On the Design of Flight-Deck Procedures - Intelligent Systems ...

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technical deficiencies, induce workload, create conflicts in time management, or produce other problems,flight crews may react by resisting and deviating from SOP.We have used the word “formal” to describe the desired feedback path. Bland statements frommanagement such as “my door is always open,” or “you can always go to your chief pilot” do notconstitute a sufficient feedback path. Likewise, offhand comments given while passing in the corridorsand in coffee shops do not qualify as effective feedback mechanisms. The line pilot must feel that his orher input is desired, and will be taken seriously. Ideally, feedback should be in written form. Werecommend that all written communications from line to management result in a written reply. Thefrustration of a crew member who felt that management was unresponsive to feedback from the line canbe seen in the following ASRS report.I am very concerned about the safety of the company's new checklist policy. The climb checklist has threedifferent segments and it not completed until about of 18,000 feet. The approach checklist has a descent checkthat precedes it. The landing check has four segments. The “landing check" is called after the approach flapsettings. The "landing gear" call stands alone, and the final segments are completed after the final flaps are set.The last segment requires both pilots to watch the flaps come down, no matter how busy an approach [we areflying]. We have had several major checklist changes over the last two years. This latest one is the mostradical. Having flown with 20-30 F/Os using it, I find that about 30 to 40 percent of the time we are able to doall the checklists correctly. Since it takes so long to complete all the segments of the list, something usuallygets left out. Many times it's the "gear down" check, since it no longer is "gear down/landing check" as we haveall done since day-one in our careers. Also much of the check is done with a flow that does not match thechecklist. After time off you have to re-memorize the flow since it's so different from the list. I note that whena situation is tight we are all, at times, reverting back to some of the calls from the previous procedures. Eventhe new hires who never used another checklist are not able to remember all the steps. The company imposedthe procedures without input from the line, and is not interested in our input. Please help us convince thecompany that these procedures are not user friendly before someone makes a serious mistake. (ASRS ReportNo. 155183)Discussing the feedback path from line to management forces us to consider briefly labor-managementrelations at airlines. To be successful, the feedback process must involve the participation of theappropriate pilots' representative group. The feedback path then would consist of a communication fromthe line to the pilots' representative group, and thence to management. This may have some advantagesover direct pilot-to-management communication, in that the pilot may wish, for various reasons, to beinsulated from his or her managers. Also, by working through a committee, patterns can be observed bythe committee members.For this system to be effective, it is essential that a cooperative, non-adversarial relationship existbetween management and the representative group. This is sometimes difficult when contractnegotiations are underway, or when for whatever reason tensions exist between pilots and management(e.g., a furlough has been announced). The feedback process can be effective only if managementmakes it clear that they are eager to receive input from the pilots' representative group on a nonadversarialbasis, and the pilots' group in turn must resolve to stick to its safety mandate, and not betempted to use safety as a smoke screen for contractual matters. It is a measure of the maturity of themanagement of both the company and the union if both sides can transcend “politics as usual” for thesake of promoting safety.Guideline #1: A feedback loop from line pilots to flight management and procedure designersshould be established. This feedback loop should be a formal process, as opposed to aninformal process. It must be maintained as a non-punitive, reactive system, with mandatoryfeedback from management to the initiating line pilot about the progress of his report and/orsuggestion.Having built a foundation for procedure development, and explored the reasons for non-conformity toprocedures, we attempted to verify the model by a field study of actual airline management and linepractices. This is described briefly in Chapter 4.14
4. FIELD STUDY4.1 RATIONALEThe previous sections detailed our framework, or model, of what we felt was the rational process. Wewished to test this framework in the real world of airline operations and to modify it depending on whatwe might discover. For this reason we sought and obtained the cooperation of three major U.S. airlinesin hosting a field study. In a sense our approach was “anthropological”: we went into the field andobserved both management and flight crews doing their jobs.There are two entities that design procedures: the operators of aircraft and the airframe manufacturers (oralternatively component manufacturers, such as avionics firms). Despite their common interest inestablishing procedures which will promote flight safety, their approach and objectives are quitedifferent. Our field study focused on the operators, and only briefly surveyed the second. The mainbody of this report is based on the operators' approach to procedures and not that of the manufacturers.4.2 METHOD4.2.1 Activities at Participating AirlinesThree major U.S. airlines agreed to participate in this research study. These airlines had previouslyexpressed an interest in evaluating the way they design procedures, and wished to cooperate with thisproject. We visited each of the three airlines, conducted interviews with flight management and linepilots, and attended procedural design meetings. We focused our research on procedures for automatedcockpits (e.g., B-757/767, A-320, B-737-300).In addition, we wanted to see how procedures are actually conducted on the line (i.e. practices). Wetherefore conducted observations and informal discussions with line pilots while occupying the jumpseatwith all three carriers. All companies and individuals were promised anonymity. No companies orindividuals would be identified in connection with any particular statements, events, or findings.Interviews with flight management and line pilots. Prior to conducting the interviews, wepresented our initial concepts to personnel in flight management. Since the “Four-P” modelencompassed both high level management and line pilots, we decided to interview both. The underlyingrationale was that if we wanted to examine how the organization directs flight operations, we must firsthave a clear understanding of how flight operation concepts are perceived at each level within theorganization. The questions for top management were aimed at philosophies and policies (see Appendix3). As we descended the organizational ladder, the questions moved toward procedures and ultimately,toward practices.At each of the participating carriers, we started with the vice-president for flight operations, and workedour way down the ranks of flight management. The following personnel in each flight department wereinterviewed:1. The head of the flight operation department (usually vice-president for flight operations)2. The senior aid to the head of the flight department3. Manager responsible for flight standards4. Manager responsible for flight training5. Manager responsible for checking (check-airman program)6. Fleet manager of an advanced technology aircraftIn cooperation with the pilot representative group, we conducted interviews with line pilots who werecurrently flying FMS equipped aircraft. We interviewed three or four pilots in each session. The sampleat each airline ranged from nine to twelve pilots. We asked the flight crews the same questions that weasked flight management personnel (see Appendix 4). We wanted to test whether the concepts of15
Page 2 and 3: TABLE OF CONTENTSSUMMARY ..........
Page 4 and 5: 1. INTRODUCTIONWhen we try to pick
Page 6 and 7: Hendrick (1987) states that human f
Page 8 and 9: influenced by the individual philos
Page 10 and 11: 3. THE FOURTH P: PRACTICES3.1. AN E
Page 12 and 13: To summarize, the ultimate factor t
Page 14 and 15: Humor. Humor is closely related to
Page 18 and 19: operations and the philosophy of th
Page 20 and 21: 5.3 MERGERS AND ACQUISITIONSMergers
Page 22 and 23: Figure 7. A Boeing B-757 checklist
Page 24 and 25: e made. Consider, also, the followi
Page 26 and 27: flight operations, the philosophy m
Page 28 and 29: 5.7.3 Technique and PoliciesAny giv
Page 30 and 31: For example, one company constantly
Page 32 and 33: 6. ISSUES IN PROCEDURE DESIGN6.1 CO
Page 34 and 35: solution involves “anchoring” a
Page 36 and 37: On August 19, 1980, a Saudi Arabian
Page 38 and 39: 3. The procedures allow the other a
Page 40 and 41: coordination of tasks between agent
Page 42 and 43: Similarly, it has been a common pra
Page 44 and 45: 7.1.3 Structure of ProceduresAs men
Page 46 and 47: mission simulation (see Wiener et a
Page 48 and 49: felt that this is an efficient tech
Page 50 and 51: esponse. The PF, therefore, can con
Page 52 and 53: 7.5.1 Cross-fleet StandardizationCr
Page 54 and 55: 1. Training department (for both pi
Page 56 and 57: REFERENCESAviation Week and Space T
Page 58 and 59: Perrow, C. (1986). Complex organiza
Page 60 and 61: APPENDICESAppendix 1 - Guidelines f
Page 62 and 63: 14. In managing automated cockpits,
Page 64 and 65: APPENDIX 3 - QUESTIONS ASKED OF FLI
Page 66 and 67:
APPENDIX 5 - QUESTIONS ASKED DURING
Page 68 and 69:
8. Change in operational environmen
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