Un-Alerted Smoke and Fire: Checklist Content and Intended Crew Response

An in-flight smoke or fire event is an emergency unlike almost any other. The early cues for un-alerted conditions, such as air conditioning smoke or fire, are often ambiguous and elusive. The checklists crews use for these conditions must help them respond quickly and effectively and must guide their decisions. Ten years ago an industry committee developed a template to guide the content of Part 121 checklists for un-alerted smoke and fire events. This template is based upon a new philosophy about how crews should use the checklists and respond to the events. To determine the degree to which current un-alerted checklists of in-flight smoke or fire comply or are consistent with the guidance outlined in the template, I collected and analysed checklists from North American air carriers

Aircraft Emergencies: Challenge and Response

Emergency and abnormal situations in aviation present flight crews with a number of challenges. Checklists are essential tools that have been developed to assist them to meet these challenges. However, in order for checklists to be most effective in these situations they must be designed with the operational and situational demands of emergencies and abnormal conditions in mind as well as human performance capabilities and limitations under high stress and workload

The Challenge of Aviation Emergency and Abnormal Situations

Emergency and abnormal situations occur on flights everyday around the world. They range from minor situations readily managed to extremely serious and highly time-critical situations that deeply challenge the skills of even the most effective crews. How well crews respond to these situations is a function of several interacting sets of issues: (1) the design of non-normal procedures and checklists, (2) design of aircraft systems and automation, (3) specific aspects of the non-normal situation, such as time criticality and complexity of the situation, (4) human performance capabilities and cognitive limitations under high workload and stress, (5) design of training for non-normal situations, (6) philosophies, policies and practices within the industry, and (7) economic and regulatory constraints. Researchers and pilots working on NASA's Emergency and Abnormal Situations project are addressing these issues in a long-range study. In this paper we discuss these issues and illustrate them with examples from recent incidents and accidents

Factors Affecting the Use of Emergency and Abnormal Checklists: Implications for Current and NextGen Operations

The purpose of the current study was two-fold: 1) identify current practices associated with the design and content of checklists used to guide pilot response to emergency and abnormal situations, particularly those known to be challenging for checklist developers and affect checklist usability, including aspects that affect pilots' ability to identify and access the correct checklist and to complete only those items that are pertinent for a specific situation; and 2) identify and analyze checklists for use in aspects of NextGen operations that have already been implemented (e.g., Data Comm, in oceanic operations, and required navigation performance (RNP))

Impact of the WHO Surgical Safety Checklist Relative to Its Design and Intended Use: A Systematic Review and Meta-Meta-Analysis

BackgroundThe aim of this study was to identify what parts of the World Health Organization Surgical Safety Checklist (WHO SSC) are working, what can be done to make it more effective, and to determine if it achieved its intended effect relative to its design and intended use. Study DesignWe conducted a qualitative thematic analysis and meta-meta-analyses of findings in WHO SSC systematic reviews following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Results Twenty systematic reviews were included for qualitative thematic analysis. Narrative information was coded in 4 primary areas with a focus on impact of the WHO SSC. Four themes—Clinical Outcomes, Process Measures, Team Dynamics and Communication, and Safety Culture—pertained directly to the aims or purposes behind the development of the SSC. The other 2 themes—Efficiency and Workload involved in using the checklist and Checklist Impact on Institutional Practices—are associated with SSC use, but were not focal areas considered during its development. Included in the 20 systematic reviews were 24 unique observational cohort studies that reported pre-post data on a total of 18 clinical outcomes. Mortality, morbidity, surgical site infection, pneumonia, unplanned return to the operating room, urinary tract infection, blood loss requiring transfusion, unplanned intubation, and sepsis favored the use of the WHO SSC. Deep vein thrombosis was the only postoperative outcome assessed that did not favor use of the WHO SSC. ConclusionsThe WHO SSC positively impacts the things it was explicitly designed to address and does not positively impact things it was not explicitly designed for

Autonomous, Context-Sensitive, Task Management Systems and Decision Support Tools II: Contextual Constraints and Information Sources

Recent advances in artificial intelligence, machine learning, data mining and sensor technology have resulted in the availability of a vast amount of digital data and information and the development of advanced automated reasoners. This creates the opportunity for the development of a robust dynamic task manager and decision support tool that is context sensitive and integrates information from a wide array of on-board and off aircraft sourcesa tool that monitors systems and the overall flight situation, anticipates information needs, prioritizes tasks appropriately, keeps pilots well informed, and is nimble and able to adapt to changing circumstances. This is the second of two companion reports exploring issues associated with autonomous, context-sensitive, task management and decision support tools. In the first report, we explored fundamental issues associated with the development of such a system. In this report, we extend this work to focus on two critical aspects of these systems: 1) the constraints and conditions that drive the dynamic prioritization and presentation of data and information to the pilots, and 2) specific data and information to be accessed, monitored, integrated, and displayed in such a system

Autonomous, Context-Sensitive, Task Management Systems and Decision Support Tools I: Human-Autonomy Teaming Fundamentals and State of the Art

Recent advances in artificial intelligence, machine learning, data mining and extraction, and especially in sensor technology have resulted in the availability of a vast amount of digital data and information and the development of advanced automated reasoners. This creates the opportunity for the development of a robust dynamic task manager and decision support tool that is context sensitive and integrates information from a wide array of on-board and off aircraft sourcesa tool that monitors systems and the overall flight situation, anticipates information needs, prioritizes tasks appropriately, keeps pilots well informed, and is nimble and able to adapt to changing circumstances. This is the first of two companion reports exploring issues associated with autonomous, context-sensitive, task management and decision support tools. In the first report, we explore fundamental issues associated with the development of an integrated, dynamic, flight information and automation management system. We discuss human factors issues pertaining to information automation and review the current state of the art of pilot information management and decision support tools. We also explore how effective human-human team behavior and expectations could be extended to teams involving humans and automation or autonomous systems

Single Pilot Workload Management During Cruise in Entry Level Jets

Advanced technologies and automation are important facilitators of single pilot operations, but they also contribute to the workload management challenges faced by the pilot. We examined task completion, workload management, and automation use in an entry level jet (ELJ) flown by single pilots. Thirteen certificated Cessna Citation Mustang (C510-S) pilots flew an instrument flight rules (IFR) experimental flight in a Cessna Citation Mustang simulator. At one point participants had to descend to meet a crossing restriction prior to a waypoint and prepare for an instrument approach into an un-towered field while facilitating communication from a lost pilot who was flying too low for ATC to hear. Four participants experienced some sort of difficulty with regard to meeting the crossing restriction and almost half (n=6) had problems associated with the instrument approach. Additional errors were also observed including eight participants landing at the airport with an incorrect altimeter setting

Urban Air Mobility Airspace Integration Concepts and Considerations

Urban Air Mobility (UAM) - defined as safe and efficient air traffic operations in a metropolitan area for manned aircraft and unmanned aircraft systems - is being researched and developed by industry, academia, and government. Significant resources have been invested toward cultivating an ecosystem for Urban Air Mobility that includes manufacturers of electric vertical takeoff and landing aircraft, builders of takeoff and landing areas, and researchers of the airspace integration concepts, technologies, and procedures needed to conduct Urban Air Mobility operations safely and efficiently alongside other airspace users. This paper provides high-level descriptions of both emergent and early expanded operational concepts for Urban Air Mobility that NASA is developing. The scope of this work is defined in terms of missions, aircraft, airspace, and hazards. Past and current Urban Air Mobility operations are also reviewed, and the considerations for the data exchange architecture and communication, navigation, and surveillance requirements are also discussed. This paper will serve as a starting point to develop a framework for NASA's Urban Air Mobility airspace integration research and development efforts with partners and stakeholders that could include fast-time simulations, human-in-the-loop (HITL) simulations, and flight demonstrations

Biased decision making in realistic extra-procedural nuclear control room scenarios

In normal operations and emergency situations, operators of nuclear control rooms rely on procedures to guide their decision making. However, in emergency situations, where several interacting problems can cause unpredictable adverse effects, these procedures may be insufficient in guiding operators to safe shutdown of the power plant. Little is known about the decision making strategies that operators employ in these extra-procedural situations. To address this, a realistic simulation study was conducted with five crews of active, licensed nuclear operators to see the behavioural patterns that occur when procedures are not sufficient. This paper, a re-analysis of a dataset collected for a different study, investigates how the design and existence of procedures influence, and possibly bias, decision making strategies. We found evidence that operators were affected by confirmation bias, and that, in some cases, the mismatch between their home power plant and the simulated power plant made them commit errors due to misapplied expertise. We further found that this effect was amplified by the existence and design of the procedures used. Based on these findings, we suggest that designers may improve safety by creating procedures that bear the risks of these biases in mind, or by specifically aiming to debias the users. Avenues for debiasing through design are discussed