Human factors approaches and models in LOC-I accident analysis and prevention: flight crew resource management techniques as a risk mitigation tool

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Sikora, Ivan ORCID: https://orcid.org/0000-0003-2314-9724, Hari, Benjamin L. and Hanusch, Moritz (2020) Human factors approaches and models in LOC-I accident analysis and prevention: flight crew resource management techniques as a risk mitigation tool. International Journal of Safety and Security Engineering, 10 (3). pp. 301-310. ISSN 2041-9031

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Official URL: https://doi.org/10.18280/ijsse.100301

Abstract

Increased cockpit automation on modern jet aircraft aim to reduce the risk of Undesired Aircraft State (UAS) instances such as Loss of Control in Flight (LOC-I). Although LOCI globally accounts for only 9% of all analysed accidents IATA has reported that it was responsible for 58% of all accident fatalities in 2017. The focus of this paper is to answer whether Threat and Error Management and Crew Resources Management (CRM) techniques are an efficient risk management tool when facing a LOC-I threat. Three LOCI final aircraft accident reports were analysed to understand the structure of Human Factors (HF) during these flights. Methods from the HF field such as the Generic Error Modelling System (GEMS) and Skill-, Rule- and Knowledge-based (SRK) error approach provided invaluable insights to identify potential findings. A holistic investigation of cognitive structures in flight path management helped to visualise latent conditions and cognitively demanding tasks during LOC-I in routine operations. Bearing in mind the limited number of cases considered in this paper it should be considered as an overview in LOC-I accident analysis. It shows that leadership and teamwork, as essential aspects of CRM training, can serve as key strategies to mitigate HF problems and LOC-I risks.

Item Type:	Article
Identifier:	10.18280/ijsse.100301
Additional Information:	The original publication is available also at https://www.iieta.org
Keywords:	automation, human factors, manual flying skills, crew resource management, threat and error management
Subjects:	Business and finance > Business and management > Corporate governance Hospitality and tourism > Hospitality > Risk and reputation management
Related URLs:	Author Publisher
Depositing User:	Ivan Sikora
Date Deposited:	22 Oct 2020 10:10
Last Modified:	04 Nov 2024 11:46
URI:	https://repository.uwl.ac.uk/id/eprint/7414

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References

[1] Bureau d‘Enquêtes et d’Analyses. (2012). Final report on the accident on 1st June 2009 to the Airbus A330-203 registered F-GZCP operated by Air France flight AF 447 Rio de Janeiro–Paris. Paris: Bureau d‘Enquêtes et d’Analyses.

[2] Australian Transport Safety Bureau. (2013). In-flight uncontained engine failure Airbus A380-842, VH-OQA. Canberra: Australian Transport Safety Bureau.

[3] Statens Haverikommission. (2016). Final report RL 2016: 11e Accident in Oajevágge, Norrbotten County, Sweden on 8 January 2016 involving the aeroplane SE-DUX of the model CL-600-2B19, operated by West Atlantic Sweden AB. File no. L-01/16. Stockholm: Statens haverikommission.

[4] Rasmussen, J. (1982). Human errors - A taxonomy for describing human malfunction in industrial installations. Journal of Occupational Accidents, 4(2-4): 311-333. https://doi.org/10.1016/0376-6349(82)90041-4

[5] European Aviation Safety Agency. (2007). Certification specification for large aeroplanes CS-25. Cologne: European Aviation Safety Agency.

[6] Komite Nasional Keselamatan Transportasi. (2019). Aircraft accident investigation report, PT. Lion Mentari Airlines Boeing 737-8 (MAX); PK-LQP, Tanjung Karawang, West Java, Republic of Indonesia, 29 October 2018. Jakarta, Indonesia: Komite Nasional Keselamatan Transportasi.

[7] Aircraft Accident Investigation Bureau. (2019). Aircraft accident investigation preliminary report: Ethiopian airlines group B737-8 (MAX) registered ET-AVJ, 28 NM South East of Addis Ababa, Bole International Airport, March 10, 2019. Addis Ababa, Ethiopia: Federal Democratic Republic of Ethiopia, Ministry of Transport, Aircraft Accident Investigation Bureau.

[8] International Air Transport Association. (2015). Loss of control in-flight accident analysis report 2010-2014. Montreal-Geneva: International Air Transport Association.

[9] Wilborn, J.E., Foster, J.V. (2004). Defining commercial transport loss-of-control: A quantitative approach. AIAA Atmospheric Flight Mechanics Conference and Exhibit, 16 - 19 August 2004, Providence, Rhode Island. Reston, VA: American Institute of Aeronautics and Astronautics. http://dx.doi.org/10.2514/6.2004-4811

[10] International Civil Aviation Organization. (2018). ICAO safety report, 2018 edition. Montreal, Quebec, Canada: International Civil Aviation Organization.

[11] International Air Transport Association. (2018). Safety report 2017. 54th Edition issued in April 2018. Montreal-Geneva: International Air Transport Association.

[12] European Aviation Safety Agency. (2017). Annual safety review 2017. Cologne: European Aviation Safety Agency.

[13] Hari, B. (2015). Prevention of loss of control accidents in flight (LOC-I) through implementation of evidence based training in basic pilot training and type rating courses. London: City University London.

[14] Flight Deck Automation Working Group. (2013). Operational use of flight path management systems. Washington, DC: Performance-based operations Aviation Rulemaking Committee.

[15] International Air Transport Association. (2015). Safety report 2014. 51st Edition issued in April 2015. Montreal-Geneva: International Air Transport Association.

[16] Jacobsen, S. (2010). Aircraft loss of control study. AIAA GNC Conference, Toronto, Canada. Edwards, CA: NASA Dryden Flight Research Center.

[17] International Air Transport Association. (2015). Loss of control in-flight (LOC-I) prevention: beyond the control of pilots. 1st Edition. Montreal-Geneva: International Air Transport Association.

[18] International Air Transport Association. (2015). Guidance material and best practices for the implementation of upset prevention and recovery training. Montreal-Geneva: International Air Transport Association.

[19] Netherland Aerospace Center. (2015). Man4Gen: Manual operation of 4th generation airliners. Amsterdam: Netherland Aerospace Center.

[20] European Aviation Safety Agency. (2015). Annual safety review 2014. Cologne: European Aviation Safety Agency.

[21] Dismukes, R.K., Berman, B.A., Loukopoulos, L.D. (2007). The limits of expertise: Rethinking pilot error and the causes of airline accidents. Surrey: Ashgate Publishing Ltd. http://dx.doi.org/10.4324/9781315238654

[22] Ebbatson, M. (2009). The loss of manual flying skills in pilots of highly automated airliners. Cranfield, London: Cranfield University.

[23] Airbus. (2018). A statistical analysis of commercial aviation accidents 1958-2017. Blagnac Cedex, France: Airbus S.A.S.

[24] European Aviation Safety Agency. (2013). EASA automation policy. Cologne: European Aviation Safety Agency.

[25] Casner, S.M., Geven, R.W., Recker, M.P., Schooler, J.W. (2014). The retention of manual flying skills in the automated cockpit. Human Factors: The Journal of the Human Factors and Ergonomics Society, 56: 1506-1516. http://dx.doi.org/10.1177/0018720814535628

[26] Reason, J.T. (1990). Human Error. Cambridge: University Press. http://dx.doi.org/10.1017/CBO9781139062367

[27] Dekker, S.W.A. (2017). Rasmussen’s legacy and the long arm of rational choice. Applied Ergonomics, 59: 554-557. http://dx.doi.org/10.1016/j.apergo.2016.02.007

[28] National Transportation Safety Board. (2010). Aircraft accident report AAR-10/01– Loss of Control on approach, colgan AIR, Inc., Operating as Continental Connection Flight 3407, Bombardier DHC-8-400, N200WQ, Clarence Center, New York, February 12, 2009. Washington, DC: National Transportation Safety Board

[29] Embrey, D. (2005). Understanding human behaviour and error. Human Reliability Associates, 1: 1-10.

[30] Sinnett, S., Soto-Faraco, S., Spence, C. (2008). The co-occurrence of multisensory competition and facilitation. Acta Psychologica, 128(1): 153-161. http://dx.doi.org/10.1016/j.actpsy.2007.12.002

[31] Bundesstelle für Flugunfalluntersuchung. (2015). Interim report BFU 6X014-14. Braunschweig: BFU – Bundesstelle für Flugunfalluntersuchung / German Federal Bureau of Aircraft Accident Investigation

[32] Warm, J.S., Parasuraman, R., Matthews, G. (2008). Vigilance requires hard mental work and is stressful. Human Factors, 50(3): 433-441. http://dx.doi.org/10.1016/j.actpsy.2007.12.002

[33] Civil Aviation Authority. CAA. (2013). Monitoring matters. Guidance on the Development of Pilot Monitoring Skills. London: Civil Aviation Authority.

[34] European Aviation Safety Agency. (2014). Notice of proposed amendment 2014-17 – Crew resource management (CRM) training – RMT.0411 (OPS.094) — 26.6.2014. Cologne: European Aviation Safety Agency.

[35] Kunz, C. (2015). Resilienz von Piloten im Cockpit bei SWISS. Olten, Switzerland: Fachhochschule Nordwestschweiz (FHNW).

[36] European Aviation Safety Agency. EASA. (2015b). EASA Safety Information Bulletin SIB No. 2010-33R1: Automation Policy – Mode Awareness and Energy State Management. Cologne: European Aviation Safety Agency.

[37] Hari, B. (2013). Coursework A – Air Accident Investigation. London: City University London.

[38] Ebbatson, M., Harris, D., Huddlestone, J., Sears, R. (2010). The relationship between manual handling performance and recent flying experience in air transport pilots. Ergonomics, 53(2): 268-277. http://dx.doi.org/10.1080/00140130903342349

[39] Haslbeck, A., Hoermann, H.J. (2016). Flying the needles: Flight deck automation erodes fine-motor flying skills among airline pilots. Human Factors, 58(4): 533-545. http://dx.doi.org/10.1080/00140130903342349

[40] Landry, D.J. (2014). Keeping manual flying skills sharp. Air Line Pilot, June 2014, 24-25.

[41] Hanusch, M. (2017). Manual Flying Skills – Airline Procedures and Their Effect on Pilot Proficiency. London: City University of London.

[42] Ferris, T., Sarter, N., Wickens, C.D. (2010). Cockpit automation: Still struggling to catch up. In: Human Factors in Aviation, 2nd ed., Salas, E., Maurino, D.E. (eds.). Amsterdam; Boston, MA: Academic Press/Elsevier. http://dx.doi.org/10.1016/B978-0-12-374518-7.00001-8

[43] Transport Canada. (2015). Advisory circular AC 600-006 – Flight deck automation policy and manual flying in operations and training. Ottawa: Transport Canad.

[44] Department of Transport. (2016). Audit report - Enhanced FAA oversight could reduce hazards associated with increased use of flight deck automation. Report Number AV-2016-013. Washington, DC: Department of Transport, Office of Inspector General.

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Human factors approaches and models in LOC-I accident analysis and prevention: flight crew resource management techniques as a risk mitigation tool

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