ERROR MANAGEMENT ON MODERN FLIGHT DECKS:HOW PILOTS EXPLAIN AND RECOVER FROM UNINTENDED ACTIONS AND OUTCOMES

摘要

Errors are a fundamental aspect of human adaptation in complex systems. Efforts to reduce and/or eliminate errors through training and design have met with only limited success. Therefore, it is critical to invest also in effective support for error management (the detection, explanation, and recovery from errors) to mitigate their negative consequences. To date, most research on error management has focused on the first step in this process – error detection. Instead, this paper presents a subset of results from a recent simulator study that examined the role of error explanation and the nature and effectiveness of error recovery strategies. Process tracing was used to analyze error management activities of pilots on highly automated flight decks. Our findings suggest that incomplete mental models of automation function limit error explanation and often lead to recovery strategies that rely on either “resetting” the system or serendipitous error evasion prior to negative consequences, or reverting to lower levels of automation when immediate corrective actions become necessary. These findings will be discussed in terms of their implications for training and design.