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

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TABLE OF CONTENTSSUMMARY ..........................................................................................................................................11. INTRODUCTION1.1 Background ............................................................................................................... 21.2 Procedural Deviation: Its Influence on Safety ........................................................... 31.3 Objectives of the Study ............................................................................................. 42. THE THEORY OF THE THREE P's2.1 Procedure Development............................................................................................ 52.2 Philosophy ................................................................................................................ 52.3 Policy ........................................................................................................................ 63. THE FOURTH P: PRACTICES3.1 An Extension of the Three P's ................................................................................... 83.2 Features of the Four-Ps Framework ......................................................................... 104. FIELD STUDY4.1 Rationale.................................................................................................................... 154.2 Method....................................................................................................................... 155. FACTORS THAT BEAR ON PROCEDURE DESIGN5.1 Procedural Development by Airframe Manufacturer ................................................. 175.2 What Prompts a Procedure Change? ......................................................................... 175.3 Mergers and Acquisitions.......................................................................................... 185.4 Differences Among Carriers...................................................................................... 195.5 Economically-Driven Influences.............................................................................. 215.6 Automation................................................................................................................ 225.7 Using Technique........................................................................................................ 246. ISSUES IN PROCEDURE DESIGN6.1 Compatibility of Procedures...................................................................................... 306.2 CRM and Procedures ................................................................................................ 356.3 Callouts..................................................................................................................... 386.4 Procedural Deviation During an Abnormal Situation................................................. 407. MECHANICS OF PROCEDURE DESIGN7.1 Objectives and Structure of Procedures..................................................................... 417.2 Scheduling of Tasks and Procedures......................................................................... 437.3 Decoupling of Tasks .................................................................................................. 477.4 Implementing Procedures.......................................................................................... 487.5 Implementing Standardization................................................................................... 498. SUMMARY AND CONCLUSIONS ................................................................................... 53REFERENCES ........................................................................................................................... 54NOTES AND ACKNOWLEDGMENTS ......................................................................................... 57APPENDICES............................................................................................................................ 58iii
SUMMARYIn complex human-machine systems, operations, training, and standardization depend on a elaborate setof procedures which are specified and mandated by the operational management of the organization.These procedures indicate to the human operator (in this case the pilot) the manner in which operationalmanagement intends to have various tasks performed. The intent is to provide guidance to the pilots, toensure a logical, efficient, safe, and predictable (standardized) means of carrying out the missionobjectives.However, in some operations these procedures can become a hodge-podge, with little coherency in termsof consistency and operational logic. Inconsistent or illogical procedures may lead to deviations fromprocedures by flight crews, as well as difficulty in transition training for pilots moving from one aircraftto another.In this report the authors examine the issue of procedure use and design from a broad viewpoint. Theauthors recommend a process which we call “The Four P's:” philosophy, policies, procedures, andpractices. We believe that if an organization commits to this process, it can create a set of procedures thatare more internally consistent, less confusing, better respected by the flight crews, and that will lead togreater conformity.The “Four-P” model, and the guidelines for procedural development in Appendix 1, resulted fromcockpit observations, extensive interviews with airline management and pilots, interviews and discussionat one major airframe manufacturer, and an examination of accident and incident reports involvingdeviation from standard operating procedures (SOPs). Although this report is based on airlineoperations, we believe that the principles may be applicable to other complex, high-risk systems, such asnuclear power production, manufacturing process control, space flight, law enforcement, militaryoperations, and high-technology medical practice.1
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 16 and 17: technical deficiencies, induce work
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
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7.5.1 Cross-fleet StandardizationCr
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1. Training department (for both pi
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REFERENCESAviation Week and Space T
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Perrow, C. (1986). Complex organiza
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APPENDICESAppendix 1 - Guidelines f
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14. In managing automated cockpits,
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APPENDIX 3 - QUESTIONS ASKED OF FLI
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APPENDIX 5 - QUESTIONS ASKED DURING
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8. Change in operational environmen
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