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Source: Palmer, E.A., Hutchins, E.L., Ritter, R.D., & VanCleemput, I. (1993). Altitude Deviations: Breakdown of an Error-Tolerant System. NASA Technical Memorandum 108788. Moffett Field, CA: NASA Ames Research Center.
Source Type:   Incident Study
Synopsis: "This report examines the error-tolerant properties of today's aviation task of changing altitude. Our approach is to study pilot reports to the Aviation Safety Reporting System (ASRS) of breakdowns in this normally error-tolerant task. These reports are used to assemble a composite description of the flight deck as an information processing system. ... The report emphasis is on the effect of increased cockpit automation - for aircraft navigation, guidance, and control in the current generation of glass cockpit airliners - on the type of altitude deviations reported by pilots. ... A one-page coding form was developed that allowed the ASRS incidents to be described in terms of the factors that were present in the incident. In the initial part of this study, this form was completed for altitude-deviations reports from the pilots of 50 conventional-cockpit and 50 glass cockpit aircraft. ... Examples of ASRS narratives that illustrate the trends observed in this collection of altitude deviations incidents are provided. ... The incidents are then used to construct a descriptive model of the information flow in the error-tolerant human-machine system that performs and monitors the altitude-change task. The report concludes with recommendations for procedures for the altitude-change task and for future equipment design."
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