Communication in safety-critical domains

1. Communication in safety-critical domains Henning Boje Andersen Professor, Management Engineering Dept. Technical University of Denmark Simtrans Seminar 16 November 2011, Rederiforeningen, København

2. Communication Communication in safetycriticalworkcontexts • provides information • establishes ’commonground’/ team situation awareness • establishesinterpersonalrelationships • establishespredictablebehaviourpatterns • maintains attention to task and monitoring • is a tool to managetechnical/cognitiveresources in the worksetting (adapted from Kanki & Palmer 1993)

3. Problems in transfer of information (1:2) Problems in transfer of information found in 70% of 28,000 reportssubmitted to ASRS (Billings & Cheany, 1981)

4. Problems in transfer of information (2:2) ”Close examination of ASRS reports led to the findingthat transfer of information .. did not ordinarilyresult from unavailability of information nor because the information waswrong at the source … Instead.. information was not transferredbecause (1) the person who had the information did not think it necessary to transfer it or (2) that the information wastransferred, but inaccurately” (Billings & Cheanym 1981)

5. The beginnings of pragmatics Naturalmeaning vs. non-naturalmeaning (i.e., meaningcreated by humans) • “Those spots means she has measles.” • “The three rings on the bell means that the bus is full” • ”The smoke rings over theremeanstherearegusts of windaround the fire” • ”The smoke rings over theremeans the indiansareon the warpath” (Paul Grice, 1967)

6. Implicature(impliedmeanings) When a diplomat saysyes, hemeans ”Perhaps” Whenhesaysperhaps, hemeans ”No” Whenhesaysno, he is not a diplomat (ascribed to Voltaire, Stanford Enc. Philos., ”Pragmatics”)

7. Implicature • Air AviancaOn January 25, 1990, Avianca Flight 52 was much delayed in approaching its destination due to congestion and bad weather. It had been in a holding pattern off the coast near New York for over one hour due to fog and wind interfering with smooth arrivals and departures into John F. Kennedy International Airport. During this hold the aircraft was exhausting its reserve fuel supply, which would have allowed it to divert to its alternate, Boston, in case of an emergency or other critical situation. • When first put on hold, the crew of Flight 52 thought that they would be landing soon, after a few aircraft also on hold in front of them had landed. The bad weather, wind shear and other factors caused the pilots of these aircraft to abort their landings, and the hold time increased. • Seventy-seven minutes after entering the hold, New York air traffic control (ATC) asked the crew how long they could continue to hold, to which the first officer replied, "[A]bout five minutes." The first officer then stated that their alternate was Boston, but since they had been holding for so long they would not be able to make it there anymore. Even though Flight 52 had fuel issues, ATC passed the flight to another person, presumably unaware there was any urgency to landing this airplane. The delay of the handover may have increased the pilots' stress and fear response, which may have led to less than optimal piloting. The new controller then cleared the aircraft for an approach to runway 22L and informed the flight of wind shear at 1,500 feet (460 m).

8. Tjeklister - historien 1935: Boeing “Model 299” Detmestavancerede fly tilbudtdetamerikanskeluftvåben

10. Ref: Phillip S. Meilinger. Air Force Magazine, Oct. 2004

12. Model 299 Crashinvestigation/ “Airmen realized that aircraft were becoming too complex to fly safely without standardized procedures. Theseprocedures were too numerous and complicated to commit entirely to memory. “Checklists” were now developed thatspelled out specifictasks to be accomplished by each crew member at various times throughout the flight and on the ground.

13. Thankyou!