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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
24 October 2002 2
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.
24 October 2002 3
CY01 US Runway Incursions
OE/D21%
PD56%
VPD23%
VPD: vehicle or pedestrianOE/D: operational error or deviationPD: pilot deviationCY: calendar year
24 October 2002 4
• 1981 Bellatoni & Kodis – ATC conflicting clearances– Need better reporting process
• 1986 National Transportation Safety Board– Memory errors– Coordination errors– Lack of supervision
Previous Research
24 October 2002 5
• 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
24 October 2002 6
• 2001 Cardosi & Yost– Poor observation of aircraft– Poor coordination between controllers– Communication misunderstandings
between pilots and controllers– Improved data collection techniques
Previous Research
24 October 2002 7
• 2001 Kelley, Krantz, & Spelman – Lack of situational awareness– Inadequate scanning– No use of memory aids– Poor planning/prioritizing– Revise investigation forms
Previous Research
24 October 2002 8
• 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
24 October 2002 9
• 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
24 October 2002 10
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
24 October 2002 13
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.
24 October 2002 14
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.
24 October 2002 15
Organizational
Influences
UnsafeSupervisio
nPreconditions
for Unsafe Acts
UnsafeActs
HFACSLatent Conditions
Latent Conditions
Latent Conditions
Active Conditions
Failed or Absent Defenses
24 October 2002 16
Organization
Supervision
Preconditions
Controller
HFACS-ATCLatent Vulnerabilities
Latent Vulnerabilities
Latent Vulnerabilities
Separation Violation
Critical Human Error
24 October 2002 17
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
24 October 2002 18
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 --
24 October 2002 19
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 --
24 October 2002 20
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 --
24 October 2002 21
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 --
24 October 2002 22
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 --
24 October 2002 23
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 --
24 October 2002 24
• 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
24 October 2002 26
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
24 October 2002 27
ATCATC
FLT
GROUND
Performance in a Complex Environments
