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Environmental Benefits U.S. Department of Transportation Research and Innovative Technology Administration Volpe National Transportation Systems Center A Review of Human-Automation Interaction Failures and Lessons Learned NASA Airspace Systems Program Final Report October 2006 Thomas B. Sheridan and Eric D. Nadler Notice This document is disseminated under the sponsorship of the Department of Transportation in the interest of information exchange. The United States Government assumes no liability for its contents or use thereof. Notice The United States Government does not endorse products or manufacturers. Trade or manufacturers’ names appear herein solely because they are considered essential to the objective of this report. Human-Automation Interaction Failures and Lessons Learned Form Approved REPORT DOCUMENTATION PAGE OMB No. 0704-0188 Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 J efferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20503. 1. AGENCY USE ONLY (Leave blank) 2. REPORT DATE 3. REPORT TYPE AND DATES COVERED October 2006 Final Report September 2005 to September 2006 4. TITLE AND SUBTITLE METRIC/ENGLISH CONVERSION FACTORS5. FUNDING NUMBERS A Review of Human-Automation Interaction Failures and Lessons Learned NA23/DM345 ENGLISH TO METRIC METRIC TO ENGLISH 6. AUTHOR(S) LENGTH (APPROXIMATE) LENGTH (APPROXIMATE) Thomas B. Sheridan and Eric1 inch D. (in)Nadler = 2.5 centimeters (cm) 1 millimeter (mm) = 0.04 inch (in) 7. PERFORMING ORGANIZATION1 NAME(S) foot (ft) AND = 30ADDRESS(ES) centimeters (cm) 1 centimeter (cm) = 0.48. inchPERFORMING (in) ORGANIZATION U.S Department of Transportation REPORT NUMBER 1 yard (yd) = 0.9 meter (m) 1 meter (m) = 3.3DOT feet- VNTSC(ft) -NASA-06-01 Research and Innovative Technology Administration 1 mile (mi) = 1.6 kilometers (km) 1 meter (m) = 1.1 yards (yd) John A. Volpe National Transportation Systems Center 1 kilometer (km) = 0.6 mile (mi) 55 Broadway, Cambridge, MA 02142-1093 AREA (APPROXIMATE) AREA (APPROXIMATE) 9. SPONSORING/MONITORING AGENCY NAME(S)2 AND ADDRESS(ES) 2 10. SPONSORING/MONITORING2 1 square inch (sq in, in ) = 6.5 square centimeters 1 square centimeter (cm ) = 0.16 AGENsquareCY inch REPORT (sq in,NUMBER in ) National Aeronautics and Space Administration(cm2) Washington, DC 20546-0001 2 2 2 1 square foot (sq ft, ft ) = 0.09 square meter (m ) 1 square meter (m ) = 1.2 square yards (sq yd, yd2) 2 2 2 2 1 square yard (sq yd, yd ) = 0.8 square meter (m ) 1 square kilometer (km ) = 0.4 square mile (sq mi, mi ) 11. SUPPLEMENTARY1 square NOTES mile (sq mi, mi2) = 2.6 square kilometers 10,000 square meters (m2) = 1 hectare (ha) = 2.5 acres This paper can be accessed at http://www.volpe.dot.gov/hf/pubs.html(km2) /. 2 12a. DISTRIBUTION/AVAILABILITY1 acre = 0.4 hectare STATEMENT (he) = 4,000 square meters (m ) 12b. DISTRIBUTION CODE MASS - WEIGHT (APPROXIMATE) MASS - WEIGHT (APPROXIMATE) 1 ounce (oz) = 28 grams (gm) 1 gram (gm) = 0.036 ounce (oz) 1 pound (lb) = 0.45 kilogram (kg) 1 kilogram (kg) = 2.2 pounds (lb) 13. ABSTRACT (Maximum1 short 200 words) ton = 2,000 = 0.9 tonne (t) 1 tonne (t) = 1,000 kilograms (kg) pounds (lb) This report reviews 37 accidents in aviation, other vehicles, process control and other complex = systems1.1 short where tons human-automation interaction is involved. VOLUMEImplications (APPROXIMATE) about causality with respect to design, procedures,VOLUME management (APPROXIMA and TE)training are drawn. A number of caveats and1 teaspoon recommendations (tsp) = 5 frommilliliters the salient(ml) literature are discussed1 milliliter with respect (ml) to= 0.03human fluid-automation ounce (fl oz) interaction. 1 tablespoon (tbsp) = 15 milliliters (ml) 1 liter (l) = 2.1 pints (pt) 1 fluid ounce (fl oz) = 30 milliliters (ml) 1 liter (l) = 1.06 quarts (qt) 1 cup (c) = 0.24 liter (l) 1 liter (l) = 0.26 gallon (gal) 1 pint (pt) = 0.47 liter (l) 1 quart (qt) = 0.96 liter (l) 14. SUBJECT TERMS 15. NUMBER OF PAGES 1 gallon (gal) = 3.8 liters (l) Next Generation Air Transportation3 System (NGATS), human3 factors, automation, aviation3 443 accidents 1 cubic foot (cu ft, ft ) = 0.03 cubic meter (m ) 1 cubic meter (m ) = 36 cubic feet (cu ft, ft ) 1 cubic yard (cu yd, yd3) = 0.76 cubic meter (m3) 1 cubic meter (m3) = 1.3 cubic16. PRICE yards CODE (cu yd, yd3) TEMPERATURE (EXACT) TEMPERATURE (EXACT) 17. SECURITY CLASSIFICATION[(x-32)(5/9)] 18.F SECURITY= y C CLASSIFICATION 19. SECURITY[(9/5) CLASSIFICATION y + 32] C = x F 20. LIMITATION OF ABSTRACT OF REPORT OF THIS PAGE OF ABSTRACT Unlimited Unclassified QUICK INCHUnclassified - CENTIMETER LENGTHUnclassified CONVERSION NSN 7540-01-280-5500 0 1 2 3 4 Standard5 Form 298 (Rev. 2-89) Prescribed by ANSI Std. 239-18 Inches 298-102 Centimeters 0 1 2 3 4 5 6 7 8 9 10 11 12 13 QUICK FAHRENHEIT - CELSIUS TEMPERATURE CONVERSION °F -40° -22° -4° 14° 32° 50° 68° 86° 104° 122° 140° 158° 176° 194° 212° i °C -40° -30° -20° -10° 0° 10° 20° 30° 40° 50° 60° 70° 80° 90° 100° For more exact and or other conversion factors, see NIST Miscellaneous Publication 286, Units of Weights and Measures. Price $2.50 SD Catalog No. C13 10286 Updated 6/17/98 Human-Automation Interaction Failures and Lessons Learned TABLE OF CONTENTS 1.0 INTRODUCTION AND SCOPE.....................................................................................1 2.0 FAILURE EVENTS INVOLVING AIRCRAFT.................................................................3 2.1 Korean Airlines Flight 007 747 Shot Down by Soviet Air Defense Command (flaw in mode indication)..................................................................................................3 2.2 China Airlines 747 Engine Malfunction Near California (over-reliance on autopilot after fatiguing flight)................................................................................................3 2.3 Simmons Airlines ATR-72 Crash Near Chicago (icing disengaged autopilot, surprise manual recovery failed).............................................................................4 2.4 Lockheed L-1011 Crash Over the Florida Everglades (automation state change not communicated to pilot)......................................................................................4 2.5 A300 Accident Over the Florida Coast (state transition not communicated to pilot) 4 2.6 A300 Crash in Nagoya (pilot misunderstanding of how automation worked)..........5 2.7 Non-identified General Aviation Crash (pilot impatience, lack of training or judgment)................................................................................................................5 2.8 American Airlines B-757 Crash Over Cali, Columbia (confusion over FMS waypoint codes)......................................................................................................6 2.9 A320 Crash in Bangalore, India (control mode error, misunderstanding the automation).............................................................................................................6 2.10 Aero Peru 613 Crash (pitot tubes taped for painting: sloppy maintenance, poor inspection by pilot)..................................................................................................7 2.11 2002 Midair Collision Over Uerberlingen, Germany (pilot decision to follow ATM advice rather than TCAS resolution advisory).........................................................7 2.12 2004 Roller Coaster Ride of Malaysia Airlines B777 (unanticipated software failure)....................................................................................................................8 2.13 October 2005 British Airways A319 Electronics Failure (unanticipated and unreplicated software problem)...............................................................................8 2.14 Embraer Test Flight: One-Minute Blackout of Computer Displays (presumably due to a software glitch).................................................................................................8 2.15 2003 Crash of Air Midwest/U.S. Airways Express Beech 1900D (shortcutting of required maintenance procedures).........................................................................8 2.16 John Denver Crash into the Pacific (cutting corners in manufacture, poor human interface).................................................................................................................9 2.17 U.S. Soldier in Afghanistan Inadvertently Calls for Air Strike on Own Position (ignorance of reset operation).................................................................................9 2.18 Loss of Black Hawk Helicopters to Friendly Fire (ill-defined procedures and traffic management responsibilities).................................................................................9 2.19 Upset in Descent of NASA M2F2 Lifting Body (design led to pilot control reversal) 10 2.20 Concorde Crash Precipitated by Runway Debris (control tower automation may reduce controller vigilance of airport surface).......................................................10
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