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Evidence from Resource 13 pieces of evidence from this resource.

Bruseberg, A., & Johnson, P. (not dated). Collaboration in the Flightdeck: Opportunities for Interaction Design. Department of Computer Science, University of Bath. Available at http://www.cs.bath.ac.uk/~anneb/collwn.pdf.

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  2. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.7 The FMS turns the white dashed line into a solid magenta line and orients the map towards the new heading. The pilot fails to identify the unintended route. Design analysis: The system has an aid function in showing the progress of the plan being executed. This is displayed graphically through the present active plan, the current orientation (as is gradually changes), and the current flight parameters through several dial representations. Problem analysis: The significant heading change, bank, and map turn was not identified by either pilot, since not actively monitored. The change was visible but there may have been a lack of attention in a busy environment. The severity of the change was not identified. Collaboration analysis: In a situation where pilots do not expect to find a problem, their attention must be drawn to vital pieces of information in a better way. This may require a better understanding of the nature of such occurrences to make their essence more apparent. (page 6)
    Issue: automation use may be vulnerable to cockpit distractions (Issue #171) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation: displays

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  4. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.6 The FMS displays a route discontinuity warning and insufficient fuel warning. The pilot ignores the warnings, does not identify the error, and executes the change. Design analysis: The system was given a support function by providing an assessment of the new waypoint as to whether or not it connects to the previously chosen route, and an assessment of fuel capacity. Problem analysis: The route discontinuity warning to indicate that the new waypoint interrupts the pre-programmed route was not effective. The warnings may have been on a different screen. The system is instructed to fly to an undesired waypoint. Collaboration analysis: 1. The system recognises the instruction as part of a plan that connects several waypoints up to the landing point. However, assessments and warnings by the FMS were not sufficiently meaningful: the route discontinuity warning would have been expected for Rozo too, since the route was being changed in any case. Thus, the FMS only provides a partial plan assessment by noticing that the new route does not connect to the old one. However, the system may have been able to provide more useful assessments based on the information it had access to. Thus, the design insufficiently anticipated what information would be useful to the pilot here. (page 6)
    Issue: human-centered design philosophy may be lacking (Issue #100) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation: displays

  5.  
  6. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.6 The FMS displays a route discontinuity warning and insufficient fuel warning. The pilot ignores the warnings, does not identify the error, and executes the change. Design analysis: The system was given a support function by providing an assessment of the new waypoint as to whether or not it connects to the previously chosen route, and an assessment of fuel capacity. Problem analysis: The route discontinuity warning to indicate that the new waypoint interrupts the pre-programmed route was not effective. The warnings may have been on a different screen. The system is instructed to fly to an undesired waypoint. Collaboration analysis: 1. The system recognises the instruction as part of a plan that connects several waypoints up to the landing point. However, assessments and warnings by the FMS were not sufficiently meaningful: the route discontinuity warning would have been expected for Rozo too, since the route was being changed in any case. Thus, the FMS only provides a partial plan assessment by noticing that the new route does not connect to the old one. However, the system may have been able to provide more useful assessments based on the information it had access to. Thus, the design insufficiently anticipated what information would be useful to the pilot here. (page 6)
    Issue: displays (visual and aural) may be poorly designed (Issue #92) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation & FMS

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  8. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.6 The FMS displays a route discontinuity warning and insufficient fuel warning. The pilot ignores the warnings, does not identify the error, and executes the change. Design analysis: The system was given a support function by providing an assessment of the new waypoint as to whether or not it connects to the previously chosen route, and an assessment of fuel capacity. Problem analysis: The route discontinuity warning to indicate that the new waypoint interrupts the pre-programmed route was not effective. The warnings may have been on a different screen. The system is instructed to fly to an undesired waypoint. Collaboration analysis: 1. The system recognises the instruction as part of a plan that connects several waypoints up to the landing point. However, assessments and warnings by the FMS were not sufficiently meaningful: the route discontinuity warning would have been expected for Rozo too, since the route was being changed in any case. Thus, the FMS only provides a partial plan assessment by noticing that the new route does not connect to the old one. However, the system may have been able to provide more useful assessments based on the information it had access to. Thus, the design insufficiently anticipated what information would be useful to the pilot here. (page 6)
    Issue: insufficient information may be displayed (Issue #99) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation & FMS

  9.  
  10. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.5 The pilot may not have consulted the map display. Problem analysis: To be able to see the system feedback the pilot was required to select a different content for the screen and pay additional attention. The map display was probably never selected or considered. Collaboration analysis: Important feedback information was available but the pilot’s attention was never drawn to it. The system provided no mechanism to ensure that the information available had actually been considered. (page 5)
    Issue: behavior of automation may not be apparent (Issue #83) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation: displays

  11.  
  12. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.4 The FMS map display shows the intended new route as a white dashed line, which points off the screen. Design analysis: The system is given a support function by providing feedback of the implications for the selected instruction. It graphically shows the new route in relation to the old one. Moreover, the navigational display helps perception by showing route and route plan in different colours. Problem analysis: The significant course diversion (angle and distance of Romeo) was probably only partially visible since Romeo was off the screen. Collaboration analysis: As a mechanism to ensure a match of understanding, and to provide a prediction of the effects of the instruction, the FMS repeats back the instruction in a different data format (graphically). The feedback also shows context and implications. However, not all information available was communicated. Important aspects were not visible due to the map scale and orientation. (page 5)
    Issue: displays (visual and aural) may be poorly designed (Issue #92) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation: displays

  13.  
  14. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.2 The FMS displays a list of possible options, with 'Romeo' at the top. The pilot selects the first option on the list without verifying whether the first listed waypoint is Rozo. Design analysis: The FMS has been given the function to support the pilot in making a selection by displaying the waypoint closest to the current position and route first. The purpose of displaying the list is two-fold in terms of providing support. It aims to stipulate an easy selection, as well as to provide feedback of the systems’ understanding. The information is displayed in the format of coordinates, not waypoint name. Problem analysis: The coordinates are difficult to check for accuracy in the time available since they require comparing with documentation to retrieve the associated name. Complacency and lack of time prevents the pilot from checking the accuracy of the first item on the list through comparing the coordinates. Habit leads to choosing the first displayed waypoint without checking. The fact that Rozo was not in the list at all was not identified. Collaboration analysis: Whilst the system anticipates the pilot’s likely first choice on top of the list, it does not effectively support the pilots’ task in using their active relevant terminology (i.e. the full name of the waypoint). The reliance on the system’s choice encouraged complacency and unjustified trust since experience showed that checking is not necessary. If there is virtually no function in making a choice, then why give the pilot the option to do so? (page 5)
    Issue: automation may adversely affect pilot workload (Issue #79) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation & FMS

  15.  
  16. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.2 The FMS displays a list of possible options, with 'Romeo' at the top. The pilot selects the first option on the list without verifying whether the first listed waypoint is Rozo. Design analysis: The FMS has been given the function to support the pilot in making a selection by displaying the waypoint closest to the current position and route first. The purpose of displaying the list is two-fold in terms of providing support. It aims to stipulate an easy selection, as well as to provide feedback of the systems’ understanding. The information is displayed in the format of coordinates, not waypoint name. Problem analysis: The coordinates are difficult to check for accuracy in the time available since they require comparing with documentation to retrieve the associated name. Complacency and lack of time prevents the pilot from checking the accuracy of the first item on the list through comparing the coordinates. Habit leads to choosing the first displayed waypoint without checking. The fact that Rozo was not in the list at all was not identified. Collaboration analysis: Whilst the system anticipates the pilot’s likely first choice on top of the list, it does not effectively support the pilots’ task in using their active relevant terminology (i.e. the full name of the waypoint). The reliance on the system’s choice encouraged complacency and unjustified trust since experience showed that checking is not necessary. If there is virtually no function in making a choice, then why give the pilot the option to do so? (page 5)
    Issue: pilots may be overconfident in automation (Issue #131) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation & FMS

  17.  
  18. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.1 The pilot enters 'R' to retrieve a list of waypoints. Design analysis: To communicate the waypoint to the system, the pilot is required by a procedure to type an abbreviation into the FMS, as can be found on the (paper) approach chart, which shows and legislates how to approach an airport. Due to the system logic, only inputs of the exact correct identifier can be recognised. The FMS is given the function of retrieving a list of waypoints from its database that may match the intended waypoint selection. Problem analysis: There was a mismatch between the printed approach charts and the FMS database. Since there were two waypoints with the identifier ‘R’ in same area, pilots needed to type ‘R-O-Z-O’ to get Rozo, not ‘R’ as they expected from experience and approach chart information. Collaboration analysis: The design has not allowed for the possibility that the common reference system may be faulty. Pilots needed to know what the FMS does with the instruction – they needed to understand its restriction of not truly being able to ‘guess’ from first letter, since it can only assign one meaning to one letter in a given area. Hence it could fail to match the abbreviation altogether. (page 5)
    Issue: insufficient information may be displayed (Issue #99) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation & FMS

  19.  
  20. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.1 The pilot enters 'R' to retrieve a list of waypoints. Design analysis: To communicate the waypoint to the system, the pilot is required by a procedure to type an abbreviation into the FMS, as can be found on the (paper) approach chart, which shows and legislates how to approach an airport. Due to the system logic, only inputs of the exact correct identifier can be recognised. The FMS is given the function of retrieving a list of waypoints from its database that may match the intended waypoint selection. Problem analysis: There was a mismatch between the printed approach charts and the FMS database. Since there were two waypoints with the identifier ‘R’ in same area, pilots needed to type ‘R-O-Z-O’ to get Rozo, not ‘R’ as they expected from experience and approach chart information. Collaboration analysis: The design has not allowed for the possibility that the common reference system may be faulty. Pilots needed to know what the FMS does with the instruction – they needed to understand its restriction of not truly being able to ‘guess’ from first letter, since it can only assign one meaning to one letter in a given area. Hence it could fail to match the abbreviation altogether. (page 5)
    Issue: programming may be susceptible to error (Issue #170) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation & FMS

  21.  
  22. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.1 The pilot enters 'R' to retrieve a list of waypoints. Design analysis: To communicate the waypoint to the system, the pilot is required by a procedure to type an abbreviation into the FMS, as can be found on the (paper) approach chart, which shows and legislates how to approach an airport. Due to the system logic, only inputs of the exact correct identifier can be recognised. The FMS is given the function of retrieving a list of waypoints from its database that may match the intended waypoint selection. Problem analysis: There was a mismatch between the printed approach charts and the FMS database. Since there were two waypoints with the identifier ‘R’ in same area, pilots needed to type ‘R-O-Z-O’ to get Rozo, not ‘R’ as they expected from experience and approach chart information. Collaboration analysis: The design has not allowed for the possibility that the common reference system may be faulty. Pilots needed to know what the FMS does with the instruction – they needed to understand its restriction of not truly being able to ‘guess’ from first letter, since it can only assign one meaning to one letter in a given area. Hence it could fail to match the abbreviation altogether. (page 5)
    Issue: database may be erroneous or incomplete (Issue #110) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation & FMS

  23.  
  24. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.3.1 The pilot enters 'R' to retrieve a list of waypoints. Design analysis: To communicate the waypoint to the system, the pilot is required by a procedure to type an abbreviation into the FMS, as can be found on the (paper) approach chart, which shows and legislates how to approach an airport. Due to the system logic, only inputs of the exact correct identifier can be recognised. The FMS is given the function of retrieving a list of waypoints from its database that may match the intended waypoint selection. Problem analysis: There was a mismatch between the printed approach charts and the FMS database. Since there were two waypoints with the identifier ‘R’ in same area, pilots needed to type ‘R-O-Z-O’ to get Rozo, not ‘R’ as they expected from experience and approach chart information. Collaboration analysis: The design has not allowed for the possibility that the common reference system may be faulty. Pilots needed to know what the FMS does with the instruction – they needed to understand its restriction of not truly being able to ‘guess’ from first letter, since it can only assign one meaning to one letter in a given area. Hence it could fail to match the abbreviation altogether. (page 5)
    Issue: understanding of automation may be inadequate (Issue #105) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: automation & FMS

  25.  
  26. Evidence Type: Excerpt from Accident Review Study
    Evidence: 4.1 The Cali accident We have re-examined the Cali air accident [1, 7, 16, 20] in depth, to analyse interaction breakdowns between computer-based agents and users (pilots). This accident is an example of a ‘controlled flight into terrain’ accident, which was attributed to pilots’ actions rather than aircraft malfunction. These lead to a collision of the American Airlines Boeing 757-223 with a mountain, whilst attempting to approach Cali Airport (Colombia) in darkness. The pilots had to deal with a serious flight delay. Air Traffic Control (ATC) asked the pilots to accept a late runway change. The pilots’ acceptance significantly increased their (normally high) workload during this flight phase due to the need to re-program the FMS (Flight Management System). There were a number of miscommunications with ATC, one of which led to the deletion of intermediate navigational waypoints in the FMS, after the pilot inputted ‘direct’ to Cali. Thus, the important navigational aid ‘Tulua’ disappeared from the flight path as well as the map display. Consequently they were not aware that ‘Tulua’ had already been passed and the plane was already much closer to the mountain ridges surrounding the approach path to Cali. A further erroneous input of the waypoint ‘Romeo’ instead of ‘Rozo’, as intended, took the aircraft significantly off course into mountainous terrain. The pilots failed to notice the inappropriate direction for about a minute. They then failed to diagnose the correct position of the plane, whilst continually descending. Although they oriented the aircraft towards Cali through a heading change, they did not realize that there were mountains in the way for this (non­standard) flight path. They were alerted through the alarm of the Ground Proximity Warning System but could not avoid collision. Sadly, of the 163 people on board, only 4 passengers survived. The Cali accident highlights a series of interaction failures with the FMS. We will focus here on only one of them – the erroneous input of the waypoint ‘Romeo’ into the FMS, instead of the intended ‘Rozo’ – a miscommunication of an instruction. This was a critical error during the accident sequence since it led to a major course deviation and the loss of situational awareness. (page 3)
    Issue: automation may demand attention (Issue #102) See Issue details
    Strength: +1
    Aircraft: B757-223
    Equipment: FMS & ATC
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