Analysis of Comair flight 5191 with the functional resonance accident model

International audienceThe goal of an accident investigation is to determine why a certain combination of conditions, events, and actions led to the specific outcome. Accidents in complex high risk operations, such as aviation, are frequently explained as the result of system failures, but few methods exist that can adequately be used to investigate how the variability of individual, technical, and organisational performance in combination may lead to an adverse outcome. The Functional Resonance Accident Model (FRAM) provides an approach to identify these elements and determine their interrelationship. This paper presents the principles of FRAM and illustrates how it was used to analyse a highly publicized aviation accident, the crash of Comair Airlines (Delta Connection) flight 5191 in Lexington, KY on August 27th, 2006. The use of FRAM provided details that were not found in the NTSB analysis and as such this approach model may help future investigations better elucidate causal factors and yield improved safety recommendations

Angle of Attack Equipment in General Aviation Operations

The Federal Aviation Administration (FAA) in conjunction with the general aviation (GA) industry formed the General Aviation Joint Steering Committee (GAJSC) with the goal to improve overall general aviation safety. The GAJSC tasked their technical division, the Safety Analysis Team (SAT), with identifying safety issues present within GA. Upon review of fatal GA accidents between 2001 and 2010, it was concluded that over half of the fatal accidents were a result of loss of control inflight, or LOC-I. A Loss of Control Working Group (LOCWG) was formed between the FAA and the GA industry to research and recommend safety improvements. One of the recommended safety improvements offered is to consider the use of Angle of Attack Indicators in GA aircraft. This project is being conducted by the Partnership to Enhance General Aviation Safety, Accessibility and Sustainability (PEGASAS), an FAA Center of Excellence

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

Single-Pilot Workload Management

Integrated glass cockpit systems place a heavy cognitive load on pilots (Burian Dismukes, 2007). Researchers from the NASA Ames Flight Cognition Lab and the FAA Flight Deck Human Factors Lab examined task and workload management by single pilots. This poster describes pilot performance regarding programming a reroute while at cruise and meeting a waypoint crossing restriction on the initial descent

Human-in-the-Loop Method to Test the Effectiveness of Training Pilot Responses to Unexpected Events. Task 4: Training Development Plan

692M151940001This report is one of three from a Research Grant / Cooperative Agreement number 692M151940001 entitled, \u201cAir Carrier Training Recommendations to Address Limitations of Pilot Procedures during Unexpected Events in NextGen Operations\u201d. The related reports are also available in this repository.This report provides a primer as to how to conduct human-in-the-loop (HITL) research in which pilots\u2019 responses to unexpected events can be explored for potential mitigations through training. The results of this effort conclude the following findings and recommendations: Identification of key independent and dependent variables for assessing pilot responses during unexpected events; recommendations on types of training interventions and measurable skills and behaviors that pilots may exhibit during unexpected events; recommendations for HITL scenario selection criteria and candidate scenario examples; recommendations for conducting a HITL; and a recommended performance assessment method for measuring pilots\u2019 behaviors during unexpected events. Research results can ultimately lead to testing and validation to inform FAA personnel who develop evaluation criteria for pilot tasks, skills, knowledge, and proficiency and incorporate this information into human factors related documentation

Relevant Research Assessment Concerning Pilot Response to Unexpected Events. Task 2: Relevant Research Assessment

692M151940001This report is one of three from a Research Grant / Cooperative Agreement number 692M151940001 entitled, \u201cAir Carrier Training Recommendations to Address Limitations of Pilot Procedures during Unexpected Events in NextGen Operations\u201d. The related reports are also available in this repository.This report provides a review of the existent information pertinent to the response to novel, unexpected, surprising, and/or unanticipated events, primarily focused on the context of aviation. The primary effort here is to identify ways in which to mitigate the brittleness of accepted traditional forms of response and to foster both adaptive and resilient response capacities throughout the whole of the operational systems. We have examined existing information and have assembled a series of definitions of terms and concepts, primarily revolving around resilient response. We look to knit these terms together and evaluate how the synthetic understanding can be used as a foundational basis for advance. This is a proactive perspective and one that looks to anticipate future threats to aerospace safety to counteract their more adverse influences. The work also provides the foundation for subsequent empirical evaluations of possible challenges by those experiencing unexpected events

Human Factors Issues of Navigation Reference System Waypoints

As part of the Next Generation Air Transportation System initiative the Navigation Reference System waypoint grid was developed to realize additional benefits of area navigation. Despite industry and government involvement in the original design of the grid, it has been met by operators and air traffic controllers with limited enthusiasm. The FAA is sponsoring research to identify human factors issues that might explain this lack of usage and the development of mitigations or recommendations for those issues discovered. In this paper, we will discuss our initial examination of the Navigation Reference System and review potential recommendations to several areas for improvement with specific focus on changes to waypoint nomenclature

Mid Morning Concurrent Sessions: Human Factors: Human Error and Cockpit Automation: Presentation: Cognitive Processes and Challenges during Surprise on the Flight Deck

In today’s modern aircraft, both large transport category, smaller business jets and general aviation aircraft, the majority of flight time is spent at cruise where pilot decision making is light as compared to other phases of flight. While event tempo is low and while in this supervisory mode, extra cognitive resources are available and sufficient to not only recognize changes but also understand any developing situation and re-adjust the systems as required. However, when an initiating event occurs during higher workload phases of flight or when system failures result in conflicting or erroneous data inputs to automated systems, staying in control is far more challenging. During these times, under reduced time for reflection, the initiating or triggering event produces a type of surprise situation where flight crews must recognize that the state of control of the aircraft has changed, scan information sources, understand the changed situation, prioritize and decide on new courses of action. Incident and accident reports indicate that these events are challenging and contribute to safety risks. A recent full-motion simulator observational study examined how experienced flight crews handle an unexpected event similar to the Air France Flight 447 event there were several ways pilots can become trapped in these assessment requirements which include; reorientation, assessment, scanning, decisive action and re-assessment. Within this framework we discuss our understanding of the risks for breakdowns within this structure: the initial delay in accommodating to the surprise event, a fragmented scan, narrow assessment, inability to commit to a course of action, and failure to re-check the new course of action is working as intended and as needed