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

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