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Emergency Emergency and Abnormal Situations and Abnormal Situations in Aviation Symposiumin Aviation Symposium
Santa Clara, June 2003
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Responding to Responding to Emergencies and Emergencies and
Abnormal SituationsAbnormal Situations
Neil JohnstonAerospace Psychology Research Group
Trinity College [email protected]
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IntroductionIntroduction
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l Conference Challenge– Alternative Perspectives– Identify and Challenge Assumptions– Challenge Conventional Training Wisdom
l 4 Topics – Emergency & Non-Normal Events– Non-Normal Checklists– Human Factors / Human Performance– Solutions
l Pilot Expertisel Training Themes and Issues
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
OverviewOverview
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EventsEvents– Emergencies – very rare– Non-normal events – rare– “Abnormal” situations – common
» Unexpected departures from the norm
l Reflexive Questions– What exactly is being managed ?– How best can this be done ?– Are we looking at the right things ?
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
PreliminariesPreliminaries
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ChecklistsChecklists– Subtle changes over time– Implicit assumptions
» Pilot function – and functioning» Cockpit management
l Not just “lists” + “check”» Sources of aid and confusion» Subtle shaping of pilot behaviour
v Airline specific simulator practices
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
PreliminariesPreliminaries
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Human Factors/Performance Issuesl Perfect engine shutdown drill
– Wrong engine
l Good Drills + Leisurely Preparation– Undesired Outcome
l Poor Cockpit Management– Confusion & coordination breakdowns
– Ambiguity and absence of focus
– Departures from the norm
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
PreliminariesPreliminaries
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Solutionsl The Conventional Wisdom
– More / Better Training – what exactly ?
l Experience– What part of “Experience” ?
l Better Checklists – Design ?– Content ?
l Problematic
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
PreliminariesPreliminaries
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Developing The Developing The
Four ThemesFour Themes
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l Low Frequency of Events – Reliability / Automation / Technology– Low exposure
» reduced co-pilot apprenticeship
l Unexpected events / variations – common– Unexpected issues and variants
• Real world presentation of problems• Real world demands and problem management• Real world inhibitors of performance
l Real world : simulator rituals
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
1. Events1. Events
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l Exemplar: Cockpit Electrical Smoke– B707 Checklist (1960’s)
» 5 detailed - technical – “flow logic” pages» “Isolation” trouble-shooting
l Assumptions & Emphasis» Pilots will / should “trouble-shoot”» Checklist - a list - a technical technical document
l Cockpit management: independent skill-set» Somebody is flying the aircraft» Taken for granted
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
2. Checklist Development2. Checklist Development
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l Exemplar: Cockpit Electrical Smoke– Original B737 Checklist (1970’s)
» 2 QRH Pages» Simplified “Isolation” format: some reasoning
l Assumptions» Limited “trouble shooting” required» Checklist: isolate the source at a global level» Cockpit management: some notes / guidance
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
2. Checklist Development2. Checklist Development
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l Exemplar: Cockpit Electrical Smoke– B737 Checklist (post-1970’s)
» 1 QRH Page» Minimal switching – design feature» Systemic “Isolation” format – stop the smoke
l Assumptions» Minimal “trouble shooting” – observation» Checklist directed: isolate the source» Cockpit management: “Land ASAPLand ASAP ”
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
2. Checklist Development2. Checklist Development
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l Wrong engine shutdown “perfectly”– Less common– Still occurs in simulator
• Inexperienced pilots or rushing / confusion
– Crew co-ordination– Stress– Perception of time pressure
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
3. Human Factors Issues3. Human Factors Issues
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l First Identify the problem– Where does it say this ?
– Fly the aircraft» Self evident ?
– Crew agreement» Clear task allocation
» Crew co-ordination
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
3. Human Factors Issues3. Human Factors Issues
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l Good Drills and Preparationl Poor Outcomes
– Loss of global picture• UAL Portland Oregon• SR 111
– Sometimes time is important• Ordering priorities
l CRM a key factor – Important … but …– CRM may be over-privileged
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
3. Human Factors Issues3. Human Factors Issues
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l Poor Cockpit Management– Cockpit confusion– Increased errors and risk exposure– CRM
• A means, a process – not the solution• CRM not an end in itself: task specific
deployment• Poor CRM can be a symptom
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
3. Human Factors Issues3. Human Factors Issues
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l The Target– Good Cockpit / Error Management
l Causes of poor cockpit management?– Confusing Causes and Symptoms
» Workload» CRM» Decision-making, » Crew co-ordination breakdowns» Etc. …
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
3. Human Factors Issues3. Human Factors Issues
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l Training– What kind, what content, when, how … ?– “Bang for the Training Buck”
l Experience– What is it ?– More than hours … than mere “exposure”
l Checklist Design / Content–– Technical Issues: Technical Issues: Securing, configuring, …–– Cockpit ActionsCockpit Actions : Support, aiding, …–– Cockpit ManagementCockpit Management : Structuring, ordering, ...
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
4. Solutions4. Solutions
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l Checklists are changing– Underlying philosophies often undocumented– Transition and orientation changes 707 ààà à 737– Less and less pilot reasoning– More operational hints / refs in checklists
l Basic Human Factors– Some issues not clearly addressed– CRM not a “catch all” HF solution
l It is not entirely clear what we need to train
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
SummarySummary
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Expertise, Skills, HabitsExpertise, Skills, Habitsand Repertoiresand Repertoires
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l Expertise is Domain-specific
l Expert Knowledge & Skills– Highly organised and structured– Distinction between experts and novices
» Distinguishing noise from signal
–– Accessible, functional and efficientAccessible, functional and efficient
l Expert : Novice differences– Applied vv abstract knowledge– Source of findings & training insights– Problem of access
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
ExpertiseExpertise
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l Domain experts and real tasks– Importance of practical skills– Heuristics, rules of thumb– Habitual, patterned behaviours
» Invariably undocumented: individualised
l Domain expertise–– Domain specific knowledge, Implementation skillsDomain specific knowledge, Implementation skills–– Mental models, Scripts, Scenarios, Schemas …Mental models, Scripts, Scenarios, Schemas …
l Linking of knowledgeknowledge --conceptsconcepts --actionaction– Implies key training elements – what is done– Formal task analysis - operational practice analysis
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
ExpertiseExpertise
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l Operational Management of Events– Fly the Aircraft – Complete Technical Drills
» Assess Consequences» Coordinate activity
– Adhere to Procedures– Apply CRM Principles– Communications (multiple)– Decide + Implement a Plan
» Competing layers of activity» Manage Time / Task stress, etc., etc
– Context : Weather, Aircraft, Airfield, etc.
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
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Basic OperationalSkills
OperationalManagement Skills
Basic Flying Skills
Core OperationalCore OperationalSkillsSkills
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Core OperationalCore OperationalSkillsSkills
ObservableObservable
SpecifiableSpecifiable
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Core OperationalCore OperationalSkillsSkills
This is where we see This is where we see the symptoms of the symptoms of
cockpit management cockpit management problems: workload, problems: workload,
breakdowns in breakdowns in communications,communications,
coordination,coordination,CRM, etc. etc. …CRM, etc. etc. …
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Basic OperationalSkills
OperationalManagement Skills
Basic Flying Skills
Core OperationalCore OperationalSkillsSkills
High Level Operational Skills
UnobservableUnobservable
“Inaccessible”“Inaccessible”
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Basic OperationalSkills
OperationalManagement Skills
Basic Flying SkillsStrategic Management
Skills
Core OperationalCore OperationalSkillsSkills
High Level Operational Skills
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• Recognition• Prioritisation• Anticipation• Projection• Planning
Strategic ManagementSkills
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Basic OperationalSkills
OperationalManagement Skills
Basic Flying Skills
Implementation Skillsand Repertoires
Strategic ManagementSkills
Core OperationalCore OperationalSkillsSkills
High Level Operational Skills
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Implementation Skillsand Repertoires
• Mental Flight Path Control• Rules of Thumb• Gates and Triggers• Event Flow Patterns• Generic Response Patterns• Situational Concepts• Time Management
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BasicOperational
Skills
Cockpit Organisational
Skills
BasicFlyingSkills
Implementation Skills and Repertoires
• Mental Flight Path Control• Rules of Thumb• Gates and Triggers• Event Flow Patterns• Generic Response Patterns• Situational Concepts• Time Management
• Prioritisation• Anticipation• Planning• Recognition
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Basic OperationalSkills
OperationalManagement Skills
Basic Flying Skills
Implementation Skillsand Repertoires
Strategic ManagementSkills
Proactive Proactive Operational Operational Skills ( Skills ( ExpertsExperts ))
ReactiveReactive OperationalOperationalSkills ( Skills ( NovicesNovices ))
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High Level Operational Skills
This is where This is where the “action the “action
takes place”takes place”-- this is where this is where problems are problems are
avoidedavoided
This is where This is where problems problems
appearappear
Core OperationalCore OperationalSkillsSkills
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High Level Operational Skills
Core OperationalCore OperationalSkillsSkills
The Domain of The Domain of ProactionProaction
The Domain of The Domain of ReactionReaction
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High Level Operational Skills
This is where This is where we will get the we will get the “bang for our “bang for our training buck”training buck”
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Drawing Lessons: Drawing Lessons: Personal ExperiencePersonal Experience
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l Unexpected events / variations»Two “War Stories”
v The unexpected Go Aroundv The “well managed” Go Around
l Lessons Learnedv What went well – and why
v What went not so well – and why
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
Issues Issues -- EventsEvents
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l 2. “Well managed” event – Dispatch electrical problem– Early gear deployment
»Red Light»ATC – “defensive call”»Briefed cabin crew / passengers»Briefed co-pilot for Go-around
• Intentions, division of tasks, fuel, time …
l Clearly in charge … in control
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
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l Sent to holding pattern– Surprised, but had briefed
» Being “ahead” works!
– Alternate gear deployment» Clearly an indication problem
– Joined pattern for landing– Longer than expected
» Under control
– Post landing issues» Spoke to ATC, cabin crew, company, co-pilot
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
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l What went well here ?– Management was proactive– All anticipated issues went very well
» Situation under control throughout
– Communications» No adverse passenger problems» No cabin crew problems» Post-landing events managed quickly
– Time & Space Created» Stress, workload, error growth prevented
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
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““ Chance favours the mind Chance favours the mind that is prepared ”that is prepared ”
Louis PasteurLouis Pasteur
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l What went badly here ?– Items not in my management “model”– Items conditioned by simulator rituals
» Alternate Gear deployment» Maintained configuration
– Failure to seek landing priority– Significant fuel burn
» Needless risk creation» Layer of defence removed
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
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““ I learned about flying from I learned about flying from that ”that ”
Title of Column in Aviation PeriodicalTitle of Column in Aviation Periodical
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l Source of Strategic Skills– Prior experience– “Event management” model
l Framework for event management» Generic » Modified for circumstances
l Problem areas» Not previously experienced» Not anticipated» Not thought about» Inappropriate flow patterns / habitual links
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
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““ We first make our We first make our habits and then our habits and then our
habits make us ”habits make us ”
John DrydenJohn Dryden
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l This became a “war story”l War stories = “hangar talk”
– Direct learning for participants– Others: A means of vicarious learning– I told my story– I heard other stories
l My story helps a friend ...l A source of learning
– Rarely formalised– Applies to most job functions
Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
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Generic StructureGeneric StructureHabitual RoutinesHabitual RoutinesGeneric ChecklistGeneric Checklist
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l Generic Framework & Habitual Routinesl Source of Help
– Thinking about / ordering operational issues– Specific Categories of non-normal event
l Translating lessons learned into:» Training materials» Enduring value» A format that will form an operational bedrock
l An example– Transforming these principles into training– An example, one way …– New trainees, prior to type transition (JAA-MCC)
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AIRCRAFT HANDLING ......................... ASSIGN
PROBLEM ...................... IDENTIFY & X-CHECK
CREW CO-ORDINATION/TASKS ....... ASSURE
CIRCUIT BREAKERS ............................. CHEC K
OPERATIONAL CONSEQUENCES..EVALUATEOPERATIONAL CONSEQUENCES..EVALUATE
RELEVANT SYSTEM SWITCHES..................OFF
SUPPLEMENTARY ITEMS................COMPLETE
SYSTEMS MALFUNCTION CHECKLISTSYSTEMS MALFUNCTION CHECKLIST
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SYSTEMS MALFUNCTION CHECKLISTSYSTEMS MALFUNCTION CHECKLIST
Q EVALUATE OPERATIONAL CONSEQUENCES
w Time / Fuel Constraintsw Aircraft Performancew Airfield Performancew Available Resources to Managew Communications
wATC, Cabin Crew, Passengers, Company …
Ø Hand flying: all real time drills
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l Role– Encourage desired operational behaviours– Encourage good cockpit management behaviours– Provide a generic structure
» for thinking about non-normal flight management» for cockpit : cabin communications» smoke drills, etc., etc.
– Evoke desired CRM behaviours– Evoke consideration of external factors– Create a shared framework / orientation
l Assure flying basics addressed
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l Complexity– Reduced, ordered, structured– Action oriented framework
l Initial training– Short period– Not mandated afterwards– Formalising
» what has to be learned» initial point of departure
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Drawing ConclusionsDrawing Conclusions
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l Better Pilots and Events– possess a good operational picture– clear sense of how they will manage events
» clear as to their objectives» clear in their communications» clear in their actions» are in charge of events : proactive control
– Their performance looks good
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l Better Pilots are “cognitively primed”– Generic frames/scenarios align & focus events– Implementation repertoires– Means to monitoring effective implementation
l Good performances– Decisive, focused & appropriate decisions– Early decision making
l Avoid confusion, delay, poor decisions » Characteristic of poor crew performance» Is this fundamentally a CRM issue?
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l Impact of the “Real World”– Interferes with our plans– Break cycle of expectation– Break cycle of implementation
• Whether from the simulator • … or from previous experience
l Introduces novel elements• Sources of distraction, of confusion, of workload …
» (a) doing things» (b) unexpected / unanticipated events, consequences
l Mental workload, reactive, intensive demands on mental resources
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Issues Issues -- EventsEvents
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Emergencies and Abnormal SituationsEmergencies and Abnormal Situations
l Capturing Pilot Expertise– A lot can be done– Requires research– Perhaps less difficult than it looks
l A Practical Activity» Cognition without the theory» Theoretical models
l More Emphasis on Cognition – Cognition and CRM
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l No correct or immutable answers– Cannot be “definitive”– A source of key training insights
l Training– Does not have to be in the simulator– Written Scenarios– Guidance materials
» hints, traps, rules of thumb, linkages …
l Flexible thinking– Training methods, training solutions
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Responding to Responding to Emergencies and Emergencies and
Abnormal SituationsAbnormal Situations
Neil JohnstonAerospace Psychology Research Group
Trinity College [email protected]