The Human Factors Implications for Flight Safety of Recent Developments in the Airline Industry

92 Pages·2003·0.65 MB·English

by  Flight Safety Foundation

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MARCH–APRIL 2003
FLIGHT SAFETY
D I G E S T
The Human Factors
Implications for Flight Safety
Of Recent Developments
In the Airline Industry
FLIGHT SAFETY FOUNDATION Flight Safety Digest
For Everyone Concerned With the Safety of Flight
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Vol. 22 No. 3–4 March–April 2003
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The Human Factors Implications for Flight Safety of
Recent Developments in the Airline Industry
A Research Study for the Joint Aviation Authorities
Contents
Executive Summary ..................................................................................................................................................4
1. Introduction ........................................................................................................................................................7
1.1 Background to the Study..............................................................................................................................7
1.2 Scope of the Study........................................................................................................................................7
1.3 Methodology.................................................................................................................................................8
1.4 Layout of Report...........................................................................................................................................8
2. Culture ................................................................................................................................................................9
2.1 Professional Culture......................................................................................................................................9
2.2 Organizational Culture .................................................................................................................................9
2.3 National Culture..........................................................................................................................................10
2.4 Managing Cultural Issues on the Flight Deck............................................................................................13
2.5 Conclusions.................................................................................................................................................13
3. Errors Arising From the Performance of Team Tasks ..................................................................................13
3.1 Introduction ................................................................................................................................................13
3.2 Information Acquisition..............................................................................................................................15
3.3 Information Sharing....................................................................................................................................16
3.4 Decision Making.........................................................................................................................................19
3.5 Latent Failures ...........................................................................................................................................20
3.6 Summary of Factors Infl uencing Flight Deck Errors ................................................................................20
4. Commercial Developments in the Airline Industry ......................................................................................20
4.1 Historical Perspective.................................................................................................................................20
4.2 Effects of Deregulation...............................................................................................................................23
4.3 Privatization ...............................................................................................................................................24
4.4 Alliances ....................................................................................................................................................24
4.5 Mergers and Acquisitions ..........................................................................................................................25
4.6 Low-cost Carriers.......................................................................................................................................26
5. Effects on Flight Crew of Commercial Developments...................................................................................26
5.1 Multicultural Flight Crews .........................................................................................................................26
5.2 Merging of Company Cultures ..................................................................................................................29
5.3 Commercial Pressure..................................................................................................................................32
FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 1
6. Mitigating Factors.............................................................................................................................................35
6.1 Crew Resource Management (CRM).........................................................................................................35
6.2 Standard Operating Procedures (SOPs)......................................................................................................38
6.3 Professional Culture....................................................................................................................................40
6.4 Safety Regulation .......................................................................................................................................42
7. Effectiveness of Mitigating Factors on Human Factors Problems
Arising From Commercial Developments ......................................................................................................44
7.1 Teamwork...................................................................................................................................................44
7.2 Communication ..........................................................................................................................................45
7.3 Fatigue........................................................................................................................................................46
7.4 Morale and Job Satisfaction .......................................................................................................................46
7.5 Experience and Competence.......................................................................................................................47
7.6 Situational Awareness ................................................................................................................................48
7.7 Safety Auditing and Internal Oversight .....................................................................................................49
7.8 Summary of Mitigation Effectiveness........................................................................................................50
8. Comparison With the Marine Industry..........................................................................................................50
8.1 Introduction ................................................................................................................................................50
8.2 Differences Between Aircraft Cockpit and Bridge Navigation Operations................................................51
8.3 Multicultural Crews ...................................................................................................................................51
8.4 CRM and Professional Culture...................................................................................................................51
8.5 Safety Regulation .......................................................................................................................................51
8.6 Conclusion .................................................................................................................................................52
9. Approaches to Human Factors in Other Safety-critical Industries .............................................................52
10. Conclusions........................................................................................................................................................53
10.1 CRM...........................................................................................................................................................54
10.2 SOPs...........................................................................................................................................................55
10.3 Professional Culture....................................................................................................................................55
10.4 Overall .......................................................................................................................................................56
11. Recommendations.............................................................................................................................................56
12. References..........................................................................................................................................................57
Appendix A: Postal Questionnaire.........................................................................................................................60
Appendix B: Interview Questionnaire...................................................................................................................66
Appendix C: Comparison With the Marine Industry..........................................................................................74
C.1 Introduction.................................................................................................................................................74
C.2 Globalization...............................................................................................................................................74
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C.3 Economics of Change in Merchant Shipping ............................................................................................74
C.4 Characteristics of the Merchant Shipping Industry....................................................................................74
C.5 Regulation of the Shipping Industry...........................................................................................................75
C.6 Differences Between Aircraft Cockpit and Bridge Navigation Operations................................................75
C.7 Multicultural Crews in Shipping.................................................................................................................77
C.8 SOPs ..........................................................................................................................................................77
C.9 Crew Resource Management .....................................................................................................................77
C.10Professional Culture....................................................................................................................................77
C.11Reference....................................................................................................................................................77
FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 3
Executive Summary literature on possible human factors impacts. The following
paragraphs provide a very short summary of the principal
dimensions in which commercial developments potentially
Introduction
have a human factors impact.
The study was carried out during 2000, on behalf of the Joint
Culture
Aviation Authorities (JAA), by a team led by Icon Consulting
and including Human Reliability Associates, International Air
Transport Association (IATA) Aviation and Research1 and The impacts of national, professional and organizational
experienced pilots. The aim of the study is to consider the cultures were investigated.
human factors implications of recent commercial developments
in the airline industry and to assess their potential impact, if A link between national culture and potential flight-deck
any, on flight-deck safety. behavior was established. National differences were identified
in the dimensions of individualism/collectivism (achieving
individual desires as opposed to group harmony), power
Approach
distance (relationship between subordinates and superiors)
and uncertainty avoidance (tolerance to risk and uncertainty).
The overall approach was as follows:
These differences may result in different attitudes to following
standard operating procedures, (SOPs) to the use of automation
(cid:127) To investigate whether there is a theoretical possibility
and to relationships and management on the flight deck.
of commercial developments having a safety impact
on the flight deck — it was concluded that there is a
In terms of globalization, therefore, flight deck crews composed
possibility;
of individuals from different cultural backgrounds might
experience conflict in the dimensions identified.
(cid:127) If there is a theoretical possibility, to identify whether
the conditions exist for a safety impact to occur — it was
The professional culture of the flight crew is strong. However,
concluded that the conditions do exist and that continuing
the satisfaction level achieved is largely determined by the
changes in the industry are increasing the likelihood of
organizations that they work for and the conditions under
their occurrence;
which they work. In addition, the sense of professional pride
can result in an unrealistic denial of vulnerability to factors
(cid:127) If the conditions exist, to seek evidence on whether
such as fatigue.
incidents are occurring as a consequence — relevant
incidents were identified, but it was concluded that there
A link between a negative organizational culture and negative
is insufficient evidence to link them directly to this cause;
attitudes and behavior was established which would not
and,
necessarily be mitigated by the high level of professionalism
of flight crews.
(cid:127) To identify any mitigating factors that could be used to
reduce the threat — it was concluded that there are factors
Flight Deck Error
and that they should be enhanced to deal with this threat.
A wide range of people were consulted for the study, including Researchers have recorded that errors were made on 68 percent
airline management, management pilots, line pilots, safety of flights they observed, with an average of two errors per flight.
regulators, an airframe manufacturer, a flight crew agency Not all crew errors will lead to adverse consequences. This
and pilot-representative organizations. The airlines consulted report identifies the types of errors and their causes.
included national, regional and cargo carriers, charter airlines
and new entrants in the low-cost sector. The countries represent Direct causes of failures are primarily due to a breakdown
a broad cross section of the whole of the JAA region and are in crew-related interactions such as decision making, verbal
not biased toward any one part of Europe. communication, team organization and workload distribution,
rather than a lack of technical proficiency. Team skills are
All contributions to the study are confidential to the study therefore vital to a safe flight. The indirect or latent causes
team. of failures can be due to inadequate training, supervision,
resources or oversight, and faulty procedures and policies.
At the beginning of the study, the team reviewed commercial
developments in the air transport industry and the published Commercial Developments
The report describes past, recent and possible future
1 International Air Transport Association Aviation Information and Research
developments in the air transport industry that have been
(IATA-AIR) input was related to describing and analyzing commercial trends
in the industry. motivated by deregulation, liberalization and privatization.
4 FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003
Alliances are formed partly to improve market access and partly effect on interpersonal relations during off-duty periods, which
to reduce cost. Cost-reduction mechanisms include: will reduce the likelihood of the crew building up a shared
knowledge base and a shared set of assumptions about how
(cid:127) Management contracts, leading to the reduction in the the team should work together.
management head count of members;
Other factors that are thought to cause difficulties are different
(cid:127) Joint ventures in areas such as ground handling and religious beliefs, membership in different trade unions, different
aircraft maintenance, which allow alliance members safety or crew resource management (CRM) philosophies and
to enjoy the benefits of bulk purchasing from key concerns over flying skills and technical knowledge.
suppliers;
Commercial Pressure
(cid:127) Sharing of facilities such as training, maintenance and
aircraft spares; and,
In some instances, there is strong pressure to increase flying
hours up to the legal limits. Many airlines treat the legal limit as
(cid:127) Higher utilization of aircraft.
a performance target to be achieved if utilization of flight crew
is to be maximized and operational costs reduced. In addition,
Cost efficiency does not automatically mean a loss of safety,
some airlines allow very little, if any, reduction in flying hours
particularly as all carriers are subject to the same regulation.
for management pilots, some with critical responsibilities such
However, the emergence of numerous new-entrant airlines,
as flight safety.
each of which requires specific regulatory effort, may stretch
the resources of the regulators. While previous airline
Unsympathetic rostering increases fatigue, upsets sleep patterns,
mergers generally took place between airlines within the
reduces morale and has a detrimental effect on the personal life
same country, mergers that cross national boundaries are
of crew. In some cases, this is combined with a reduced ratio
becoming increasingly common. This is likely to give rise
of crew per aircraft, leading to a loss of flexibility and pressure
to a more complex mix of cultural factors to be dealt with
to fly despite personal welfare.
by the new companies. Further mixing is likely to result
from an increase in the number of pilots from the former
Many pilots interviewed in a wide range of airlines observed
Soviet Bloc seeking improved employment conditions in
that there is a tendency for business people with no flying
Western airlines.
experience to fill senior operational positions. Their concern
was that these managers might not understand the implications
The growth of the low-cost carriers has generated new demand
of their decisions.
for air travel, a new market sector and new commercial
pressures. Not all low-cost carriers have survived, and those
Training is an expensive activity, and there is a fear that training
that have face increased costs, not least because they now have
budgets might be reduced to achieve cost savings.
to compete in the marketplace for the considerable number of
pilots they require. Overall, they have contributed toward an
Captains are increasingly being required to make economic
increase in volatility in the employment of pilots.
decisions, which is often counter to their traditional role of
safely flying the aircraft. There is sometimes a dilemma
between safety and economics: A captain has the responsibility
The Effect of Commercial Developments
for the safety of a flight but may be blamed by management if
he or she is thought to have taken a commercially detrimental
The consequences of recent developments have the potential to
decision. If a pilot succumbs to commercial pressure and as a
affect flight deck performance. Airline mergers and alliances will
result is involved in an incident, he cannot, in law, defend his
change the organizational culture in which individuals work, and
position by saying that the company pressured him to take the
this in turn may influence individual performance. They are likely,
actions that he did. Some pilots find this dilemma difficult to
also, to increase the incidence of multinational flight crews. As
resolve on a day-to-day basis.
more flexibility is required of airline staff, effects such as changes
in morale and increased fatigue may be seen.
Mitigating Factors
Of all the potential problems arising from multinational flight
crews, differences in language are an obvious concern, and During the research, a number of factors that might mitigate
an increase in mixed-language operations is likely to have the effects of globalization were identified. These factors have
a negative effect on safety. Language is also a social issue been classified into three categories: CRM training, SOPs and
affecting both duty and off-duty time. Social interaction may professional culture. Safety regulation is also available as a
help to reduce fatigue, maintain alertness between the crew and controlling measure. The report identifies to what extent each
contribute to teamwork during flights. A lack of conversational category is likely to produce effective mitigation and whether
or colloquial ability in a common language may have an adverse other control measures can be brought to bear.
FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 5
CRM training is the approach used within aviation to tackle Several airlines stressed the highly proceduralized nature of
issues of teamwork among flight crew. Whereas benefits have the flying task, claiming that procedures existed for every
been claimed by the industry from the use of CRM, there is eventuality. However, crews working in highly proceduralized
little hard evidence that CRM has a measurable effect on safety. environments may encounter difficulties when faced with a
There are particular concerns that behavior in training sessions situation that is not covered by a procedure. Furthermore,
is not correlated with behavior under real circumstances. In crews who normally use SOPs when working for an airline
addition, CRM cannot deal with other causes of error such as that strongly adheres to procedures may experience difficulties
fatigue, poor interfaces, cockpit automation issues and problems should they then operate in an airline which allows a greater
related to SOPs quality and compliance. degree of individual interpretation of SOPs.
The use of a standard, outsourced CRM “product” that has not been Airline personnel display strong ownership toward their own
adapted for the particular culture in which it is applied may also SOPs. It would appear that new-entrant airlines tend to adopt
reduce its effectiveness. There appears to be no process in place manufacturers’ SOPs with little, if any, modification, whereas
in the industry to spread to others either the experience gained in established airlines will often have adapted these SOPs quite
developing appropriate CRM training or best practices. considerably. Problems may arise if there are differences in the
degree of compliance with SOPs by flight crews from different
The scope of CRM is being extended in some airlines. airlines.
While the previous emphasis was on team-building skills
and communication, other aspects are now being introduced, Safety regulators do not allow the operation of mixed SOPs
such as monitoring skills and the management of time and within a single aircraft type under an aircraft operating
workload. Some airlines run CRM training for mixed groups certificate (AOC). Therefore, it would be difficult to mix
of cabin and flight deck crew, and in one case also maintenance crewmembers within an alliance unless all partners of the
personnel. alliance were using the same SOPs.
However, there is a serious danger that CRM will be seen as The professional culture in aviation is strong and distinctive,
the solution to all human factors issues in commercial aviation. and this is particularly apparent in the professional culture
This is reflected in the fact that the human factors departments among pilots.
of airlines are often staffed by CRM specialists rather than by
human factors professionals. Flight crew were described as intelligent, although not necessarily
formally educated, with a high degree of self-confidence. Strong
The emphasis on CRM may in some cases lead to a culture in self-discipline and self-motivation were said to be essential to
which all errors are considered to arise (and be contained) in the cope with the working environment. Flight crew tend to be
cockpit environment. However, many factors that may adversely conservative in nature and are generally uncomfortable with
influence flight safety originate, as in all other industries, from change unless it is long-term and gradual.
management and organizational failures that occur deeper in
the system and are outside the control of individual flight A strong professional culture has both strengths and
crewmembers. High levels of flight crew training, experience or weaknesses. On the positive side, pilots take great pride in
personal capability will not automatically mitigate the adverse their profession and have a strong motivation to perform to
effects of such factors. the best of their ability. On the negative side, there may be an
unrealistic denial of vulnerability to factors such as fatigue,
The CRM industry is responding to changes due to globalization, stress or personal issues. Given the great responsibility of
and no doubt the more recent versions of such training will pilots, this may be a psychological defense mechanism to
improve its effectiveness. avoid performance anxiety.
SOPs form the basis for the operation of the aircraft, and There is a danger that globalization may degrade those aspects
it is thought by the whole industry that very few incidents of professional culture that do act as a control mechanism.
would occur if SOPs were adhered to rigidly. However, it For example, the movement of crew between countries
is clear that, in common with most safety-critical industries, and companies may diminish the perception of a common
absolute compliance with the letter of all written procedures identity.
is not regarded as feasible. The extent of the noncompliance
is influenced by the prevailing safety culture in the company. Safety regulation in Europe is not yet harmonized. Differences
In addition, pilots who have experience with more than one among member states mean that European airlines are not
set of procedures may inadvertently revert to a previously overseen by a coherent legal entity, unlike the situation in the
familiar procedure, particularly under conditions of duress. In United States. Given that overall regulation is the remaining
a multicultural environment, a flight crewmember’s knowledge control mechanism to deal with conditions not controlled by
of an SOP may lead him to interpret ambiguous communication the other three identified mitigating factors, this has to be a
in terms of SOPs with which he is familiar. matter of concern to the JAA.
6 FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003
Some regulators are taking a less active role in enforcing Hawkins (1993) states that, despite the low level of accidents
standards by allowing airlines to take greater responsibility per passenger carried or hours flown, the current accident rate
for their own oversight by means of self-audits. However, it is is still too high for the comfort of the public. The Final Report
apparently becoming increasingly difficult for airlines to recruit of the (U.S.) White House Commission on Aviation Safety
suitably experienced people as nominated post-holders to carry and Security (1997) states that if the current accident rate is
out this important role. maintained, the expected growth in air transport means that
by 2015 there will be one major accident somewhere in the
Conclusions world each day, a situation which would be totally untenable.
Therefore, the accident rate must be reduced to ensure that the
total number of accidents per annum is no greater, and hopefully
The aviation industry in Europe is developing rapidly, and
lower, than current figures. As a part of this improvement
a number of human factors effects that can arise from these
process, human factors issues need to be addressed.
commercial developments have been identified. Some of these
effects have the potential to impact negatively on flight safety,
The global nature of aviation means that issues of
and this threat is likely to increase as the pace of commercial
communication and interaction between cultures are of
developments increases.
particular interest, perhaps more so than in any other industry,
apart from international shipping (see Chapter 8). The constant
There is a belief in the industry that the control measures of
drive for cheaper and more flexible travel may lead airlines to
CRM, SOPs and professional culture will mitigate these threats.
look further afield for their flight crews and to increase their
This report suggests that these measures may not be fully
use of multicultural crews.
effective in preventing or controlling the issues. An evaluation
of the extent to which the three measures are thought to be
However, it would be a mistake to assume that issues arising
effective is presented in Table 1.
from differences in national cultures are the only or even the
1. Introduction most important flight safety issues arising from commercial
developments in the airline industry. Mergers between airlines
also involve a merger of the individual cultures and practices
1.1 Background to the Study
that have existed in the previously independent companies.
The aim of this study is to consider the human factors implications
To remain competitive, airlines will also seek more efficient
for flight safety, if any, of recent commercial developments in
and cheaper ways of doing business, which is likely to result in
the airline industry. In particular, the study focuses on recent
greater flexibility being required of flight crew and may increase
tendencies for airlines to merge and form global alliances, and
their sense of commercial pressure. The rapid expansion in low-
the growth in new entrants with different business models.
cost carriers and the future movement of flight crew between
these airlines and more conventional carriers with very different
The functional reliability of aircraft has improved beyond
company cultures may also have human factors implications.
all recognition over the course of the last century. This
improvement, however, has drawn attention to the importance
of the human element in determining system safety (David, 1.2 Scope of the Study
1997). It has been suggested that around 70 percent of aviation
incidents and accidents are attributable to human error on the The scope of the study is countries in the JAA area. No
flight deck (Foushee, 1984). organizations were consulted from outside this area, although,
Table 1
Tabulation of Human Factors Issues and Mitigating Factors
Mitigation Effectiveness
Crew Resource Standard Operating
Human Factors Issue Management Procedures Professional Culture
Teamwork/power gradient Medium Medium Medium
Communication Medium Medium Low
Fatigue Low Medium Low
Morale and job satisfaction None Low Low
Experience/competence Medium Medium None
Situational awareness and mental models Medium Low Medium
Source: Icon Consulting, Human Reliability Associates and International Air Transport Association Information and Research.
FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 7
during the course of the study, some examples were provided Using the output from this research, two questionnaires were
of airlines based beyond the boundaries of the JAA that have developed to elicit relevant information from airlines. The
experienced and resolved human factors issues that are relevant first was a postal questionnaire that could be sent to selected
to this study. Some of these examples are referred to in this airlines to obtain some preliminary information. The second
report. was a list of follow-up questions that could be used by
members of the team in a face-to-face, structured interview.
The main thrust of the study has been in obtaining the The interview questionnaire provided a framework for the
views, concerns and experience of a variety of stakeholders meeting but was used flexibly to ensure that all matters
in European aviation. Table 2 shows the sample of different relevant to the study could be pursued as they arose. The
types of organizations that were consulted by means of either a postal questionnaire appears in Appendix A, and the interview
questionnaire or a face-to-face interview, and their geographic questionnaire in Appendix B.
spread.
These two questionnaires were particularly suitable for
interviewing management and management pilots in airlines,
Table 2 and a less structured approach was taken with line pilots and
safety regulators. In particular, questions that were asked at
Dimensions of Representation
meetings with regulators were based on issues that had already
In the Study
emerged from the airline interviews.
Number Countries
Much of the content of the main part of this report is derived
Organization Type Consulted Represented
from an analysis of the information collected at meetings and
Airline 21 14
from questionnaires.
Safety Regulator 4 4
Airframe Manufacturer 1 1 The human factors issues identified are not only being
Flight Crew Agency 1 1 experienced in the aviation industry but also occur in other
Pilots’ Representative Association 1 Europe safety-critical industries where globalization is taking place.
The study team has used its prior experience of the marine
Source: Icon Consulting, Human Reliability Associates and International Air industry to compare it with aviation to determine if there are
Transport Association Information and Research.
lessons that can be learned.
The airlines consulted include national, regional and cargo
1.4 Layout of Report
carriers, charter airlines and new entrants in the low-cost
sector. Airline managers, management pilots and line pilots
Chapter 2 puts the remainder of this report into context
were interviewed. The countries represent a broad cross section
by reviewing previous work that has been carried out on
of the whole of the JAA region and are not biased towards any
cultural factors in aviation. It discusses three types of culture
one part of Europe. To preserve confidentiality, neither the
— professional, organizational and national — and explores
organizations nor the countries are named.
how flight crew attitudes are influenced by these cultures. It
also considers how cultural issues might be managed on the
It should be noted that in this report, “flight crew” refers to
flight deck.
all those members of the crew who work on the flight deck,
including captains, first officers and flight engineers. It does
Chapter 3 reviews different types and causes of human error on
not include cabin crew.
the flight deck. It provides a framework model of flight deck
error based on the acquisition of information, the sharing of
1.3 Methodology this information between flight crew and its use for decision
making. A summary table is provided to illustrate the type of
To set the scene at the beginning of the study, two pieces of error that can occur during each stage of the framework and
research were carried out: relates each error type to possible cultural causes.
(cid:127) A review of significant historical and current developments Chapter 4 highlights some of the significant historic and
in the structure of the air transport industry, together with current structural changes in the air transport industry of
a look at likely future developments; and, particular relevance to this study. It considers the effects of
deregulation, its impact on different types of carriers, the rapid
(cid:127) A review of published literature relating to the professional growth in global airline alliances and the emergence of low-
culture of pilots, the mixing of national and organizational cost carriers.
cultures, the management of culture on the flight deck
and the causes of flight deck errors. Chapters 5 to 7 are based on the results of the interviews.
8 FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003