Predicting Design-Induced Error on the Flight Deck

Abstract

Objective: To explore the types of errors that commercial pilots may make when trying to resolve a suspected engine oil leak using the interfaces currently available. Background: The decisions that pilots make often have to be made quickly and under time pressure, with the emphasis on avoiding critical situations from arising. To make the correct decisions, it is vital that pilots have accurate and up-to-date information available. However, interaction with flight deck interfaces may lead to error if they are not effectively designed. Method: A hierarchical task analysis was conducted using evidence from pilot interview data to understand the pilots’ typical response to a suspected engine oil leak scenario. This was used as the primary input into the Systematic Human Error Reduction and Prediction Approach (SHERPA). Results: A total of 108 possible errors were identified. The most common error type was a retrieval error, in which flight crews may retrieve the wrong information about the engine. A number of remedial measures are proposed to try and overcome such issues. Conclusion: This analysis provides an initial starting point for identifying potential future design ideas that can assist the pilots in dealing with oil leaks. Application: This work has identified the value of applying human error identification methodologies to the assessment of current flight deck processes surrounding engine oil leaks. The method presented permits the operational analysis of possible errors on the flight deck and facilitates the proposition of remedial measures to implement technological innovations that can mitigate error.

Using the Perceptual Cycle Model and Schema World Action Research Method to generate design requirements for new avionic systems

“…The rationale behind focusing on an engine oil leak scenario is that despite being rare, they can have serious repercussions on flight operators, maintenance teams, and passengers when handled inappropriately (ATSB, 2012, 2017; Parnell et al, in press). In addition, the presentation of engine system parameters has remained largely unchanged for a number of decades with analog displays simply being replaced by digital equivalents (Harris, 2011).…”

“…At the point of notification, pilots have few options available to them and they must either throttle back or shut down the engine completely, to prevent the engines from reaching oil starvation (ATSB, 2012, 2017). Engine shutdowns in particular have significant implications for the flight operator both in terms of economics and safety so there is great value, both from operations and economic perspectives, in exploring how such situations can be prevented (Parnell et al, in press). The limited options available to pilots within this scenario was also ideal for the explorative nature of the current work.…”

Designing flight deck applications: combining insight from end-users and ergonomists

“…A total of 78 tasks were identified in the HTA. Once the HTA was completed, it was reviewed by both a Human Factors expert with over 30 years of experience and an experienced pilot with over 10 year flight experience (see Parnell et al 2019 for further details of the HTA). This ensured that all relevant information was captured.…”

“…Once the tasks required to manage the oil leak were understood, the possibility for error to occur within each of these tasks was assessed. Tasks from the bottom of the HTA (which represent the specific individual tasks that comprise all of the higher level goals of the process) were then reviewed for all possible errors that could arise across each stage in the process and within the system (Parnell et al 2019).…”

Modelling Automation–Human Driver Handovers Using Operator Event Sequence Diagrams

“…Other modelling approaches in Ergonomics and Human Factors have determined predictions about human error [18][19][20][21], time to perform tasks [22][23][24]), visual sampling behaviour [2,25] and the structure of work [26,27]. The advantage of Operator Event Sequence Diagrams is that they make the interactions between various subsystems (including the human operators) explicit, within and between 'swim-lanes' (the columns containing work associated with each of the actors).…”