Predicting Design-Induced Error on the Flight Deck : An Aircraft Engine Oil Leak Scenario.

Abstract

To explore the types of errors that commercial pilots may make when trying to resolve a suspected engine oil leak using the interfaces currently available. The decisions that pilots make often have to be made quickly and under time pressure, with the emphasis on avoiding critical situations from arising. To make the correct decisions, it is vital that pilots have accurate and up-to-date information available. However, interaction with flight deck interfaces may lead to error if they are not effectively designed. A hierarchical task analysis was conducted using evidence from pilot interview data to understand the pilots' typical response to a suspected engine oil leak scenario. This was used as the primary input into the Systematic Human Error Reduction and Prediction Approach (SHERPA). A total of 108 possible errors were identified. The most common error type was a retrieval error, in which flight crews may retrieve the wrong information about the engine. A number of remedial measures are proposed to try and overcome such issues. This analysis provides an initial starting point for identifying potential future design ideas that can assist the pilots in dealing with oil leaks. This work has identified the value of applying human error identification methodologies to the assessment of current flight deck processes surrounding engine oil leaks. The method presented permits the operational analysis of possible errors on the flight deck and facilitates the proposition of remedial measures to implement technological innovations that can mitigate error.