HAWKING, F.J. Human Factors in Flight. 2017
HAWKING, F.J. Human Factors in Flight. 2017
HAWKING, F.J. Human Factors in Flight. 2017
To Suzette
Human Factors
in Flight
Frank H Hawkins
second edition
Edited by
Harry W Orlady
First published 1987 by Ashgate Publishing
Notice:
Product or corporate names may be trademarks or registered trademarks, and
are used only for identification and explanation without intent to infringe.
Acknowledgements 8
Preface 10
1 The Meaning of Human Factors 16
A hundred years of Human Factors 16
Defining Human Factors 19
A conceptual model of Human Factors 22
A foundation for progress 26
2 Human Error 27
The nature of error 27
The sources of error 34
The classification of errors 46
Meeting the challenge of human error 48
5
Human Factors in Flight
10 Documentation 208
Costing documentation inadequacies 208
General principles 209
Checklists 218
Manuals, handbooks and technical papers 225
Questionnaires and forms 229
Maps and charts 237
Conclusions 240
6
Contents
Appendices 342
Appendix 1 Notes on procedural recommendations and other data 342
Appendix 2 Recommended books, journals and bulletins 351
Appendix 3 Abbreviations used in the text 356
References 359
Index 373
7
Acknowledgements
Others who have generously contributed their time and expertise to reviewing the
book critically as a whole or in part, include:
Dr M Carruthers; Director, Positive Health Centre, Harley St, London, UK.
Mr K G Dougan; Operational Adviser, Smiths Industries Ltd, Cheltenham, UK.
Captain B A Draper; Training Manager, Flight Instructor, Stocksfield, UK.
Dr J A Home; Department of Human Sciences, Loughborough University, UK.
Dr P Naitoh; Psychophysiologist, San Diego, USA.
Captain E R Parfitt; Airline Senior Route Instructor, Gata de Gorgos, Spain.
The tireless and skilled assistance of Suzette Burghard during the years of devel
opment of the material and its preparation for publication has been invaluable and
has made a significant contribution to the project. Acknowledgement must be
given, too, for the contribution of graphic artist Michael Hawkins in preparing the
many illustrations for publication.
Illustrations
Acknowledgement with thanks is due to the following for their kind permission to
use illustrations or tabulated data.
Academic Press, Figs 3.5, 9.3, 9.4; American Institute of Physics, Fig 7.5;
American Psychological Association, Fig 9.2; Aviation, Space and Environmental
8
Acknowledgements
Medicine, Figs 3.2, 3.3, 3.4, 4.3; Band J H, Figs 5.12, 6.4, 8.1, 9.6, 11.3, 11.7, 13.1,
13.4, 13.5; British Airways, Fig 3.6; Central Office of Information (UK), Fig 8.2;
Chorley R A, Fig 12.4; Department of Health and Social Security (UK), Fig 8.2;
Department of the Army (USA), Fig 13.2; Department of Transport (UK), Fig 8.2;
Edwards E Prof, Figs 2.2, 6.2; Elseviers Scientific Publications, Figs 10.1, 10.2;
Flight Safety Foundation, Fig 5.15; Health Education Council, Figs 4.1, 8.2; Her
Majesty’s Stationery Office, Fig 8.2; Human Factors Society, sample notices in
Chapter 10; IPC Science & Technology Press, Figs 10.4, 11.5; Klein K E Dr,
Tables 3.1, 3.2; Kryter K D Dr, Fig 7.1; McGraw-Hill Book, Figs 4.2, 11.1;
NASA-Ames, Fig 11.2; Plain English Campaign, Fig 10.5; Prentice-Hall, Fig 7.4;
Shell International Trading Company, Figs 5.11, 12.5, 12.7; University of Colorado,
Fig 13.6.
Every effort has been made to trace copyright owners. However, if advised of
any inadvertent omission, the publisher and I would be pleased to incorporate
proper acknowledgement in future editions.
F H Hawkins
At the time of his untimely death Captain Hawkins was in the midst of preparing an
updated edition of Human Factors in Flight. Virtually all of the material he had
compiled has been included in this edition which is dedicated to his pioneering
work. The contribution made by the late Captain William Price, who had been
working with Captain Hawkins, in this updating of the first edition of Human
Factors in Flight cannot be adequately acknowledged. The revision of this edition,
beyond the work of Captain Hawkins, was done by Captain Harry W. Orlady.
The Publisher
9
Preface
Since 1940, data have been published periodically showing that three out of four
aircraft accidents apparently result from inadequate performance of the human
component in the aircraft man-machine system. This proportion has persisted in
spite of years of exhortation to pilots to perform more consistently and with fewer
errors. This exhortation has been notably, but predictably, ineffective in modifying
the relative magnitude of this source of accidents.
Scientists, particularly in the USA and the UK, have been engaged in Human
Factors research relevant to aviation during and since the Second World War, but
only part of this research has found its way into flight operations and unfortunately,
very little of it involved our major problem - the operational behaviour of pilots
flying multicrew transport aircraft. The 1947 work in Dayton of Fitts, Jones and
Grether on the misreading vulnerability of three-pointer altimeters is a good example.
By 1980, the National Aeronautical and Space Administration (NASA) felt obliged
to declare that despite these and other related studies, it was unlikely that this type
of altimeter would be replaced in older operational aircraft. And in 1984 they were
able to report yet another 10 000 ft misreading and flight deviation with this kind of
altimeter.
On the other side of the Atlantic, at Cambridge in England, valuable Human
Factors work was being done in the early 1940s on what became known as the
Cambridge Cockpit. Yet more than a quarter of a century later, an eminent aero
nautical society was able to make a policy statement declaring that it was too early
for them yet to take ergonomics or Human Factors seriously.
When the first edition of this book was written, it was unusual to find a degree-
qualified Human Factors specialist anywhere in the aircraft operational field, even
in larger companies with more than 10 000 staff on the payroll. In the aircraft
manufacturing industry, few of the world’s civil aircraft constructors could claim
properly qualified Human Factors staff, and even then, their role was normally only
an advisory one and there were many reasons why their advice could be overruled.
Most manufacturers were poorly endowed in this respect. A major European aircraft
builder, for example, found it appropriate to seek help from a motor car manufacturer
in the design of its new flight deck. This was in spite of the totally different
environments in which the vehicles operate, the quite different levels of skill of the
operators involved and the fundamental difference in the team-work task on a large
10
Preface
11
Human Factors in Flight
meet the needs of senior or supervisory personnel and their cost prohibited a wider
application. It was left to the national airline of the Netherlands, KLM, to initiate in
1977 a systematic educational programme to increase an awareness of Human
Factors amongst its operational staff. This programme, now acquired by numerous
other airlines and aviation bodies, consisted of a 15-unit audio-visual course, with
each unit being designed to fill a basic educational gap in a different aspect of
Human Factors. But the limited amount of time available in such formal courses to
assimilate the very considerable information presented, stimulated a demand for
more information in an easily readable documented form. This was needed for use
as a textbook during the course and then for reading at leisure later. It is the
purpose of this volume to meet that demand and also to provide the expanded
information for those who are unable to do the basic classroom course but are
nevertheless interested in acquiring more knowledge of the role of man in the
aeronautical system.
To continue to move forward in achieving a better application of Human Factors
in civil aviation, two broad principles must be accepted. Firstly, that questions
about the role of man within complex systems are technical questions requiring
professional expertise. And secondly, that adequate resources must be allocated to
the design and management of man-hardware-software systems. While in many
circles these principles are generally accepted today, neither of these principles has
enjoyed widespread popularity in the past. The following chapters, while in no way
constituting a comprehensive academic treatment of the subject, should provide a
foundation of knowledge upon which a sound structure of Human Factors expertise
and application in aviation can be built. For those not directly involved in civil air
transport, this text should provide an insight into the role of man - passengers as
well as crew - in the complex man-machine system which is today’s transport
aircraft.
Presentation format
Human Factors is an applied technology and so Human Factors in Flight is de
signed primarily for industry and aims to bridge the gap between academic sources
of knowledge and the practical operation of aircraft. This orientation is apparent in
the titles and sequence of chapters.
Chapter titles will be immediately recognised by those associated with aircraft
operation as reflecting areas of Human Factors concern in their routine work.
While the contents of each chapter and the appendices provide practical guidance,
adequate references are included to enable the serious student to pursue his quest
for knowledge beyond this introductory volume.
The chapters have also been sequenced with the interest of industry primarily in
mind. In view of the widespread confusion which envelops the term Human Factors,
it is essential to ensure from the beginning that we are all talking the same language
- that we are all on the same frequency. Chapter 1 therefore provides this clarifica
tion and introduces a model which is utilised throughout the book as a tool for
aiding understanding.
Safety is a theme never far beneath the surface in all activities connected with
12
Preface
flying. For many, human error, which is inextricably linked with safety, has be
come almost synonymous with Human Factors and so very early attention is given
to this subject, which forms the basis of Chapter 2. The principles discussed here
will later be referred to in other chapters where the question of error is raised.
Reduced performance is increasingly being attributed by crew members to stress
such as fatigue and the disturbance of sleep and biological rhythms. This forms,
then, the subject matter of Chapter 3 and it is followed by two more chapters also
with a physiological orientation.
Chapters 6 to 10 still retain the underlying concern with human performance but
shift from physiological to more cognitive aspects of the technology. Throughout
these five chapters the vitally important theme of communication is prominent.
Perhaps the most commonly recognised task of the ergonomist or Human Factors
practitioner lies in the design of the workplace and this area forms the subject
matter of the following three chapters. In transport flying, the workplace encompasses
the cabin as well as the flight deck. Traditionally, the former has received less
specialised Human Factors attention than the latter, so a complete chapter here is
dedicated to the cabin. Not only does this approach the cabin as a workplace for the
crew but also as a confined environment for large numbers of inactive passengers.
Finally, having provided an introduction to Human Factors in flight, we address
the obvious and justifiable question which can be expected from readers in industry,
‘... now we have been introduced to the subject, where do we go from here?’
13
Human Factors in Flight
14
Preface
full. In addition, for ease of later reference, a list of abbreviations used in the text is
provided in Appendix 3. On the first occasion that a term is used which may not be
familiar to aircraft operational staff, an explanation is given.
When it is found necessary to differentiate between flight deck and cabin crew
and the inference is not clear from the context, then the distinction will be made
specifically. Otherwise, crew or aircrew refers to all flying staff.
The word ‘man’ is used in its generic sense. Therefore it includes both sexes
unless it is specifically indicated to the contrary. For example ‘man’ should be
understood to mean people or humans including both males and females,‘he’ should
be understood to mean he/she, ‘him’ should be understood to mean him/her etc.
F H Hawkins
H W Orlady
15
1
The Meaning
of Human Factors
‘Not only will men of science have to grapple with sciences that deal with
man but - and this is a far more difficult matter - they will have to persuade
the world to listen to what they have discovered.’
Bertrand Russell (1872-1970)
16
The Meaning o f Human Factors
bom and this represented a fundamental departure from earlier ideas which con
centrated on the more direct and physical relationship between man and machine.
The Second World War again provided a stimulus to Human Factors progress as
it became apparent that more sophisticated equipment was outstripping man’s ca
pability to operate it with maximum effectiveness. Problems of selection and training
of staff, too, began to be approached more scientifically.
At Oxford during the war, a Climatic and Working Efficiency Research Unit was
established. At Cambridge, the Psychology Laboratory of the University was re
sponsible for what might be seen as a second major milestone. They constructed a
cockpit research simulator which has since become known as the ‘Cambridge
Cockpit’. From experiments in this simulator it was concluded that skilled behaviour
was dependent to a considerable extent on the design, layout and interpretation of
displays and controls. In other words, that for optimum effectiveness, the machine
has to be matched to the characteristics of man rather than the reverse, as had been
the conventional approach to system design. In 1945, the Applied Psychology Unit
(APU) was established at Cambridge and this continues to be a source of much
valuable Human Factors research work in the UK. At about this time in the USA,
the much quoted research on three-pointer altimeter misreadings was beginning
and this work was destined to be used as a standard illustration in discussions of
design-induced error. And during this decade of the 1940s, aviation psychology
centres were being initiated at Ohio State and Illinois Universities.
Perhaps a third milestone in this hundred years of Human Factors was the estab
lishment of ergonomics or Human Factors as a technology in its own right. This
was institutionalised by the founding of the Ergonomics Research Society in the
UK in 1949, followed in 1959 by the formation of the International Ergonomics
Association (IEA). In 1957 in the USA the Human Factors Society was founded
and this was later affiliated to the IEA.
It was first calculated in 1940 that three out of four aircraft accidents are due to
what has been called human failure of one kind or another. This figure was confirmed
by IATA 35 years later. The next milestone in aviation Human Factors may be seen
as the recognition that basic education in Human Factors was needed throughout
the industry. In 1971 the ‘Human Factors in Transport Aircraft Operation’ two-
week course was established at Loughborough University in England, later transferred
to Aston University and also conducted elsewhere. In the USA a short course was
established at the University of Southern California (USC), and at about this time,
the US Air Line Pilots Association (ALPA) introduced, for selected representatives,
an accident investigation course that stressed Human Factors and featured USC
faculty. By 1978, KLM in the Netherlands provided the first ‘Human Factors
Awareness Course’ for large-scale, low-cost, in-house indoctrination of staff in
basic Human Factors principles. This course was later acquired by organisations in
numerous other countries (see Chapter 14).
In the early 1970s, the International Air Transport Association (IATA), concerned
with the basic problem of Human Factors in air transport operations, organised a
Human Factors committee which later led to the 1975 Istanbul Conference. During
this same period, United Airlines started a confidential non-punitive incident reporting
system which led to the FAA/NASA Aviation Safety Reporting System (ASRS),
(Reynard et al., 1986). Both are covered in more detail in succeeding paragraphs.
17
Human Factors in Flight
As though to emphasise the urgent need for effective action, a fifth and tragic
milestone was erected during this period when educational programmes were tak
ing shape. In 1977 at Tenerife two aircraft collided at a cost of 583 lives and about
$150 million, creating the greatest disaster in aviation history and resulting entirely
from a series of Human Factors deficiencies (see Chapter 7).
An important aviation event in this first one hundred years of Human Factors
was the establishment by FAA/NASA in 1976 of the confidential Aviation Safety
Reporting System (ASRS), the principles and feasibility for which had been previ
ously established by the United Airlines programme. The ASRS is operated by
NASA for the FAA which finances virtually all of the costs associated with this
breakthrough programme.
The ASRS recognised officially for the first time that it is unrealistic to expect to
obtain meaningful and adequate information for analysis of human behaviour and
lapses in human performance while at the same time holding the threat of punitive
action against the person making the report. This basic change of attitude towards
both pilots and administrators has been justified by the accumulation during the
first 15 years of operation of the scheme of a data bank of more than 180 000
reports from which analyses were made and published periodically.. During this
period more than 2450 Search Requests were made and more than 1000 Alert
Bulletins (ABs) were issued (ASRS Callback No. 143). After 15 years, ASRS was
able to report that although statistical totals were increasing annually, event types,
consequences and percentages remained generally consistent. The single exception
being an increase in altitude deviations following the FAA inauguration of its
Quality Assurance Program (QAP). Under this programme, any loss of separation
in US airspace is automatically recorded by radar and requires examination of the
incident by an FAA supervisor. An altitude deviation of more than 300 feet can
cause a loss of separation if there is traffic at a conflicting altitude. Submission of
an ASRS report provides immunity from FAA prosecution to the reporter in these
instances. This increase in altitude deviations does not necessarily mean that there
has been an increase in actual altitude deviations, but may only mean that there has
been an increase in the number of altitude deviations reported.
The ASRS data bank now (mid-1992) includes over 210 000 reports. The pro
gramme receives an average of slightly under 3000 reports per month, the majority
from airline pilots. This vast store of operational reports may have revealed, in
principle, nothing new to those who have been for years concerned with the study
of air transport Human Factors. However, it remains an extremely valuable exer
cise and has provided sufficient data for meaningful computer analysis - data that
was previously unobtainable. The sheer weight of the evidence, backed by the
authority and analytical facilities of NASA, has focused more regulatory and indus
try attention on the problem area than previously could be elicited.
Six years after the ASRS programme was set up in the USA, a similar scheme,
the Confidential Human Factors Incident Reporting Programme (CHIRP), was ini
tiated in the UK. In 1986 a similar scheme called the Confidential Aviation Safety
Reporting Programme (CASRP) was initiated in Canada. At about the same time,
New Zealand instituted an Independent Safety Assurance Team programme (ISAT)
and in 1988 Australia instituted a comparable programme, the Confidential Avia
tion Incident Reporting (CAIR). Germany has recently established a similar pro
18
The Meaning of Human Factors
gramme which will serve as an anchor for a new European Community (EC)
Directive which is now being formulated.
The monthly bulletin of ASRS is called ‘Callback’. This safety bulletin has a
wide circulation in about 60 countries. By 1991 some 60 000 copies were being
circulated monthly. The periodic bulletin of the British CHIRP system is called
‘Feedback’. Canada produces a bi-lingual bulletin ‘In-Flight’ or ‘Apr^’, while New
Zealand’s bulletin is called ‘Flashback’. In Australia data and reports are included
in its Basic Aviation Safety Information (BASI) publications.
In 1991, ASRS began a new publication called ‘Directline’ to meet the needs of
operators and flight crews of complex aircraft. Distribution is directed to managers
and management personnel, safety officers, and training and publications depart
ments. Occasional reference will be made in the following chapters to examples
taken from these bulletins to illustrate Human Factors problems.
A very comprehensive mandatory occurrence reporting system has been conducted
in Australia for many years and this also has a provision for anonymous submission
of reports. Although a very large number of incidents are reported annually, providing
an impressive data base, and using computer processing since 1969, only limited
analyses have been made compared with the later ASRS programme. Together,
these reporting systems provide a wealth of statistics for the study of the role of the
human component in aviation safety.
We now move into the second century of Human Factors. As we do so, it is fair
to ask whether this technology has been adequately applied in aviation in the past
and what can usefully be done to ensure adequate progress in the future. The
chapters which follow will provide a basis upon which reasoned assessment of
these issues can be made.
19
Human Factors in Flight
contribute towards filling the basic educational gap which Istanbul and other
conferences have revealed.
20
The Meaning of Human Factors
in this chapter were a good example, with Frank Gilbreth being an engineer and
his co-worker wife, Lilian, a psychologist.
Because of these origins and the fact that Human Factors is a multi-disciplinary
technology, certain myths and misconceptions have arisen. Perhaps the most per
sistent of these is that Human Factors is a branch of, or somehow related to,
medicine. This confusion may have emerged because some of the earliest problems
recognised in flying were physiological in nature. The physician was probably the
person nearest at hand with a knowledge of physiology and it was natural that he
should become concerned with these aspects of flight.
But since the pioneering days of flying, optimising the role of man and integrat
ing him in this complex working environment has come to involve more than
simply physiology. In particular, it has come to be concerned with human behaviour
and performance; with decision-making and cognitive processes; with effective use
of the equipment in all operating environments; with the design of controls and
displays, and with flight deck and cabin layout; with communication and with the
software aspects of computers, maps, charts and documentation. It is also con
cerned with the refinement of staff selection, and training and checking, all of
which require skilled Human Factors input. Properly controlled experimental stud
ies are now sometimes required to seek solutions to the more difficult operational
problems, often involving very large sums of money. A shift of emphasis has
clearly taken place from physiology towards psychology and this has introduced
qualifications well outside the field of medicine.
Nevertheless, there are times, notably where physiology and health are concerned,
when there should be effective communication between the physician and the
ergonomist or Human Factors specialist. A typical example in aviation is in the use
of medication to counter the sleep and biological rhythm disturbance induced by
long-range flying, as performance on board as well as personal well-being are
involved. The lumbar region back pain associated with sitting for long periods in
uncomfortable seats may come to the notice of the aviation physician before the
Human Factors specialist where no proper operational feedback system has been
established. This also applies to accidents such as bums or abrasions which occur
while working on board using badly designed equipment.
The predominantly psychological basis of Human Factors is illustrated not only in
the professional disciplinary background of its modem practitioners, but also in the
literature which supports it. Almost all of the Human Factors reference books and
textbooks are authored or edited by psychologists from one or other branch of the
discipline.
Nevertheless, this multi-disciplinary technology uses, as the Edwards definition
makes clear, many sources of information from the human sciences. In spite of the
shift in emphasis towards psychology, physiology is still an important source of
Human Factors knowledge and is necessary, for instance, for an understanding of
vision and hearing. Anthropometry and biomechanics, involving measures and
movements of the human body, are relevant to the design of the workplace - in this
case the flight deck and the cabin - and to the equipment in it. Biology and its
increasingly important sub-discipline, chronobiology, are necessary for an under
standing, for example, of the body’s rhythms, which have an influence on perform
ance. Genetics may be a factor in understanding the variations in behaviour and
21
Human Factors in Flight
Liveware
Physical size and shape. In the design of any workplace and most equipment,
body measurements and movement play a vital role. These will vary not only
between ethnic, age and sex groups, but extensive differences can be expected to
occur within any particular group. Fundamental decisions must be taken at an early
stage in the design process as to the human dimensions, and consequently the
population percentage, which the design is going to satisfy. Data to make such
decisions are available from anthropometry and biomechanics.
Fuel requirements. In order to function properly, man needs fuelling with food,
water and oxygen. Deficiencies in this fuel supply can affect his performance and
well-being. This type of information is available from physiology and biology.
Input characteristics. Man has been provided with a vast system for collecting
22
The Meaning of Human Factors
information from the world about him. He has means for sensing light, sound,
smell, taste, movement, touch, heat and cold. This information is needed to enable
him to respond to external events and to carry out his required tasks. Some senses
involve more directional information; some are more sensitive than others. And all
are subject to degradation for one reason or another. Physiology and biology are
the main sources of knowledge here.
Information processing. While the sensing apparatus is vast, the information
processing capabilities of man have severe limitations. It is fruitless to provide an
operator with information from displays, for example, without an understanding of
how effectively the information can be processed. Poor instrument and warning
system design has frequently resulted from a failure properly to take into account
the capabilities and limitations of the human information processing system. Short-
and long-term memory are involved here and we also encounter other factors
which can influence the effectiveness of the system, such as motivation and stress.
Many human errors find their origin in this area of information processing. The
source of background knowledge here is the discipline of psychology.
Output characteristics. Once information is sensed and processed, messages are
sent to the muscles and a feedback system helps to control their actions. We need
to know the kind of forces which can be applied and the acceptable direction of
movement of controls. Speech characteristics are vital components in the design of
efficient voice communication procedures. Here we look to biomechanics and
physiology for support.
Environmental tolerances. People, like equipment, are constructed to function
effectively only within a rather narrow range of environmental conditions. Tem
perature, pressure, humidity, noise, time-of-day, light and darkness, can all be
reflected in performance and sometimes also well-being. In less tolerant individu
als, performance can also be affected by heights (acrophobia), enclosed spaces
(claustrophobia), and even by flying itself (flight phobia), to name just a few. A
boring or a stressful working environment can also be expected to influence per
formance. Physiology, biology and psychology all provide relevant information on
these environmental effects.
An important characteristic of this central component, which will become in
creasingly apparent as the reader progresses through these chapters,- is that people
are different. This will become particularly evident when we come to discuss
motivation and attitudes. While it is possible to design and produce hardware to a
precise specification and expect consistency in its performance, this is not the case
with the human component in the system, where some variability around the normal,
standard product must be anticipated. Some of the effects of these differences, once
they have been properly identified, can be controlled in practice through selection,
training and the application of standardised procedures. Others may be beyond
practical control and our overall system must then be designed to accommodate
them safely.
The Liveware is the hub of the SHEL model of Human Factors. The remaining
components must be adapted and matched to this central component.
23
Human Factors in Flight
Liveware-Hardware
Fig. 1.1 In the SHEL model, Software includes symbology which is reflected in this collection of
signs which can be seen in and around airports.
24
The Meaning of Human Factors
Liveware-Liveware
Other interfaces
There are within the aeronautical system other interfaces outside the field of Human
25
Human Factors in Flight
Factors. Interfaces between different Hardware can be seen in plugs and connec
tors. Hardware-Environment interfaces are apparent in equipment packaging and
insulation. Hardware-Software interfaces are involved in certain aspects of equip
ment instruction manuals. These are not within the scope of the technology of
Human Factors and so will not be discussed further in the chapters of this book.
26
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