Anatomy of a system accident: the crash of Avianca Flight 052

Dangerous intersections? A review of studies of fatigue and distraction in the automated vehicle

The impacts of fatigue on the vehicle driver may change with technological advancements including automation and the increasing prevalence of potentially distracting in-car systems. This article reviews the authors' simulation studies of how fatigue, automation, and distraction may intersect as threats to safety. Distinguishing between states of active and passive fatigue supports understanding of fatigue and the development of countermeasures. Active fatigue is a stress-like state driven by overload of cognitive capabilities. Passive fatigue is produced by underload and monotony, and is associated with loss of task engagement and alertness. Our studies show that automated driving reliably elicits subjective symptoms of passive fatigue and also loss of alertness that persists following manual takeover. Passive fatigue also impairs attention and automation use in operators of Remotely Piloted Vehicles (RPVs). Use of in-vehicle media has been proposed as a countermeasure to fatigue, but such media may also be distracting. Studies tested whether various forms of phone-based media interacted with automation-induced fatigue, but effects were complex and dependent on task configuration. Selection of fatigue countermeasures should be guided by an understanding of the form of fatigue confronting the operator. System design, regulation of level of automation, managing distraction, and selection of fatigue-resilient personnel are all possible interventions for passive fatigue, but careful evaluation of interventions is necessary prior to deployment.

Crew Resource Management Training Research, Practice, and Lessons Learned

Crew resource management (CRM) training was introduced to the aviation community in 1979. Since then it has evolved and matured and is now being applied in a number of domains, including health care and offshore oil production. There is abundant literature resulting from research in the area, but there is no recent comprehensive review of the origins, current state, and future direction of CRM. The purpose of this chapter is to perform that review and provide the reader with an understanding of the research, practice, and training associated with CRM. We also provide a number of lessons learned based on the literature and our observations, as well as future needs of the community.

Human Factors on the Flight Deck

Pilots from the United States, the Philippines, and Taiwan as well as flight attendants from the United States, Hong Kong, Japan, Korea, Thailand, Singapore, and Taiwan completed a 20-item attitudinal questionnaire about group processes on the flight deck. A three-dimensional INDSCAL analysis revealed one dimension, used primarily by the eight Asian groups, which reflected high power distance and collectivism. The second dimension, reflecting individualism and moderate power distance, was used by the U.S. flight attendants. The third dimension, individualism and low power distance, was used almost exclusively by the U.S. pilots. The attitudinal similarity among the eight Asian groups was attributed in part to the questionnaire's monocultural bias. A new study is outlined, and training recommendations are offered.

Can cultural differences lead to accidents? Team cultural differences and sociotechnical system operations

OBJECTIVE

I discuss cultural factors and how they may influence sociotechnical system operations.

BACKGROUND

Investigations of several major transportation accidents suggest that cultural factors may have played a role in the causes of the accidents. However, research has not fully addressed how cultural factors can influence sociotechnical systems.

METHOD

I review literature on cultural differences in general and cultural factors in sociotechnical systems and discuss how these differences can affect team performance in sociotechnical systems.

RESULTS

Cultural differences have been observed in social and interpersonal dimensions and in cognitive and perceptual styles; these differences can affect multioperator team performance.

CONCLUSION

Cultural factors may account for team errors in sociotechnical systems, most likely during high-workload, high-stress operational phases. However, much of the research on cultural factors has methodological and interpretive shortcomings that limit their applicability to sociotechnical systems.

APPLICATION

Although some research has been conducted on the role of cultural differences on team performance in sociotechnical system operations, considerable work remains to be done before the effects of these differences can be fully understood. I propose a model that illustrates how culture can interact with sociotechnical system operations and suggest avenues of future research. Given methodological challenges in measuring cultural differences and team performance in sociotechnical system operations, research in these systems should use a variety of methodologies to better understand how culture can affect multioperator team performance in these systems.

Cultural changes (1986-96) in a Norwegian airline company

The purpose of the study was to investigate cultural changes in a Norwegian airline company over a time span of 10 years. A questionnaire including parameters characterizing culture was administered to air crews in 1986 (n = 137) and in 1996 (n = 50). The performance part of a simulator study in 1996 indicated a significant reduction in operational failures compared with the 1986 study. The data further demonstrated significant changes in cultural variables, such as reduced Dominance and Masculinity, and improved Social climate and Communication. The direction of change in scores on the cultural variables corresponded with the principles on which the remedial actions were based.

Identifying and addressing medical errors in pain mismanagement

BACKGROUND

There is strong evidence in the pain management literature that undertreatment of pain is pervasive despite several approaches, including use of national guidelines, to completely correct the problem. Although the concept of medical errors has primarily been concerned with adverse events, it is not unreasonable that mismanagement of pain could also be classified as a medical error.

ERRORS OF PAIN MANAGEMENT

Error types can be classified as errors in assessment and documentation, errors in treatment and management, and errors in patient education. Within each of these categories, errors may be skill-, rule-, and/or knowledge-based, as suggested by evidence of mismanagement in various aspects of the pain management process as found in the literature. An examination of the root causes of medical errors may be used to detect system failures. At least ten steps can be identified in the process of pain management in the acute care setting, starting with admission, and errors can potentially occur at any step. A redesigned system could help improve error rates by incorporating use of skills, rules, and knowledge for effective management.

CONCLUSION

A new approach to the unsolved problem of pain management in acute care settings is proposed; this approach uses the concept of mismanagement as a medical error.