7/30/2019 FAA Research Briefing
1/30
University of Texas
FAA Research Briefing
Robert HelmreichJames Klinect
Michelle Harper
Department of Psychology
The University of Texas at Austin
Washington, 3 March 2004
7/30/2019 FAA Research Briefing
2/30
UT Human Factors Research Project
Studies individual / crew performance in demandingprofessions; influence of system and organizational factors
The research team: Robert Helmreich, PhD, FRAeSProject Director
James Klinect
LOSA Project Coordinator
Michelle Harper, MSASAP Project Coordinator
Ashleigh Merritt, PhDResearch Scientist
Chris Henry - Researcher
Lou Montgomery - Research Assistant
7/30/2019 FAA Research Briefing
3/30
Aviation Safety EnvelopeAccidents
Incidents
Normal Operations
Accident Investigation
LOSA
FOQA
ASAP
Good News
1. All areas of the envelope can beinvestigated
2. Strong airline buy-in
Bad News
1. Airlines overwhelmed with data
2. Lessons learned kept within each airline
3. Multiple data sources not integrated
7/30/2019 FAA Research Briefing
4/30
Bad News: Issues and Solutions
Airlines overwhelmed with data Solution: Airlines need help collecting / analyzing data
Lessons learned kept within each airline Solution: Third party conducts industry level analyses
Multiple data sources not integrated Solution: A common conceptual framework
7/30/2019 FAA Research Briefing
5/30
Threat and Error Management (TEM)
TEM providesa common frameworkfor studying flight crewperformance and the operating environment
Multiple uses of TEM
Data collection, analysis and feedback
LOSA
ASAP
Incident / Accident analysis (IATA)
Pilot training and evaluation
Curriculum development
Line checks
Licensing (ICAO)
7/30/2019 FAA Research Briefing
6/30
Threat and Error Management Model
Threat Management
Successful(Inconsequential)
Incident orAccident
Error Management
UndesiredAircraft States
Error(Threat Induced)
Error(Spontaneous)
Undesired AircraftState Management
Latent Threats Active Threats
7/30/2019 FAA Research Briefing
7/30
Line Operations Safety Audit(LOSA)
7/30/2019 FAA Research Briefing
8/30
Aviation Safety Envelope: LOSAAccidents
Incidents
Normal Operations
LOSA
7/30/2019 FAA Research Briefing
9/30
LOSA Archive
AeroMexico
Alaska Airlines
Air New Zealand 98, 03
Braathens ASA
Cathay Pacific
China Airlines
Continental 96, 98, 00, 04 Continental Express
Continental Micronesia
Delta Airlines
EVA AIR
Frontier Airlines
QANTAS
Singapore Airlines
Silk Air
UNI AIR US Airways
Since 1996 - 21 LOSAs, all TEM-based; Archive now has3000+ observations
Most foreign carriers code share with US airlines
7/30/2019 FAA Research Briefing
10/30
LOSA Data
% of flights with one ormore threats % of threats that weremismanaged
All Threats 92% 12%
ATC Threats 47% 28%
% of flights% of errors / UAS
mismanaged
Errors 71% 28%
UndesiredAircraft States
29% 3%
7/30/2019 FAA Research Briefing
11/30
LOSA Drivers
1) UTHFs reputation in the industry2) TEMs intuitive appeal
3) Airline success stories (Continental 1996-2000)
4) ICAO Formalized LOSA as best practice Sponsored LOSA weeks (Hong Kong, Panama, Dubai and
Dublin)
ICAO Document 9803 (LOSA)
5) Pilot association endorsements ALPA and IFALPA
6) The LOSA Collaborative
7/30/2019 FAA Research Briefing
12/30
LOSA: Research Plan 2004-2007
1) Concepts: Refine and expand the role of TEM
2) Method: Disseminate LOSA tools and techniques to industry
3) Research: Conduct industry level analyses of the LOSA data archive
4) Communication: Distribute findings to airlines, regulators and industry
5) Data Sharing: Develop a proof of concept for LOSA / ASAP integration
7/30/2019 FAA Research Briefing
13/30
Aviation Safety Action Program(ASAP)
7/30/2019 FAA Research Briefing
14/30
Aviation Safety Envelope: ASAPAccidents
Incidents
Normal Operations
Accidents
Incidents
Normal Operations
ASAP
7/30/2019 FAA Research Briefing
15/30
UTHF/ASAP Demonstration ProgramASAP Support Tools Development
Developing a set of tools to aid airlines in the collection,categorization and analysis of ASAP data
1) Pilot reporting form
2) ASAP manager tool kit
3) Event Review Committee (ERC) review forms
All tools internet based
Tools based on TEM Tools feed into internal airline-housed database
7/30/2019 FAA Research Briefing
16/30
UTHF / ASAP Demonstration ProgramMethodology
Participating airlines Continental Frontier Northwest
In return for support UTHF given access to airline housed ASAP data
UTHF server to airline server communication
High-speed, encrypted, intranet access
Benefits of UTHF server to Airline server access
Data Protection - Data confidentiality protected Data Sharing Ability to query data from multiple ASAP databases
Cost Sharing - Tools developed by UTHF / Maintained and supported by
airline
7/30/2019 FAA Research Briefing
17/30
1) Method: Develop ASAP data collection, categorization and analysistools
2) Research: Complete industry-level analyses of threat and error
profiles, high risk events, system level factors, and intervention
strategies
3) Communication: Distribute findings to airlines, regulators and
industry
4) Data Sharing: Develop a proof of concept for LOSA / ASAP
integration
ASAP: Research Plan 2004-2007
7/30/2019 FAA Research Briefing
18/30
Summary
7/30/2019 FAA Research Briefing
19/30
Issues and UTHF Strategies
Airlines overwhelmed with data
Provide LOSA and UTHF ASAP implementation andanalysis tools to industry
Lessons learned kept within each airline
UTHFs unique access to LOSA and ASAP data willenable industry level analysis and feedback
Multiple data sources not integrated Apply TEM as a framework for linking normal
operations, incident and accident data
7/30/2019 FAA Research Briefing
20/30
The University of Texas
Human Factors Research Project
www.psy.utexas.edu/HumanFactors
http://www.psy.utexas.edu/HumanFactorshttp://www.psy.utexas.edu/HumanFactors7/30/2019 FAA Research Briefing
21/30
Supplementary Slides
Threat and Error ManagementDefinitions and Example
7/30/2019 FAA Research Briefing
22/30
Threat and Error Management Model
Threat Management
Successful(Inconsequential) Incident orAccident
Error Management
UndesiredAircraft States
Error(Threat Induced)
Error(Spontaneous)
Undesired AircraftState Management
Latent Threats Active Threats
7/30/2019 FAA Research Briefing
23/30
Latent Threats
Aspects of the system that predispose the commission oferrors or can lead to undesired aircraft states
ATC practices
Organizational, national, professional culture
Aircraft characteristics Qualification standards
Regulatory practices and oversight
Flawed procedures
Scheduling and rostering practices
7/30/2019 FAA Research Briefing
24/30
Active Threats
1. Environmental Threats
Adverse WX
Terrain
Airport Conditions Heavy traffic / TCAS events
2. ATC Threats
Command events / errors
Language difficulties
3. Aircraft Threats
Malfunctions
Automation events
4. Crew Support Threats
Dispatch events / errors
Ground events / errors
MX events / errors
5. Operational Threats Time Pressures
Irregular Operations
Radio congestion / poor
reception
6. Cabin Threats Cabin events / FA errors
Events or errors that originate outside the influence of the flight
crew but require their attention to maintain safety
7/30/2019 FAA Research Briefing
25/30
Errors
Intentional Noncompliance intentional deviations from SOP
Ex) Performing a checklist from memory
Procedural Followed procedures with incorrect executionEx) Wrong attitude setting dialed
Communication Missing information or misinterpretation
Ex) Miscommunication with ATC
Decision Crew decision unbounded by procedures thatunnecessarily increased risk
Ex) Unnecessary navigation through adverse weather
A threat-induced or spontaneous deviation from organizational
or flight crew expectations
7/30/2019 FAA Research Briefing
26/30
Undesired Aircraft States
Lateral deviation
Vertical deviation
Speed too high
Speed too low
Incorrect aircraft configurations
Flight controls Systems
Fuel
Automation
Unstable approach
Abrupt aircraft control
Long landing
Firm landing
Wrong taxiway / ramp
Wrong runway
Runway incursion
A threat or error-induced state in which the aircraft is placed in
a compromised situation that increases risk to safety
7/30/2019 FAA Research Briefing
27/30
Sample TEM Exercise
Takeoff / ClimbDuring climb, the crew discovered that a fuel
pump low pressure light was illuminated. All crewmembers were
working the problem when ATC instructed them climb to FL350. The
First Officer (PNF) read back FL350 but failed to make the change in
the MCP. The crew also failed to cross-verify the altitude change in
the MCP. After a few moments, ATC noticed that the aircraft
remained at FL270 and called the crew to correct the problem.
7/30/2019 FAA Research Briefing
28/30
Example: Threats
Threat Aircraft Fuel pump low pressure light
Threat management Mismanaged because the crew got distracted and
failed to set the correct altitude led to a verticaldeviation
7/30/2019 FAA Research Briefing
29/30
Example: Errors
Error #1 Procedural Crew failed to dial the correct altitude in
the MCP as requested by ATC.
Error #2 Procedural Crew failed to cross-verify the altitude
change per altitude awareness SOP.
Error management Mismanaged because the crew failed to detect their
errors due to be being distracted by the fuel pumplow pressure light issue
7/30/2019 FAA Research Briefing
30/30
Example: Undesired Aircraft States
Undesired Aircraft State Vertical deviation aircraft remained level after ATC
instructed the crew to climb
Undesired Aircraft State Management Mismanaged by the crew since the errors that led to
the vertical deviation were undetected
Managed by ATC with a callback to the crew
instructing them to climb