Taking a Closer Look at Flight Crew Handling of Complex Failures
Ten Case Studies
Jelmer R. Reitsma (TU Delft - Control & Simulation)
L. Fucke (Boeing Research and Technology Europe)
C. Borst (TU Delft - Control & Simulation)
M.M. van Paassen (TU Delft - Control & Simulation)
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Abstract
Non-normal events, in particular system failures with serious operational impact are rare in flight operations. These events are not always easy to handle by flight crews. The aim of the performed study is to determine where in this process potential issues may lie. Ten incident reports are studied using a newly developed operational issue analysis framework. The framework is used to determine whether and how the current interfaces communicate the initial functional impact and functional impact delayed in time. Additionally, results from pilot interviews are presented which identified three phases of non-normal event handling: fault detection, fault management and strategic planning. Analysis of the ten cases shows that current alert systems are mainly supporting the first two phases while the strategic planning phase, requiring higher level functional information integrated into the operational context as well as failure impact later in time, is relying almost entirely on pilot knowledge and reasoning.