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Evidence from Resource 6 pieces of evidence from this resource.

Wiener, E.L. (1993). Intervention Strategies for the Management of Human Error. NASA Contractor Report NCA2-441. Moffett Field, CA: NASA Ames Research Center.

  1.  
  2. Evidence Type: Excerpt from Observational Study
    Evidence: "Workload management, or lack of it, is illustrated by the following ASRS report. [ASRS incident report #167993] Narrative: passing ARNES on CIVET 2 profile descent, we both (2 man crew) thought we were cleared after passing FUELR for the 25L ILS approach with a sidestep to runway 24R. Approach later asked if we had the airport and we reported we did and we both thought we were cleared for a visual to runway 24R. We switched the ILS to 24R and turned in that direction. Alt was 4000' and descending, the Approach told us to turn 20 deg left and that we had traffic to our right. He apparently was turning into runway 24R. Approach said our original clearance was for runway 25R, not for runway 25R. Apparently we misheard the clearance. Contributing factors: tuning in a runway and being forced to changed to another runway while trying to make altitude restrictions etc. Also flying an automated, glass cockpit aircraft in this environment pushes workload to the limit, when having to change runways on final, forcing you to reprogram the computer, re-tune the nav radios and change VHF freq and change charts. It becomes very easy to misunderstand clearances. Also no one had time to look for other traffic." (page 13-14)
    Issue: automation may adversely affect pilot workload (Issue #79) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: automation

  3.  
  4. Evidence Type: Excerpt from Observational Study
    Evidence: "The ASRS reports below are illustrative of some of the problems of autoflight. ... [ASRS incident report #141226] Narrative: Aircraft was coupled to autopilot and autopilot was armed for the ILS (8L at Atlanta). Aircraft intercepted and captured localizer at approximately 15 nm from airfield, aircraft at 5000'. I identified localizer. As per company procedures captain rotated heading (HDG) select knob to 340 deg for missed approach HDG, but unknown to either of us, the multifunction knob was pushed in far enough to activate 'HDG Hold' I did not notice the flight mode annunciator window change From 'LOC TRK' to 'HDG HLD'. Of course, the ADI (flight director) display remained as before with the pitch bar giving altitude hold at 5000' And the back bar still centered but centered because we were On HDG not localizer. Obviously we gradually started to drift right. The HSI (nav display) was selected on map mode (20 mile scale). On this scale a small deviation off localizer is too small to detect. I monitored the glide slope (raw data display) and saw it descend through the flight director pitch bar. I looked at the flight mode annunciator (FMA) and realized we were no longer armed for the ILS. I immediately announced to the captain and disconnected the autopilot to start descent and selected arc mode on the nav display. I saw we were full scale localizer deflection so I put in about a 15 deg correction to course. At that moment Atlanta Approach called to tell us we were drifting into the parallel ILS course and he told us to maintain 4500' until established. (He also gave us a HDG to correct). I leveled at 4700' and as I did the localizer centered up and the ILS was resumed uneventfully. Having map mode in HSI instead of arc does not make a localizer deviation immediately obvious. Lack of continuous cross-check of FMA by pilots is a factor. Hdg select knob doubles as HDG hold button and an imperceptible extra push in on it activates HDG hold. To correct the problem: fly ILS with arc (or rose) in map to make deviations immediately obvious. Additionally, multifunction knobs should not be accepted on aircraft. It is simply too easy at night when you are tired or distracted to activate the wrong function. (We have 3 multifunction knobs where different functions are activated depending on how far you push the knob. It can be very tricky sometimes)." (page 5-6)
    Issue: displays (visual and aural) may be poorly designed (Issue #92) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: automation

  5.  
  6. Evidence Type: Excerpt from Observational Study
    Evidence: "The problems of crew interaction with keyboard data entry can be seen in the following ASRS report. Narrative: while preparing for departure, the captain loaded incorrect position coordinates in the IRS pos. Instead of a correct position of approximately N 50 deg 15 mins, E 00 deg 01 mins, he loaded N 50 deg 15 mins W 00 deg 01 mins. Contributing factors. Rushing to beat a noise curfew; short layover; lack of crew coordination and cross check. This resulted in a NAV map shift of approximately 30 mi. The problem was discovered on initial departure when radar told us we weren't proceeding on the proper course. The problem was discovered quickly and no conflict occurred. We switched to manual nav. However, we couldn't continue our ocean crossing and diverted to Shannon, Ireland, where we made an overweight landing. Human performance considerations: although the captain was supposed to be giving me a nav check he rapidly and without asking for verification programmed the computers himself. We had sufficient time to do the job right but didn't take it. I should have cross checked our position. But didn't. (It isn't in our nav checklist to do so). (ASRS No. 150785)" (page 30-31)
    Issue: crew coordination problems may occur (Issue #84) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: autoflight

  7.  
  8. Evidence Type: Excerpt from Observational Study
    Evidence: "The ASRS reports below are illustrative of some of the problems of autoflight. Narrative: We were cleared to cross 40 nm west of LINDEN VOR to maintain FL270. The Captain and I began [to] discuss the best methods to program the CDU to allow the performance management system to descend the aircraft. We had a difference of opinion on how to best accomplish this task (since we are trained to use all possible on-board performance systems). We wanted to use the aircraft's capabilities to its fullest. As a result, a late descent was started using conventional autopilot capabilities (vert spd, max indicated Mach/airspeed, and spd brakes). Near the end of descent, the aircraft was descending at 340 KIAS and 6000 FPM rate of descent. The aircraft crossed the fix approximately 250-500 feet high. Unfortunately we made no call to ATC to advise them of the possibility of not meeting the require [in sic] alt/fix. This possible altitude excursion resulted because: 1) The captain. [in sic] and the F/O had differences of opinion on how best to program the descent; A) Both thought their method was the best, the captain's of programming (fooling) the computer to believe anti-ice would be used during descent, which starts the descent earlier. The F/O's of subtracting 5 miles from the nav fix and programming the computer to cross 5 miles prior to LINDEN at FL270. B) A minor personality clash between the captain and the F/O brought about by differences of opinion on general discipline. C) Time wasted by both captain and F/O (especially F/O) in incorrectly programming CDU and FMS for descent, which obviously wasted time at level flight, which should have been used for descent. Observation: as a pilot for a large commercial carrier at its largest base, we seldom fly with the same cockpit crew member. This normally does not create a problem. I do, however, feel that with approximately 6 years, which can cause a bit more difficult transition than, say month to month cockpit crew change on a 727 or pre-EFIS DC-9. I have flown commercially for 10 years, and have flown 2-man crew for 8 of those 10. The toughest transition for me is to determine who shares the PF and PNF duties. This historically (3 years) has been the most difficult when the other crew member has transferred from a 3-man cockpit to a 2-man 'glass cockpit.' This is especially pertinent when the crew member has been on a 3-man crew for a number of years. As F/O, when you are the PNF, you accomplish your normal duties. However, often times when one is the PF, the F/O also has to do the PNF duties because the other crew member has not been used to doing the PNF duties to the extent that is required on 2-man cockpits, whether they be conventional or EFIS. This obviously can lead to a myriad of problems. Add weather or an airport such as Washington National, LaGuardia, or Orange County, and such problems can accelerate with alarming rapidity. (ASRS No. 122778)" (page 5-6)
    Issue: crew coordination problems may occur (Issue #84) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: FMS

  9.  
  10. Evidence Type: Excerpt from Observational Study
    Evidence: "Another factor to be considered is the rapid expansion of automation in the cockpit. Many in the aviation industry have assumed that automation would remove human error, replacing the fallible human with unerring devices. The research of Wiener and Curry, including field studies with airlines bringing highly automated aircraft on line, suggests that this may be overly optimistic, and that possibly increases the severity of its consequences (Curry, 1985; Wiener, 1885a, 1985c, 19988a; 1989a,b; Wiener and Curry, 1980). The same appears to be true in the other industries mentioned. In brief, computer-controlled flight may invite large blunders while eliminating the small errors seen in manual systems. The ASRS reports below are illustrative of some of the problems of autoflight. ... [ASRS incident report #141226] Narrative: Aircraft was coupled to autopilot and autopilot was armed for the ILS (8L at Atlanta). Aircraft intercepted and captured localizer at approximately 15 nm from airfield, aircraft at 5000'. I identified localizer. As per company procedures captain rotated heading (HDG) select knob to 340 deg for missed approach HDG, but unknown to either of us, the multifunction knob was pushed in far enough to activate "HDG Hold" I did not notice the flight mode annunciator window change From "LOC TRK" to "HDG HLD". Of course, the ADI (flight director) display remained as before with the pitch bar giving altitude hold at 5000' And the back bar still centered but centered because we were On HDG not localizer. Obviously we gradually started to drift right. The HSI (nav display) was selected on map mode (20 mile scale). On this scale a small deviation off localizer is too small to detect. I monitored the glide slope (raw data display) and saw it descend through the flight director pitch bar. I looked at the flight mode annunciator (FMA) and realized we were no longer armed for the ILS. I immediately announced to the captain and disconnected the autopilot to start descent and selected arc mode on the nav display. I saw we were full scale localizer deflection so I put in about a 15 deg correction to course. At that moment Atlanta Approach called to tell us we were drifting into the parallel ILS course and he told us to maintain 4500' until established. (He also gave us a HDG to correct). I leveled at 4700' and as I did the localizer centered up and the ILS was resumed uneventfully. Having map mode in HSI instead of arc does not make a localizer deviation immediately obvious. Lack of continuous cross-check of FMA by pilots is a factor. Hdg select knob doubles as HDG hold button and an imperceptible extra push in on it activates HDG hold. To correct the problem: fly ILS with arc (or rose) in map to make deviations immediately obvious. Additionally, multifunction knobs should not be accepted on aircraft. It is simply too easy at night when you are tired or distracted to activate the wrong function. (We have 3 multifunction knobs where different functions are activated depending on how far you push the knob. It can be very tricky sometimes)." (page 4-6)
    Issue: controls of automation may be poorly designed (Issue #37) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: autoflight: autopilot

  11.  
  12. Evidence Type: Excerpt from Observational Study
    Evidence: "The ASRS reports below are illustrative of some of the problems of autoflight. Narrative: We were cleared to cross 40 nm west of LINDEN VOR to maintain FL270. The Captain and I began [to] discuss the best methods to program the CDU to allow the performance management system to descend the aircraft. We had a difference of opinion on how to best accomplish this task (since we are trained to use all possible on-board performance systems). We wanted to use the aircraft's capabilities to its fullest. As a result, a late descent was started using conventional autopilot capabilities (vert spd, max indicated Mach/airspeed, and spd brakes). Near the end of descent, the aircraft was descending at 340 KIAS and 6000 FPM rate of descent. The aircraft crossed the fix approximately 250-500 feet high. Unfortunately we made no call to ATC to advise them of the possibility of not meeting the require [in sic] alt/fix. This possible altitude excursion resulted because: 1) The captain. [in sic] and the F/O had differences of opinion on how best to program the descent; A) Both thought their method was the best, the captain's of programming (fooling) the computer to believe anti-ice would be used during descent, which starts the descent earlier. The F/O's of subtracting 5 miles from the nav fix and programming the computer to cross 5 miles prior to LINDEN at FL270. B) A minor personality clash between the captain and the F/O brought about by differences of opinion on general discipline. C) Time wasted by both captain and F/O (especially F/O) in incorrectly programming CDU and FMS for descent, which obviously wasted time at level flight, which should have been used for descent. Observation: as a pilot for a large commercial carrier at its largest base, we seldom fly with the same cockpit crew member. This normally does not create a problem. I do, however, feel that with approximately 6 years, which can cause a bit more difficult transition than, say month to month cockpit crew change on a 727 or pre-EFIS DC-9. I have flown commercially for 10 years, and have flown 2-man crew for 8 of those 10. The toughest transition for me is to determine who shares the PF and PNF duties. This historically (3 years) has been the most difficult when the other crew member has transferred from a 3-man cockpit to a 2-man 'glass cockpit.' This is especially pertinent when the crew member has been on a 3-man crew for a number of years. As F/O, when you are the PNF, you accomplish your normal duties. However, often times when one is the PF, the F/O also has to do the PNF duties because the other crew member has not been used to doing the PNF duties to the extent that is required on 2-man cockpits, whether they be conventional or EFIS. This obviously can lead to a myriad of problems. Add weather or an airport such as Washington National, LaGuardia, or Orange County, and such problems can accelerate with alarming rapidity. (ASRS No. 122778)" (page 5)
    Issue: workarounds may be necessary (Issue #107) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: FMS
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