A systemic approach to HRA: a FRAM modelling of Overflight ... · © Luigi Macchi 2008 23/11/08 A systemic approach to HRA: a FRAM modelling of Overflight Control activity L. Macchi

© Luigi Macchi 200823/11/08

A systemic approach to HRA: a FRAM modelling of Overflight Control activity

L. Macchi

[email protected]

mailto:[email protected]

mailto:[email protected]


Outline

Research context

FRAM theoretical assumption

Modelling executive controller activity

Performance variability

Conclusion and perspectives


Research contextComplex socio-technical systems:

1. Elements are tightly coupled

2. Low manageability

Methods should account for:

1. Dynamic nature of interactions

2. Non-linearity of events that lead to accidents

Systemic vs. linear perspective

Performance variability vs. Performance deviation

Functional Resonance Analysis Method


Outline

Research context






FRAM theoretical assumptionsPrinciple of equivalence of success and failures

Successes due to the ability of an organisation to anticipate, recognise and respond to risks

Failures happen when the ability is temporarily or permanently lost

Principle of approximate adjustment

Humans need to adjust to current conditions

Adjustments are achieved varying their performance

Principle of emergence

Normally variability is not an harm to safety

Variability from multiple functions could combine and result in accidents

Principal of functional resonance

Variability of a function could be reinforced by others functions variability

Variability could spread in the system

I

R

O

CT

P


Outline

Research context






System identification

ExecutiveController

Pilot

Planner

P1/ATACAS

IDVS/Omega

Adjacent sector


Executive controller tasks

1. Ensure correct radar display by adjusting equipment

2. Provide radar service to controlled aircraft

identify aircraft and maintain identification

radar vector aircraft to provide separation

issue clearance and instructions to ensure that radar separation minima are not infringed

document clearance, instruction and coordination results, update them

monitor the progress of flights

issue information to aircraft

Manual of operations for air traffic control services. Ed. November 2007


10 functions Monitoring

Planning

Issue clearance to pilot

Coordination

Strip marking

Update Flight Data Processing System

Provide met. data to controller

Provide flight and radar data to controller

Controller-Pilot communication

Sector-Sector communication


Functions description6 parameters:

Input (I): that which the function processes or that which starts the function

Output (O): that which is the result of the function, either an entity or a state change

Preconditions (P): conditions that must exist before a function can be executed

Resources (R): that which the function consumes to produce the output

Time (T): temporal constraints affecting the function (with regard to starting time, finishing time, or duration)

Control (C): how the function is monitored or controlled


Issue clearance to pilotInput Clearance plan

Output Clearance issued = [regulate speed; heading change; climb; descend; adjust vertical rate; intermediate level off; holding instruction]

Time

Control

Clearance proceduresLetter of agreementRT standardsWarning by safety net

Precon.

Aircraft identifiedandRadio contact establishedandSector capacity = [sector capacity satisfied] and Flight position = [entering the sector] or Request from pilot = [regulate speed; heading change; climb; descend ] orRequest from next sector = [flight level; speed; route; heading; flight not accepted]

Res.

Situation data display equipmentTouch input deviceFlight progress stripRT equipment


FRAM model

I

R

O

CT

P

Monitoring

I

R

O

CT

P

Planning

I

R

O

CT

P

Issue clearance to

pilot I

R

O

CT

P

Strip

marking

I

R

O

CT

P

Coordination

I

R

O

CT

P

Update FDPS

I

R

O

CT

P

Provide met. data

to controller

I

R

O

CT

P

Provide flight and radar data

to controller

I

R

O

CT

P

Sector-sector communication I

R

O

CT

P

Controller-pilot communication


I

R

O

CT

P

Monitoring

I

R

O

CT

P

Planning

I

R

O

CT

P

Issue clearance to

pilot

I

R

O

CT

P

Strip

marking

I

R

O

CT

P

Coordination

I

R

O

CT

P

Update FDPS

I

R

O

CT

P

Provide met. data

to controller

I

R

O

CT

P

Provide flight and radar data

to controller I

R

O

CT

P

Sector-sector communication

I

R

O

CT

P

Controller-pilot communication

FRAM instantiation


Outline

Research context






Performance variabilityCommon Performance Conditions

evaluation

Control Mode

Scrambled Opportunistic Tactical Strategic

Performance variability evaluation

Contextual conditions

Human error

HERA Database


Common Performance Conditions

HighNoticeableSmallQuality and support of organisation HighNoticeableSmallCrew collaboration qualityHighNoticeableSmallCircadian rhythm, stress

Very highHighSmallAvailable time, time pressure

HighHighSmallNumber of goals and conflict resolutionHighNoticeableSmallConditions of work

HighNoticeableSmallAvailability of procedures and methods

HighNoticeableSmallAdequacy of HMI and operational support

HighNoticeableSmallQuality of communication (team, organisation)

HighHighSmallTraining and experience (competence)

HighNoticeableSmallAvailability of resources (personnel, materials, equipment)

UnpredictableInadequateAdequate


Outline

Research context






Perspectives

Definition of functional resonance

Shortcuts (adjustments) within the system

Change in the Common Performance Conditions

Variability combination changes function’s output

Identification of potential barriers

Variability should not be eliminated

Barriers need to damp variability to prevent functional resonance that can lead to unwanted outcomes


Thank you for your attention



Variability Possible sources of variability:

Inherent variability due to physiological and/or fundamental psychological characteristics. E.g. fatigue, circadian rhythm, vigilance and attentionVariability due to higher level psychological phenomena e.g. adaptability in overcoming temporal constraints and underspecification.Organizationally induced variability, e.g. meeting external demands (quality, quantity), stretching resources, substituting goals.Socially induced variability e.g. meeting expectations of colleagues, complying with informal work standards.Contextually induced variability, e.g. working conditions too hot, too noisy, too humid. Performance variability induced by the unpredictability of the domain, e.g., weather conditions, number of flights, pilot variability, technical problems, etc.


Variability and Failure modes ExecutionPlanningInterpretationObservation

Erroneous action

Timing

Duration

Sequence

Object

ForceDirection

Speed Distance

Too early, too late, omission

Reversal, repetition,

commission, intrusion

Too long, too short

Wrong direction

Too fast, too low

Too far, too short

Too much, too

little

Wrong action, wrong

objectFailure mode

Missed action

Action out seq

Action wrong object

Action wrong time

Action wrong type

Inadequate plan

Priority error

Delayed interp

Decision error

Faulty diagnosis

Obsnot made

Wrong identif

Wrong object

Documents

A systemic approach to HRA: a FRAM modelling of Overflight ... · © Luigi Macchi 2008 23/11/08 A systemic approach to HRA: a FRAM modelling of Overflight Control activity L. Macchi