Managing

Interruptions & Distractions

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Purpose and contents of the presentation

Introduction : Interruptions and distractions constitute an insidious threat
Analyzing mandatory and voluntary incident reports relative to distractions

A step-by-step analysis of databases with Excel filtering

Uncover and cluster factors related to distraction issues

Consequences and descriptors, operational and human factors markers

Discuss practical ways and means to take care of this

Using tactical countermeasures

Using prevention and recovery strategies

Using practical tips

Conclusion

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Distractions and interruptions in ancient times

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OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Distractions and interruptions in modern times

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OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Effects of distractions and interruptions in approach and landing

accidents (ALA) according to the FSF ALA Task Force
Factor
Omission of action or

% of
Events
72 %

inappropriate action
Inadequate crew coordination,
cross-check and back-up
Insufficient horizontal or vertical
situational awareness
Inadequate or insufficient
understanding of prevailing

63 %
52 %
48 %

conditions
Slow or delayed action
Incorrect or incomplete pilot /
controller communications

45 %
33 %

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Using incident reports for human factors evaluations

After Sheryl L. Chappell (1994)
Lauber (1984) stated that an incident database is a
veritable gold mine of information waiting to be tapped.
Rich

source of information in aeronautical human factors

Use

by policy makers, HF practitioners to improve safety.

The limitations of incident data in research

Bias

factors: Who reports and what gets reported

To receive

immunity pilots report some occurrences more.

No knowledge of actual number, only those reported

Temptation

to attribute a coexistence of two factors to

cause & effect

Multiple

methods of looking at the data to uncover factors.

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Using Databases: goldmines of information on distraction

BASIS, AIRS, SIE excellent for health checks
BASIS
More

than 72 ASR incidents relative to distraction screened,

AIRS
over

37 HF incidents relative to distraction screened,

SIE
only

5 incidents relative to distraction screened,

We now observe less HFs in confidential reports,

We now observe more HFs in mandatory reports,
ASRs and HFRs growing together,
SIE now migrating to IATA Steades,
OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

OEAP : Involved Domains and Factors

SITUATION RECOGNITION / DIAGNOSIS

ALERTS

COCKPIT /
CABIN
EFFECTS

CREW
DIAGNOSIS

HMI
ASPECTS

PROCEDURE(S)

PROCEDURE
TYPE

PROCEDURE
ACCESS

PROCEDURE
CONTENTS

CREW PERFORMANCE

PROCEDURE
EXECUTION

OPERATIONAL
ENVIRONMENT

CREW
ERROR
MANAGEMENT

CREW
ACTIONS

WEATHER /
ENVIRONMENTAL
CONDITIONS

THREAT
MANAGEMENT

AIRCRAFT
ATTITUDE
AND
FLIGHT PATH
CONTROL

CREW
COORDINATION

:
g
a
n
i
e
r
rn
ENVIRONMENT & CIRCUMSTANCES
o
a
t
W
t
p
m
e
AIRCRAFT
t
t ORGANIZATIONAL
RUNWAY
SYSTEMS
CREW a
t
CONDITIONS
CONDITION /
FACTORS
FACTORS
o
n
CONFIG
Do

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Distraction caused by / resulting in the specific safety events

Air Traffic Control A/C communication & separation losses,
Cabin & Flight crew affection & incapacitation,
Flight Path Control (alt bust / dev,path dev,lat dev,vert dev,
flare,taxi/rwy inc/exc,swerves,spd loss/drops,stall,),

Non respect of Limitations (overspeeds,flap limit speeds),

Threat for CFIT/ALAR (stabilization criteria not met,
unstable/rushed/fast/slow approaches,),
Go-around/IFTB/Delayed starts/diversions,
Loss of System Functions,
OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Themselves caused by / resulting in specific safety issues

Flight Control Difficulties (flaps not set,speed-brakes,gear
not extended/retracted,delayed,configuration warnings),
Difficulties with automation (auto throttle,mode
management,),
Systems management (APU not shut down,parking
brakes not set,anti-ice not selected,hot start),
Fuel management (pump selections, limitations,
quantities,imbalances,),
Cabin pressurization difficulties,
Altimeter barometer setting,
TCAS/GPWS alerts,
OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Themselves caused by / resulting in specific safety issues

Ergonomics (plate/map holders,cockpit displays,sun visors),

Noises (engines,ATC buzzer,headset chatter,radio altitude

callout,warning,intercom,interference,mobiles,loudspeaker),
MEL/SOPs,checklists,procedural difficulties (omission,
item not completed / skipped / forgotten ),

Language confusion/difficulties,call sign misunderstandings,

Passenger / cabin distraction,cabin secure reports,
Hazard linked with kites,birds,wildlife,dogs,
Airport infrastructure (lighting,marking,),
Burning smell/smoke,
OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Themselves caused by / resulting in specific safety issues

Navigation issues (FMS data introduction and databases,
flying through localizer,flying past radio beacon,)
Weather issues (lightning,fog,haze,hail,turbulence,wake
turbulence,C/Bs,wind-shear) and avoidance thereof,
Technical system failures or system failures (preset altitude
not acquired,descend through selected altitude),
Load-sheet figures not obtained/not introduced, suspicious
items,fuel quantities,LMCs not communicated),
Fatigue and Alertness issues,
Crew Resource Management issues,
Concurrent Task Management issues,
OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

As mediated / accompagnied by Ops/Human Factors Markers

Situational Recognition / Diagnosis Procedures

Difficulty

in use of systems

Automation
Condition

not understood

not detected

alert not identified

Abnormal
Late

combination of
procedures

Procedure

scope

incomplete
Entry

Noise
False

Complex

indication

problem recognition

in procedure
unclear

Procedure

/ A/C
configuration mismatch

ECAM

warning

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

As mediated /accompagnied by Ops/Human Factors Markers

Crew Performance

Environment & Circumstances

Workload management

Being unstabilized at approach

gate

Over-speed

NATP SOPs

NATP C/Ls

Incomplete

configuration

NATP Sterile Cockpit

Inadequate

separation

Degraded situational awareness

Delayed action

Inadequate

ATC instruction

Cockpit/cabin comms

Undetected/unchallenged
crew error

Briefings

Flight monitoring

Pilot/controller
Operational
In-flight

communication

stress

failure

Fatigue/vigilance
Company

policies

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Interruption / Distraction: Cause and / or Effect ?

SAFETY
EVENTS
Environment/
Circumstances

Operational Factors

Situational
Recognition/
Diagnosis
Human Factors

Crew
Performance

Procedures
SAFETY
ISSUES
OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

The essence of AIRS : modeling interactions within an event

Interactions within the Human Factors

Model
ENVIRONMENT

ORGANISATION

CREW
CREW
ACTIONS
ACTIONS
PERSONAL

INFORMATION

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Concurrent Task Management as a cause of vulnerability

T/O Config warning because pre-T/O checks not carried out
Third Party
COMPANY
COMMUNICATIONS

POST INCIDENT
STRESS

OPERATIONAL
STRESS
First Party
AIRPORT
FACILITIES

WORKLOAD
MANAGEMENT

Third Party
First Party

DISTRACTION
Third Party

Third Party

First Party
MEMORY LAPSE
Third Party

RTO

AIRS Treatment : modeling a

Take-Off Configuration Event

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Concurrent Task Management as a cause of vulnerability

NASA studies on distractions, distractions and Concurrent Task Management
(by Loukopoulos,Dismukes and Barshi at NASA Ames)

Comparison of written materials with actual line operations :

Pilots

often have to interleave two or more tasks concurrently to

respond to operational demands,

written material can only prescribe serially and not frequentially,
Crews

are sometimes unable to execute a procedural step at the

point prescribed in written procedures,

information may be missing or the context can be inappropriate,
Crews

are frequently interrupted especially by other personnel,

timing of interruptions / nature of response required unpredictable,

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Concurrent Task Management as a cause of vulnerability

NASA studies on distractions, distractions and Concurrent Task Management
(by Loukopoulos,Dismukes and Barshi at NASA Ames)

Cognitive demands of concurrent task management :

Interleaving tasks and monitoring,

pilots are especially vulnerable to error if a task step unexpectedly

requires an unusual amount of attention,
documentation provides little specific guidance on how frequently to
monitor or how to divide attention between monitoring and rest,

Suspending and deferring tasks,

respond to the interruption + return to the interrupted task later or
suitably halting the ongoing before responding to the interruption,
pilots like others are quite vulnerable to forget to perform deferred tasks,
may overestimate the probability of remembering these,

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Countermeasures for Concurrent Task Management Issues

Be aware of error proneness when performing routine tasks
concurrently or out of usual sequence / time scale,
Examine contents & timing of procedures & checklists with care,
Identify situations in which procs must be interleaved with frequent
interruptions,

Design procedures to minimize concurrent task demands & interruptions

Set salient traps and strict decision criteria that must be met before
proceeding further,
Provide explicit guidance to crews on the importance of monitoring,
what to monitor,and how to monitor,

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Prevention and Recovery Strategies : Manage distractions

Recognize and Identify the disruption,
Re-establish Situational Awareness :
Identify
Ask

: WHAT WAS I DOING?

WHERE WAS I INTERRUPTED?

Decide

/ Act :
WHAT DECISION OR ACTION to get back on track?

The following decision-making process to be applied :

Prioritize
Plan

Verify

: FLY,NAVIGATE,COMMUNICATE and MANAGE!

TAKE TIME TO MAKE TIME!

THAT POSTPONED ACTIONS WERE FINALIZED!

Verbalize to mark interruptions and protect what you are doing,

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

21

Prevention and Recovery Strategies : Manage distractions

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

22

Prevention and Recovery Strategies : Mutual Crosscheck

Each flight crewmember must actively cross-check the
actions of each cockpit colleague,
These

crew monitoring and cross-checking functions are the

last line of defense : a detection may break the chain of events,

Monitoring and cross-checking accomplishes 3 VIP functions:

keeping

the crew appraised of the current aircraft status,

helping

the crew catch their own errors,

helping

them detect evolving aspects.

Photo credit : TAKEOFF - The Swiss Professional Pilots Association Magazine

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Prevention and Recovery Strategies : Think & Trap Errors

Training for improved monitoring in the simulator will translate
to better monitoring on the line and requires instructor patience.

Perceive
Students should be
allowed to make
& catch their own mistakes.
Situation
Mitigate
Errors that are not
detected timely should be better debriefed.
Awarenes
s
Comprehend
Trap
LOSA found that crews failed to detect 42% of errors noted by
Threat
cockpit observers.
Management
Project
Avoid

Improving & sharpening crew monitoring skills through ESSAI by:

Minimising

loss of Situation Awareness (SA)

Increasing

Threat Management (TM) skills

ESSAI : Enhanced Safety through Situation Awareness Integration in training (EEC program)
OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Prevention and Recovery Strategies : Monitoring Skills

Traditional CRM has excelled in training to challenge or speak
up when something seems unsafe or unwise,
To challenge

something, one must first detect it, and detection

requires effective monitoring,

Traditionally monitoring has not been held as a primary task.

Pilot-not-flying duties typically include tasks such as handling

radio comms, operating gear and flaps, and keeping a flight log.

Monitoring

is typically not listed, leading to the erroneous

conclusion that it is more or less a secondary duty to be
performed when crewmembers are not busy with other tasks.
OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Prevention and Recovery Strategies : SOPs (AC 120-71A )

The FAA recently solicited industry input to develop a template
that airlines can adopt to support enhanced monitoring which
led to a revised AC on Standard Operating Procedures ",
This Advisory Circular notes that several operators have
changed the title of Pilot Not Flying to Pilot Monitoring,
PM better defines this pilot's role, and is more descriptive
because it really states what this pilot should be doing,
This also appears to be an excellent Risk Management Tactic,

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Prevention and Recovery Strategies : Manage Fatigue & Alertness

How does your body manifest being tired?

What effect does being tired or being less alert have on your monitoring
behavior ?

How does diminished alertness affect your performance in flight ?

How did you cope with poor alertness in the past ?

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Practical Tips for avoiding lapses in Monitoring (from NASA)

Questionnaire studies based on ten incident scenarios from ASRS study on distractions
(by Loukopoulos,Dismukes and Barshi at NASA Ames)

Manage Workload : rearrange sequence, divide responsibilities, put limits,

Recognize multi-task demands and dividing attention:
Identify

specific things to monitor + periodically switch attention,

Divided

attention between tasks + avoid preoccupation with either,

Break

concurrent tasks into subtasks + pause/monitor in between,

Review task in advance to identify crucial junctures to monitor:

Brief

departure procedure ahead and review PF/PNF action plan,

Raise red flag in vulnerable situations and increase vigilance:

PNF

announcing going head-down,PF intensifies when PNF off,

Assign neglected task higher priority : e.g. collision avoidance,

Create salient visual, auditory or tactile reminders :
PNF

calling out progress so PF can monitor while doing other tasks,

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Practical Tips for avoiding lapses in Memory (from NASA)

Questionnaire studies based on ten incident scenarios from ASRS study on distractions
(by Loukopoulos,Dismukes and Barshi at NASA Ames)

Create a habit linking memory item to habitual actions :

e.g.

add landing clearance to final C/L as personal technique,

Manage workload within acceptable limits :

Divide

responsibilities + stick to it, F/O as PF so Capt manages,

Create salient visual, auditory or tactile reminders :

Hold

C/L, keep hand on radio, write down ATC, C/L for baro set,

Execute task immediately :

Call

tower early , set PNF altimeter or standby altimeter asap, then

PF at appropriate transition altitude,

Miscellaneous : enhance encoding of intentions in memory by

repeating aloud, adhere to SOPs, restart checklists if uncertain,
OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions

Conclusion : HF Analysis for Distraction Related Events

What really matters is what pilots need to have on their plate
Interruptions and Distractions constitute an insidious Threat that mandate
operational protection tips,
We need to integrate the language of Human Factors into our SOPs and
Training and Operations Manuals : crew awareness, monitoring,etc
We need to integrate the voluntary and the mandatory sides of reporting
and encourage pilots talking human factors to capture the whys,
We definitely need to develop a Human Factors Toolkit to make us
understand why this can improve aviation safety for all system actors ,
practical

briefings, training material and safety initiatives on human

factors subjects for use by the widest range of people for eye-opening,

OGHFA 1_HP_04_VIS_Managing Interruptions and Distractions