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Running Head; Substandard Flight Crew Performance i Substandard Flight Crew Performance: Recurrent Human Factors in Flight Crew Initiated Aircraft Incidents and Accidents By Raymond Newell, BSc (Hons) MSc Doctoral Thesis Submitted in partial fulfilment of the requirements for the award of Doctor of Philosophy of Loughborough University June 2017 Substandard Flight Crew Performance iii ABSTRACT The objective of this research has been to understand more about aviation accidents in which the actions of the flight crew members (hereafter FCMs) were the main cause. A new con- struct has been developed known as substandard flight crew performance (hereafter SFP) to provide framework and context for this research. To support this construct, the most recurrent examples of SFP were identified from analysis of decades of investigations and reports. Based upon the frequency of occurrence, the potential contribution to aviation safety, and the feasibility of conducting meaningful research, three diverse but interconnected factors have been identified. The first of these related to the recurrent influence of verbal phenomena in aviation accidents, in particular, distracting conversations and unclear communications. The literature indicated that even those tasked with investigating accidents where these phenome- na had been present understood very little about the underlying reasons for their occurrence. Furthermore, although these phenomena have been studied within more general research populations, as far as is known no previous research has examined their function in the avia- tion context. A questionnaire and unstructured interviews with FCMs resulted in two taxon- omies, both of which have been supported by ethnographic1 observations. The next strand of this research critically examined some of the reasons why some flight crews become unsure of their position or orientation whilst navigating both in flight and on the ground, a phenome- non that has been associated with some of the most serious instances of SFP. This original contribution to aviation knowledge involved experiments utilising realistic navigation stimuli and measurement of cognitive load and spatial awareness. All human activity is embedded within a context, and this thesis contends that the influence of context is underspecified in existing knowledge of aviation human factors. As far as is known no previous research has 1 Throughout this thesis, terms that are explained in the glossary are underlined. Substandard Flight Crew Performance iv examined how FCMs might be influenced to make errors as a result of aspects of their envi- ronmental and situational context. The contextual cueing strand of this research consisted of a series of original experiments which examined the extent to which contextual cues might be implicated in instances of SFP. The three research strands outlined in this thesis are intended to demonstrate how the detailed study of specific categories of SFP such as loss of positional awareness or unclear communications can unearth contributory factors that might otherwise have been overlooked. Furthermore, it will be demonstrated that each of the research strands addresses current issues at the forefront of aviation safety. Substandard Flight Crew Performance v ACKNOWLEDGEMENTS I would like to express my gratitude and appreciation to my supervisor, Professor Roy S. Kalawsky for his expert guidance support and encouragement during my research. He pro- vided valuable objectivity as I sought to identify some of the abstract concepts outlined in the thesis. His grounding in the technical aspects of avionics meant that he understood much of what I was trying to achieve from the beginning of the research. He also gave me free rein to examine some of the soft science aspects of this research which were far removed from his background in the hard sciences. The access he provided to his other students was invaluable as I formulated my ideas for the research. I would also like to acknowledge the University’s role in providing access to some of the most knowledgeable experts in a wide range of fields. I had occasion to access knowledge from experts in disciplines as diverse as linguistics and statistics; very few Universities could have provided this diversity in the way that Loughbor- ough did. Thanks go to Martin Ashby in the research office who spent considerable time and effort helping me to design the conversation survey questionnaire. The University also pro- vided advice regarding which computer programs would be most suitable for my studies. The provision of both the SPSS statistics program and the University’s guidance on how best to use it was invaluable. The spatial awareness strand was based upon the SuperLab response time measurement software. There were several different incarnations of the experiments be- fore the ones that feature in this thesis, some of them overly complex and difficult to design. The technical support experts at Cedrus in California were always polite and helpful as I at- tempted to explain what I was trying to achieve; their SuperLab is an excellent product and they know its capabilities very well. I am indebted to the management at Charleston Airport who permitted me to use their image of the Charleston accident and showed genuine interest in my perspective on the overrun accident at their airport. They have asked for sight of the completed thesis and I hope to do this. I would also like to acknowledge the assistance I re- Substandard Flight Crew Performance vi ceived from dozens of pilots who contributed at all stages of this research. Pilots are some- times wary of researchers so it was particularly generous of them to participate. Many showed a genuine interest and contributed insights that steered the research in the early stag- es. It is also important to acknowledge the work that goes into some of the occurrence reports that were the basis of much of this research. These reports are intended to further the interests of flight safety, and they certainly assisted in that objective in this research. Research such as outlined here is time consuming and when combined with a full time job it leaves very little time for home and family. I would therefore like to acknowledge the support given by my family during the years that this study has taken. Substandard Flight Crew Performance vii DEDICATION This thesis and the associated research are dedicated to all those aviation professionals who share in my passion for improved aviation safety through knowledge; I hope they find some of the content useful. Substandard Flight Crew Performance viii TABLE OF CONTENTS CERTIFICATE OF ORIGINALITY ...................................................................................... ii ABSTRACT ......................................................................................................................... iii ACKNOWLEDGEMENTS.................................................................................................... v DEDICATIONS ................................................................................................................... vii TABLE OF CONTENTS .................................................................................................... viii LIST OF FIGURES ............................................................................................................ xix LIST OF TABLES .............................................................................................................. xxi GLOSSARY OF TERMS AND ABBREVIATIONS ........................................................ xxiii PART I THESIS BACKGROUND ....................................................................................... 1 CHAPTER 1 INTRODUCTION ...................................................................................................... 2 1. BACKGROUND ............................................................................................................... 2 1.1 RESEARCH AIMS .......................................................................................................... 6 1.2 RESEARCH OBJECTIVES ............................................................................................. 9 1.3 RESEARCH SCOPE ...................................................................................................... 16 CHAPTER 2: EVIDENCE OF A PROBLEM REQUIRING A SOLUTION ................................ 19 OVERVIEW: HUMAN ERROR AND AVIATION SAFETY: THE CURRENT STATE OF AFFAIRS ............................................................................................................................. 19 2.1 THE TYPES OF FLIGHT CREW- INITIATED ACCIDENTS WHICH OCCURRED IN THE DECADE BETWEEN 2002 AND 2011 ................................ 20 Substandard Flight Crew Performance ix 2.2 THE LIMITATIONS OF STATISTICAL DATA RELATING TO AVIATION SAFETY .................................................................................................................. 22 2.3 THE LIMITATIONS OF THE HUMAN ERROR CAUSATION WHEN APPLIED TO AVIATION ....................................................................................... 25 CHAPTER 3: SUBSTANDARD FLIGHT CREW PERFORMANCE (SFP)....................... 31 3.1 CONCEPTUAL OVERVIEW OF THE SFP CONSTRUCT ............................... 31 3.2 RATIONALE FOR SELECTING THE THREE BASIC SFP CATEGORIES FOR EXAMINATION ............................................................................................. 39 3.3 THE ANATOMY OF AN SFP INSTANCE ......................................................
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