Key Dismukes Chief Scientist for Aerospace Human Factors Human Factors Research and Technology Division NASA-Ames Resear

1. Managing Interruptions, Distractions and Concurrent Task Demands Key Dismukes Chief Scientist for Aerospace Human Factors Human Factors Research and Technology Division NASA-Ames Research Center ATA AQP Annual Conference October 2003

2. Our Research Team • Immanuel Barshi • LaQuisha Beckum • Sean Belcher • Rahul Dodhia • Jon Holbrook • Kim Jobe • Tri Li • Loukia Loukopoulos • Jessica Lange Nowinski • Mark Staal

3. Consequences of Inadvertent Procedural Omissions • LaGuardia (1994): MD-82 ran off runway end after high-speed rejected take-off • NTSB: Anomalous airspeed indications caused by failure to turn on pitot heat • Detroit (1987): DC-9 crashed shortly after take-off • NTSB: Flaps/slats not set to take-off position • Dallas (1988): B-727 crashed shortly after take-off • NTSB: Flaps/slats not set to take-off position • Houston (1996): DC-9 landed gear-up • NTSB:Hydraulic pump not set to high position

4. Were These Accidents Unique? Not according to recent ASRS reports: • Rejected take-offs • Anomalous airspeed indications (pitot heat not on) • Configuration warning (flaps or trim not set) • Other consequences of overlooked procedural steps • Runway incursions • Broken tow-bars • Taxi into ditch • Engine flame-out • Overtemp engine • Flew wrong departure route • Go-around • Unnecessary costs and delays • But for luck any of these incidents might have become accidents • Departed with inadequate fuel • APU left running during takeoff -- fire • Packs failed in cruise • Took off without PDC • Deviated from speed or altitude restriction • Nose gear failed to retract • etc.

5. Why? • Why would experienced crews forget a procedural step they normally perform day in and day out? • Why fail to catch omissions with checklists?

6. An Ongoing NASA Research Project • “Carelessness” not an adequate explanation • Crews vulnerable to omissions when: • Interrupted or preoccupied with one of several concurrent tasks (Young, Dismukes, & Sumwalt, 1998). • Deferring tasks out of normal sequence (Loukopoulos, Dismukes, & Barshi, 2003). • Vulnerability to error among experienced pilots largely driven by: • Characteristics of tasks performed • Demands tasks place on human cognitive processes • Operating environment • Norms for actual line operations

7. Jumpseat Observation Study(Loukopoulos, Dismukes, & Barshi, 2003) • Reviewed FOMs, observed line operations, analyzed ASRS, NTSB reports • All phases of flight — focus today on preflight and taxi • Discovered disconnect between FOM/training and actual line operations in depiction of task management

8. Preflight - In theory (FOM) Ground/ Company/ Dispatch Frequencies Interphone Cabin Attendant Gate Agent ACARs / OPC CAPTAIN FIRST OFFICER Review paperwork Sign flight release Prepare/review charts Review Load Schedule Review FMC Takeoff brief Ask for checklist • Ask for checklist Obtain ATIS Obtain clearance Review paperwork Prepare/review charts (Passenger count) (Load Sheet) Program FMC Begin checklist Checklist complete Begin checklist Checklist complete procedure procedure checklist CLEARANCE checklist ENGINE START & PUSHBACK

9. Depiction of Cockpit Task Management in FOM/Training • Tasks are serial and linear: task A task B  task C in a fixed sequence.

10. Preflight - In theory (FOM) Ground/ Company/ Dispatch Frequencies Interphone Cabin Attendant Gate Agent ACARs / OPC CAPTAIN FIRST OFFICER Review paperwork Sign flight release Prepare/review charts Review Load Schedule Review FMC Takeoff brief Ask for checklist • Ask for checklist Obtain ATIS Obtain clearance Review paperwork Prepare/review charts (Passenger count) (Load Sheet) Program FMC Begin checklist Checklist complete Begin checklist Checklist complete procedure procedure checklist CLEARANCE checklist ENGINE START & PUSHBACK

11. Depiction of Cockpit Task Management in FOM/Training • Linear: task A task B  task C in a fixed sequence. • Controllable: tasks are initiated by crew at their discretion. • Predictable: • Information available to crew when needed. • Individuals can communicate as needed.

12. Taxi-out - In theory (FOM) CAPTAIN FIRST OFFICER Captain Start taxiing Ask for checklist Receive takeoff clearance Ask for checklist Line up with runway First Officer Receive taxi clearance Start checklist Checklist complete Receive takeoff clearance Start checklist Checklist complete MONITOR Ground Company/Dispatch MONITOR Ground Company TaxiClearance MONITOR Captain taxiing Takeoff Clearance TAKEOFF

13. Depiction of Cockpit Task Management in FOM/Training • Linear: task A task B  task C in a fixed sequence. • Controllable: tasks are initiated by crew at their discretion. • Predictable: • Information available to crew when needed. • Individuals can communicate as needed. • Overall picture: flight operations are pilot- driven and under moment-to-moment control of crew.

14. Review paperwork Sign flight release Prepare/review charts Review Load Schedule Review FMC Takeoff brief Ask for checklist Ask for checklist Preflight - the reality Conduct exterior walk-around no time, familiarity Ramp and/or Ground? Check charts busy frequency Keep trying Double-check charts no time, familiarity Interruption Interruption Resume flow Still refueling Check fuel quantity and pumps Inoperative item Inoperative item Call maintenance Confirm Mx responded Passenger count unavailable Confirm resolution Request passenger count Confirm Mx departed Data unavailable Confirm logbook on board Defer programming FMC Flight release still not picked up Look for ops/gate agent New PDC Delay at gate Re-program FMC New flight release/PDC? Re-set MCP Time pressure FO busy Re-flow trim & other settings Ask for checklist Takeoff brief Flight plan/ Departure runway change Interruption Resume checklist Communicate with company Compute new performance #s Re-program FMS Re-brief CAPTAIN FIRST OFFICER Obtain ATIS Obtain clearance Review paperwork Prepare/review charts (Passenger count) (Load Sheet) Program FMC Begin checklist Checklist complete Begin checklist Checklist complete Ground/ Company/ Dispatch Frequencies Interphone Cabin Attendant procedure Gate Agent ACARs / OPC procedure procedure checklist CLEARANCE checklist ENGINE START & PUSHBACK

15. Review paperwork Sign flight release Prepare/review charts Review Load Schedule Review FMC Takeoff brief Ask for checklist Ask for checklist Preflight - the reality Conduct exterior walk-around no time, familiarity Ramp and/or Ground? Check charts busy frequency Keep trying Double-check charts no time, familiarity Interruption Interruption Resume flow Still refueling Check fuel quantity and pumps Inoperative item Inoperative item Call maintenance Confirm Mx responded Passenger count unavailable Confirm resolution Request passenger count Confirm Mx departed Data unavailable Confirm logbook on board Defer programming FMC Flight release still not picked up Look for ops/gate agent New PDC Delay at gate Re-program FMC New flight release/PDC? Re-set MCP Time pressure FO busy Re-flow trim & other settings Ask for checklist Takeoff brief Flight plan/ Departure runway change Interruption Resume checklist Communicate with company Compute new performance #s Re-program FMS Re-brief CAPTAIN FIRST OFFICER Obtain ATIS Obtain clearance Review paperwork Prepare/review charts (Passenger count) (Load Sheet) Program FMC Begin checklist Checklist complete Begin checklist Checklist complete Ground/ Company/ Dispatch Frequencies Interphone Cabin Attendant procedure Gate Agent ACARs / OPC procedure procedure checklist CLEARANCE checklist ENGINE START & PUSHBACK

16. Line Observations Reveal a Different Story • Normal line operations are quite dynamic: • Each pilot must juggle several tasks concurrently. • Crews are frequently interrupted. • External demands arrive at unpredictable moments. • Conditions sometimes force task elements to be performed out of normal sequence.

17. Line Observations Reveal a Different Story • Each pilot must juggle several tasks concurrently. • Crews are frequently interrupted. • External demands arrive at unpredictable moments. • Conditions sometimes force task elements to be performed out of normal sequence. • Normal line operations are quite dynamic: • Crews must at times struggle to maintain control of the timing and sequence of their work tasks. • Lack of guidance

18. Conflict Between Theory and Reality • FOM is a powerful tool for safety by providing: • Operational reality disrupts ideal execution of procedures • Explicit description of how each task is to     be performed • Standardization across crews • Checklists and checking procedures

19. So What? • Pilots become accustomed to concurrent task demands, interruptions, distractions and disruptions. • However these situations substantially increase vulnerability to error, especially omission of critical procedural steps.

20. ERRORS attributed to concurrent task demands, interruptions, and disruptions (ASRS reports) Forgot logbook at ramp - kept deferring to check it; distractions; busy with preflight - discovered en route Skipped over checklist item - fuel pumps deferred during preflight because refueling - engine starvation in flight Omitted review of charts - distractions - speed violation on departure Entered wrong weight in FMS - tail strike at takeoff Improper setting of pressurization during preflight flow - interruptions - cabin altitude warning light in cruise Omitted flow and checklist items - interruptions; delay; change in departure runway - discover insufficient fuel at 12000 ft Read but not verify checklist item - distractions - pushback with throttles open, damage to aircraft Started taxi without clearance - crew discussing taxi instructions - struck pushback tug Neglected to set flaps -preoccupied with new departure clearance and packs-off operation - aborted takeoff FO failed to monitor CA – busy with flow; night taxi – taxi in wrong direction FO failed to monitor CA -runway change; busy reprogramming FMC - taxied past intended taxiway Omitted setting flap - busy with delayed engine start; rushed to accept takeoff clearance - aborted takeoff Failed to verify new clearance - monitoring convective activity on radar - flew wrong heading PREFLIGHT > PUSHBACK > TAXI > TAEKOFF > CLIMB > CRUISE > DESCEND > LAND Omitted climb checklist - busy copying hold instructions - missed setting altimeter and overshot altitude Failed to reset bleeds on - complex departure; multiple ATC calls; traffic - altitude warning and 02 mask deployment Did not notice wind - preoccupied with annunciator light; handling radios - track deviation Forgot to reset altimeters - distracted by FA in cockpit - TCAS RA and overshot arrival fix Failed to monitor PF - busy reprogramming FMS; weather changes - go around Failed to verify FMC settings - PNF giving IOE to PF; multiple ATC calls; hold instruction - flew pattern in wrong direction ATC instructions too close to turn fix - busy slowing aircraft; approach checklist; radios - failed to make published turn Vectored too close - busy catching up with glideslope; not instructed to switch to Tower - landed without clearance Forgot to switch to Tower at FAF - last minute runway change; busy reconfiguring aircraft - landed without clearance Unstabilized approach - accepted runway change right before FAF; did not review charts or make callouts - tailstrike Did not complete checklist - TCAS alerts; parallel runways in use; GPWS alert - did not extend gear for landing Did not extend gear; checklist interrupted; TCAS alerts; parallel runways in use; GPWS alert - struck ground on go-around

21. Why So Vulnerable to These Errors?

22. 1) “Controlled” processing Corresponds to conscious attention Slow, serial, and effortful: low capacity Required for tasks with novel aspects 2) Automatic processing Fast, minimal effort, high capacity Develops with extensive practice of habitual procedure Requires minimal conscious supervision Why So Vulnerable to These Errors? • Brain has two ways of processing information to perform tasks: • Cockpit tasks vary from requiring mainly controlled processing to being largely automatic.

23. Automatic processing has enormous advantages but also has serious vulnerabilities

24. PAX CT 107, 22, 5 3 WH ATIS Slakfj aslkfj890 Slkdfj 3409589 Slkafj f095j 019 Sa;lskdfjl Lskd LOAD Slakfj aslkfj890 Slkdfj 3409589 Slkafj f095j 019 Sa;lskdfjl Lskd Slkf9 9oy99 Slkdfj A;slkg eri kgj skj 9 FLIGHT PLAN Slakfj aslkfj890 Slkdfj 3409589 Slkafj f095j 019 Sa;lskdfjl Lskd SFAS ALSKFJ XLKAF ALKDFJJ;AL FUEL 107, 22, 5 3 WH PDC Slakfj aslkfj890 Slkdfj 3409589 Slkafj f095j 019 Sa;lskdfjl Lskd Slkf9 9oy99 Slkdfj A;slkg eri kgj skj 9 JEPP 107, 22, 5 • •x Aft Overhead Aft Overhead * * PREFLIGHT Flow (B73-300 - as trained) (checklist items are marked*) * * Forward Overhead Forward Overhead * * * * * Mode Control Panel * * Mode Control Panel * * * First Officer Instrument Captain Instrument * Center Instrument Center Instrument * * Captain Instrument First Officer Instrument * * * * Forward Electronic Forward Electronic * * Control Stand Control Stand * * * * Aft Electronic * Aft Electronic * * * Logbook/Gear Pins Logbook/Gear Pins

25. Vulnerabilities of Automatic Processing • If procedural flow is interrupted, chain is broken. • Pause prevents one step from triggering the next. • Initiation of automatic process depends on receiving signal or noticing a cue in the cockpit environment. • If signal does not occur, individual is not prompted to initiate procedure.

26. Vulnerabilities of Automatic Processing • If procedural flow is interrupted, chain is broken. • Pause prevents one step from triggering the next. • Initiation of automatic process depends on receiving signal or noticing a cue in the cockpit environment. • If signal does not occur, individual is not prompted to initiate procedure. • Highly practiced procedures and checklists tend to develop “look without seeing” automatic responses. • High workload and/or rushing prevent conscious supervision of automatic processes--exacerbates vulnerability

27. Vulnerability to Errors of Omission Can Be Reduced 1) Actions airline operations and training  departments can take 2) Actions individual pilots can take

28. Ways Airlines Can Reduce Vulnerabilities • Analyze actual line ops write procedures to minimize opportunities for disruptions. • Avoid “floating” procedural items allowed to be performed at varying times. • Anchor critical items (e.g., setting takeoff flaps) to distinct step that cannot be forgotten (e.g., before start of taxi).

29. Ways Airlines Can Reduce Vulnerabilities • Analyze actual line ops write procedures to minimize opportunities for disruptions. • Avoid “floating” procedural items allowed to be performed at varying times. • Anchor critical items (e.g., setting takeoff flaps) to distinct step that cannot be forgotten (e.g., before start of taxi). • Analyze actual fleet “norms” for how checklists are executed and bottom-lines observed. • LOSA • Train with realistic concurrent task demands.

30. Ways Pilots Can Reduce Vulnerability • Being aware of vulnerability reduces threat. • Especially vulnerable when head-down, communicating, searching for traffic, or managing abnormals. • When interrupted or deferring a task: • Pause to encode intention to resume • Create conspicuous cue as reminder (e.g. checklist in throttle quadrant) • Develop habit of deliberate execution of procedures and checklists to allow controlled supervision of habitual responses. • Avoid rushing.

31. Ways Pilots Can Reduce Vulnerability • Being aware of vulnerability reduces threat. • Especially vulnerable when head-down, communicating, searching for traffic, or managing abnormals. • When interrupted or deferring a task: • Pause to encode intention to resume • Create conspicuous cue as reminder (e.g. checklist in throttle quadrant) • Develop habit of deliberate execution of procedures and checklists to allow controlled supervision of habitual responses. • Avoid rushing. • Pause at critical junctures to review. • Schedule/reschedule activities to minimize concurrent task demands (e.g., brief before TOD). • Treat monitoring as essential task (Sumwalt).

32. For further information: http://human-factors.arc.nasa.gov/ihs/flightcognition/ This work is supported by NASA’s Airspace Systems Program and by the FAA (AFS-230), Dr. Eleana Edens, program manager.