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light with an engine failure
Company records did not provide enough evidence that training
performance was properly monitored and managed
Training did not adequately address recognition of an engine
failure at low power
Procedures and checklists worked well, but we did not don
goggles (and ended up not needing them). The thing about
goggles is they must be donned first – before the mask!
But procedures training and habit all result in donning the
mask first. Then if the goggles are required, the mask has to
be removed. ‘Smoke Procedures’ should call for goggles first
without analysis for need.
ASRS Report – Accession Number 463186
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Broad, Over-arching Issues
15 Different Categories of Issues:
Selected Emergency Equipment and Evacuation Issues
Issues Related to the Aircraft
Issues Related to Training
Issues Related to Humans
Issues Related to Checklists and Procedures
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Equipment and
Evacuation Issues
Selected Equipment and Evacuation Issues
Equipment that is problematic to use in an emergency
(e.g., smoke goggles that do not fit over eyeglasses)
Inadequate training in the use of emergency equipment
Negative transfer (interference) of equipment usage across
different aircraft types
Confusion or problems regarding the initiation of evacuations
• The forward flight attendants also noticed a burning smell in the
cabin and determined the handset used to make announcements
and contact the cockpit was inoperative
717-200 – Flushing, New York – March 26, 2003 – Preliminary Report
• Nearing the final approach fix the engine and alert display (EAD)
indicated that the left generator had failed
• The display units (DU) and standby instruments went dark and
then began flashing off and on
• After landing the lead flight attendant tried banging on the cockpit
door and speaking loudly to get the attention of the flight crew
• The crew then noticed a burning smell in the cockpit
717-200 – Flushing, New York – March 26, 2003 – Preliminary Report
The flight crew did not hear the flight attendant banging on the door
or speaking loudly
Philosophies
Definitions and
Perspectives
Economic and
Regulatory
Pressures
Development of
Checklists and
Procedures
Checklist
Structure and
Design
Checklist Type
and Availability
Checklist
Use
Human
Performance
Automation
Issues
Critical Aircraft
Systems
Personnel
Issues
Crew
Coordination
Roles and and Response
Behavior of
Others
Equipment and
Evacuation
Issues
Training
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Approach
Review: all existing guidelines, handbooks, bulletins, reports,
recommendations, documents, and pertinent literature
Analyze: ASRS reports, NTSB and FAA accident reports
Study: philosophies, policies, practices, and procedures currently
in use by manufacturers and air carriers
Observe: normal air carrier operations, initial and recurrent
emergency and abnormal training for flight crews
Interview: manufacturer procedure developers, procedure certifiers,
POIs, air carrier management, instructors, pilots, cabin
crew, dispatchers, maintenance personnel, air traffic
controllers, etc.
Conduct: surveys, field studies, simulator studies, experimental lab
studies
Develop guidance for procedure development and
certification, training, crew coordination, and
situation management based on knowledge of the
operational environment, human performance
limitations, and cognitive vulnerabilities in real-world
situations.
Goal
Products and Deliverables
Intermediate Products:
Reports, Articles, Papers, Presentations
End Products:
Field Guides for
• Training Entities and Instructors
• Operators
• Manufacturers
• Regulatory Agencies
(Certification, POIs)
Immanuel Barshi, Ph.D., ATP, CFI
Sean Belcher, M.A., ATP, CFI
Ben Berman, A.B., ATP, CFI
Barbara Burian, Ph.D., PPL
Key Dismukes, Ph.D., ATP, CFI
Captain Richard Fariello (Ret.), B.S., ATP
Colleen Geven, A.A., ATP, CFI
Richard Geven, M.A., ATP, CFI
Todd Kowalski, B.S., CPL, CFI
Chris Reed, B.S., ATP, CFI
EAS Project Team
http://human-factors.arc.nasa.gov/eas
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