KG
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Performance and technology induced
problems
Performance
More solutions?
Comprehension
Management
Back to
manual?
Negative feedbacks
SMART
Nearloss
LOSS OF CONTROL
NEEDED
Negative feedbacks
Workload Management
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Tactical and strategic options for rule
making
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Aviation
Authorities
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Cultural approach to rule making
All training should be evaluated, including Human
factors training
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ICAO annexes
A good training should combine basic knowledge
(classroom), and practice.
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Aviation
Authorities
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Cultural differences for rule making
The southern Mediterranean way of thinking
 Rules are objectives, goals, stimuli to change behaviours
 Rules are promoted when no –or very few- actors can comply
with
 Recommendations are useless
The US and Northern Europe way of thinking
 Rules are references
 They are set when all of the field actors can comply with
 Recommendations prepare field actors, well before the rule, to
comply with the future rule
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Competing philosophies for training design
Philosophy 1 :
The NORMATIVE APPROACH
Philosophy 2 :
The ECOLOGICAL APPROACH
Aviation operations can be entirely specified through
standardized procedures, programs, schedules, rules,
nominal tasks, certification, selection, norms
Aviation operations cannot be entirely specified
through standardized procedures, programs, and the like.
One reason is it includes Humans.
Safety improvement will result from more specification
and more discipline from the operators;
Safety improvement will result from a better respect of
the “ecology” of the system and a better
acknowledgment of its self-protection mechanisms
Deviations from nominal operation are both a cause of
lower performance, and the main threat for safety
Deviations from nominal operation are both a
necessity for adaptation to random dimension of real
life, and a potential threat for safety
Human operators are ultimately the only unpredictable
and unspecifiable components of the system. They are
the main source of deviation;
Human operators are up to now the only intelligent,
flexible and real time adaptable component of the system.
They are a deposit and source of safety
Errors are non intentional but regrettable deviations from
standard actions. Errors are unfortunately
inevitable
Errors are deviations from operator’s intentions, but at
the same time they are part of the normal process of
achieving intentions. Errors are necessary
The human operator is one more “black-box”
coupled through inputs (perceptive data) which are
transformed into outputs (actions) according to specified
targets (goals) using adequate transfer functions
(procedures, skills,..)
Human operators are auto-organized structures,
coupled through recursive processes of self regulation,
and ultimately governed by their internal intentions
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JARs / HF TRAINING
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Aviation
Authorities
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JAR FCL Cockpit crew training
 1.160, 1470 Ab initio : theoretical knowledge in HF /
Theoretical HF examination to get the ATPL Compliant with ICAO annex 1
 1.240 Flight check licensing : demonstrating ability in
crew co-ordination and airman ship, requirements
extended into MCC regulations
JAR OPS Recurrent training Cockpit & Cabin Crew
 1.940, 45, 55, 65 CRM for cockpit crews. Recent
change of requirements following the NPA 16,
compliant with ICAO annex 6
 CRM for Cabin crew : TGL5 in progress
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Zoom on HF training flight crew
& on the NPA 16 CRM Cockpit crew
Recurrent CRM
3Yrs cycle
Modular/LOFT
ATPL
JAR FCL
JAR OPS
1st year
HPL
MCC
Initial CRM
Conversion course
CRM training when
changing operator
Conversion course CRM
training when changing
aeroplane type
Theoretical course
in Human Factors
according JAR FCL
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Command course CRM training
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NPA 16. Appendix 1.965
New need for CRM assessment
(ii) The flight crew must be
assessed on their CRM skills in
accordance with a methodology
acceptable to the Authority and
published in the Operations Manual.
The purpose of such assessment is
to:
(A) Provide feedback
the individual and serve
identify retraining; and
(B)
to
to
Be used to improve the CRM training system.
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The NOTECHS project
“Non-technical skills refer to a pilot’s attitudes and behaviours in the
cockpit not directly related to aircraft control, system management,
technical consequences and standard operating procedures.”
THE NOTECHS PROJECT
1997-1998
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Sponsored by 4 CAAs
[NL,D,UK,&F], and DGVII
Basic design and development
THE JARTEL PROJECT
1999-2001
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NLR (J.van Avermaete, E. Kuriijsen,
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DLR ( K-M Goeters, H-J. Hormann)
Aberdeen University (R. Flin,
L. Martin)
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Same teams
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NLR (J.van Avermaete, E. Kuriijsen,
H. Nijhuis + KLM
Pilots)
H. Nijhuis + KLM Pilots), project leader
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Sponsored by DGTREN
Validation & benchmarking
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Plus
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IMASSA (R. Amalberti & C. Valot)
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DLR ( K-M Goeters, H-J. Hormann)
Aberdeen University (R. Flin, L. Martin)
IMASSA (R. Amalberti & C. Valot)
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British Airways
Alitalia
Airbus
DERA
Sofreavia (project leader)
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NOTECHS
Principles for system design and operation
FOUR PRINCIPLES FOR DESIGN
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Maximum mutual exclusivity for categories and elements
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Rule of parsimony - minimalist approach
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Everyday terminology
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Skills directly observable or inferred from other behaviours (communication)
FOUR PRINCIPLES FOR OPERATIONS, designed to ensure that each crewmember receives
as fair and as objective an assessment as possible.
 Only observable behaviour is to be assessed
The evaluation must exclude reference to a crewmember’s personality or emotional attitude and should be
based only on observable behaviour. Behavioural markers were designed to support an objective
judgement.
 Need for technical consequence
For NTS to be rated as unacceptable, flight safety must be actually (or potentially|) compromised. Thus
demanding a related objective technical consequence.
 Repetition required
Repetition of unacceptable behaviour during the check must be observed to conclude that there is a
significant problem. If, according to the JAR-paragraph concerned, the nature of a technical failure allows
for a second attempt, this should be granted, regardless of the NTS rating.
 Explanation required
For each Category rated as unacceptable the examiner must:
Indicate the Element(s) in that Category where the unacceptable behaviour was
observed.
b.
Explain where the observed NTS (potentially) led to safety consequences.
Give a free-text explanation on each of the Categories rated unacceptable, using standard
phraseology.
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The NOTECHS framework
Non-technical skills
Co-operation
Leadership &
management skills
Team building &
maintaining
Conflict
solving
Decision
making
Category
Element
Considering
others
Supporting
others
Situation
awareness
Behaviour
Helps other crew members in demanding
situations
Offers assistance
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Framework: Elements & Behaviours for Category
- Situation Awareness
Category:
Situation Awareness
Elements
System
Awareness
Environmental
Awareness
Anticipation
Behaviours
- Monitors and
reports
changes in
systems states
- Acknowledges
entries and
changes to
systems
- Collects
information about
the environment
- Contacts outside
resources when
necessary
- Shares
information about
the environment
with others
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- Discusses
contingency
strategies
- Identifies
possible/future
problems
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Conclusion
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Significant changes in the past decade
Extension to Cabin crew, Maintenance, etc, in
progress
Remaining problems for success
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Ends : Adhere to procedure Vs teach adaptation
Cost and fragility : what about HF training courses after
the initial burst of enthusiasm ?
Means : who should be the instructors ? (good recent UK
contribution)
Evaluation : Can we design HF training without evaluation?
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