24 October 2002ICAO NAM/CAR/SAM RUNWAY SAFETY/INCURSION CONFERENCE

1

Retrospective Human Factors Analysis of US Runway

Incursions(Focus: Air Traffic Control)

Julia Pounds, Ph.D.Alfretia Scarborough, M.P.H.

US Federal Aviation AdministrationCivil Aerospace Medical Institute

ICAO NAM/CAR/SAM Runway Safety / Incursion ConferenceMexico City, 22 to 25 October 2002

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Background

• FAA has aggressively developed strategies to increase runway safety

• General decline from 2000-2001• Some airports continue to increase• Global Concern• Similar activities in Europe are also

addressing human factors in incident investigation.

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CY01 US Runway Incursions

OE/D21%

PD56%

VPD23%

VPD: vehicle or pedestrianOE/D: operational error or deviationPD: pilot deviationCY: calendar year

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• 1981 Bellatoni & Kodis – ATC conflicting clearances– Need better reporting process

• 1986 National Transportation Safety Board– Memory errors– Coordination errors– Lack of supervision

Previous Research

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• 1990 Human Factors Work Group on Controller & Pilot Errors– Pilot-controller communication

• 2000 Runway Safety Joint Analysis Team– Loss of situational awareness– ATC procedures– Poor communications– Improved data collection techniques

Previous Research

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• 2001 Cardosi & Yost– Poor observation of aircraft– Poor coordination between controllers– Communication misunderstandings

between pilots and controllers– Improved data collection techniques

Previous Research

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• 2001 Kelley, Krantz, & Spelman – Lack of situational awareness– Inadequate scanning– No use of memory aids– Poor planning/prioritizing– Revise investigation forms

Previous Research

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• 2002 Khatwa – Poor procedures/deviations from

procedures– Poor decision making and failure to

anticipate– Poor communications--Incorrect

instructions and clearances– Visual monitoring and awareness of

traffic

Previous Research

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• 2002 Fisher“While traffic volume, capacity-enhancing

procedures and aerodrome layout may increase the potential for a runway incursion, human error is the mechanism that translates this potential into an actual occurrence.”

Previous Research

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Person(s)Person(s) TaskTask

EnvironmentEnvironment EquipmentEquipment

Person x Task x Equipment x Environment Interaction

THE “HUMAN” FACTOR IN CONTEXT

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Common Themes• Improve communication between

controller and pilot• Improve controller’s thinking processes

– Memory– Situational Awareness– Scanning – Planning

• Improve procedures, etc.• Data more informative about human

factors

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Replicate

Extend

Revise

This Study

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This Study

• Test the classification method to replicate other findings

• Examine results for added value• Develop a human factors technique for

analyzing incidents so that better information will be available.

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Method

• Taxonomy used: HFACS-ATC– Based on Human Factors Analysis and Classification

System (Shappell & Wiegmann, 2001).– Adapted for ATC

• Narratives from 347 FAA OE reports were used: CY1996 through June 2000

• Analysis by ATC subject matter experts with experience in terminal operations.

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Organizational

Influences

UnsafeSupervisio

nPreconditions

for Unsafe Acts

UnsafeActs

HFACSLatent Conditions

Latent Conditions

Latent Conditions

Active Conditions

Failed or Absent Defenses

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Organization

Supervision

Preconditions

Controller

HFACS-ATCLatent Vulnerabilities

Latent Vulnerabilities

Latent Vulnerabilities

Separation Violation

Critical Human Error

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ORGANIZATION

CLIMATE STRUCTURE POLICIES & PROCEDURES RESOURCE MGMT.

SUPERVISION

GENERAL SUPERVISION

PLANNINGCORRECTION OF KNOWN

PROBLEMSTEAMWORK CONTRAVENTIONS

PRECONDITIONS

ATC CONDITIONS ATC PRACTICES SITUATIONAL FACTORS

ATC

DEFICIENCIES PROCEDURE FOLLOWING

TASK

HFACS-ATC

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Task

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

R/T Comm

Tower Obs

Coordination

Planning

C-Rm Comm

Training

Supervision

PRB-Take Over

Strip Work

HMI Input

Materials

Task

% of Critical Points

RESULTS --

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Causal Factors @ Tiers

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Controller Preconditions Supervision Organization

Tier

Perc

ent

Cri

tica

l P

oin

ts

RESULTS --

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Deficiencies Procedure Following

Controller Tier

% o

f C

riti

cal P

oin

ts

Causal Factors @ PersonRESULTS --

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0%5%

10%15%20%25%30%35%40%45%50%

C/PCommunication

TowerObservation

Coordination

Task

% o

f C

riti

cal

Poin

ts

Decision Skill Misperception

Person Causal Factors @ TaskRESULTS --

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Preconditions ATC Conditions, such as

• expectation bias• spatial confusion• perceptual tunneling• distraction• integration failure• cognitive fixation• incorrect assumption

ATC Practices, such as • poor teamwork

RESULTS --

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Situational Influences

Ambient environment• noise

Distractions• job related • non-job related

Traffic and airspace/runway characteristics• excessive traffic load • unusual situation (emergency or high risk) • airspace design characteristics (complexity,

changes, etc.) Equipment problems

RESULTS --

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• Replicated and extended previous findings

• As were previous findings, it was limited by using information recordedin archival data

Revise…

Conclusions - This Study

24 October 2002ICAO NAM/CAR/SAM RUNWAY SAFETY/INCURSION CONFERENCE

25Ground ActionsGround ActionsGround- Controller CommunicationsGround- Controller Communications

Traffic & AirspaceTraffic & Airspace

Pilot-Controller CommunicationsPilot-Controller

Communications

Pilot ActionsPilot Actions

WeatherWeather

Procedures & Orders

Procedures & Orders

Documents & Materials

Documents & Materials

Personal FactorsPersonal Factors

EnvironmentEnvironment

Interpersonal & Social FactorsInterpersonal & Social Factors

SupervisionSupervision

ManagementManagement

Team FactorsTeam Factors

Workplace & HMIWorkplace & HMITraining & ExperienceTraining & Experience

Organization

ATC Performance in a Complex Environment

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Cognitive Processing

INPUT

RESPONSE SELECTION

SENSORY RECEPTION

PERCEPTION

RESPONSE EXECUTION

OUTPUT

AT

TE

NT

IO

NA

L C

AP

AC

ITY

FE

ED

BA

CK

LONG TERM MEMORY

WORKINGMEMORY

THEPICTURE

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ATCATC

FLT

GROUND

Performance in a Complex Environments

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Thank you for your attention.

julia.pounds@faa.gov