The Flight Crew s Solution. Age-Old Safety Problem

Transcription

1 The Flight Crew s Solution to an Age-Old Safety Problem Presentation before the Royal Aeronautical Society Human Factors Group 1

2 NASA s Aviation Safety Reporting System Total Incidents: 104,880 Altitude Deviations: 39,704 Altitude Deviations caused by flight crews: 33,992 That s 32.4% of the total NASA ASRS Incidents 2

3 Altitude Deviation Rates for USAir and Other Carriers Carlow International Incorporated MiTech Incorporated 3

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5 Major Reasons for Altitude Deviation Hearback Error Improperly set altitude alerter Crew distractions Flightdeck automation malfunction Improper altimeter settings Poor crew discipline and procedures ATC operational errors 5

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9 8780 pilot-caused Altitude Deviations in

10 HUMAN FACTORS RESEARCH 10

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12 :DWFK<RXU $/7,78'( The cockpit crew should all agree; If not, verify with ATC! Altitude Awareness begins in the cockpit. 12

13 &KDQJH\RXUDWWLWXGH :DWFK<RXU $/7,78'( Altitude Awareness begins in the cockpit. 13

14 US Airways Altitude Awareness Procedures Pilot not flying communicates with ATC Pilot not flying sets the altitude alerter/mode control panel Pilot not flying announces new altitude - Flying pilot points at and repeats new altitude Pilot flying makes 1000 feet-to-go callout 14

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18 Altitude Clearance Processing Task Flow Carlow International Incorporated MiTech Incorporated 18

19 ALTITUDE DEVIATI0N STUDY RESULTS 19

20 USAir Monthly Altitude Deviation Rates 20

21 Pilot Reported Altitude Deviation Rates by Aircraft Type 21

22 Altitude Deviation Rates for USAir and Other Part 121 Carriers Carlow International Incorporated MiTech Incorporated 22

23 Selected Reaction to Altitude Awareness Study Yes No Don t know/ no opinion Totals PILOTS Did altitude awareness procedures increase awareness? Controllers Should other facilities participate in altitude study? Carlow International Incorporated MiTech Incorporated 23

24 Conclusions of the Altitude Awareness Study USAir s altitude deviation rate was significantly lowered Useful data was collected from pilots and controllers Limited immunity in exchange for incident information is an effective approach to safety problem resolution Diverse groups can work together for a common good 24

25 A Team Approach US Airways User Group ALPA User Group PROBLEM SOLUTION NATCA User Group FAA Regulations MiTech & Carlow Human Factors Support 25

26 NASA Analysis of Altitude Deviation Data 1995 through

27 NASA Aviation Safety Reporting System Data: Comparison of Full-form Incidents vs. Altitude Deviation Incidents Altitude Deviations Total Full-Form Incidents 27

28 NASA Aviation Safety Reporting System Data: Altitude Deviation Incidents - Phase of Flight* January December 1997 Descent Climb Cruise Approach Maintain Missed Approach Airhold Emergency Traffic Pattern Landing Divert * Categories are not mutually exclusive. Number Of Incidents 690 Total Number Of Citations = 3,

29 NASA Aviation Safety Reporting System Data: Altitude Deviation Incidents - Deviation Breakdown* January December 1997 Overshoot 1518 Excursion From Assigned 832 Crossing Restriction Not Met Undershoot Total Number Of Citations = 3, Number Of Citations * Categories are not mutually exclusive. 29

30 NASA Aviation Safety Reporting System Data: Altitude Deviation Incidents - Top Five Altitudes January December Data represents a total of 909 incidents Altitude Ranges (MSL) 30

31 NASA Aviation Safety Reporting System Data: Altitude Deviation Incidents - Primary Operator January December 1997 Total Number Of Incidents = 2,832 Other (0.4%) Air Taxi (3.4%) Corporate (9.2%) General Aviation (7.0%) Unknown (1.8%) Air Carrier (66.6%) Commuter (11.6%) 31

32 NASA Aviation Safety Reporting System Data: Altitude Deviation Incidents - Primary Crew Size January December 1997 Total Number Of Incidents = 2,832 Unknown (0.5%) 1 Person (9.4%) 3 Person (17.8%) 2 Person (71.8%) 4 or More Person (0.5%) 32

33 NASA Aviation Safety Reporting System Data: Altitude Deviation Incidents - Top Ten Part 121 Type Aircraft January December 1997 B737 MD80 B757 DC9 B727 FK-100 MD88 A320 B747 B Data represents a total of 683 incidents Number Of Incidents 33

34 NASA Aviation Safety Reporting System Data: Altitude Deviation Incidents - Top Ten Part 135/91 Type Aircraft January December 1997 Cessna Citation 22 Learjet Series 21 BE Jetstream 31/32 EMB Gulfstream Series 12 SF 340 Cessna Data represents a total of 131 incidents King Air Series Number Of Incidents 34

35 Information Transfer Distraction Vigilance Flying Technique Complacency Fatigue Experience Level Workload Resource Utilization Unprofessional Attitude Judgement Socializing Sterile Cockpit Schedule Pressure Interpersonal Relationship Aggression US Airways Altitude Awareness Program NASA Aviation Safety Reporting System Data: Altitude Deviation Incidents - Human Factors* January December * Categories are not mutually exclusive. Number Of Citations Total Number Of Citations = 5,

36 USAir Altitude Deviations Source: ASY

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