A Situated Approach to Situation Awareness in Aircraft Accidents: A Case Study of Runway Overruns in Air Carrier Operations.

摘要

Human factors are the most frequent cause of aviation accidents, and researchers have created numerous models to explain Situation Awareness (SA), the phenomenon by which humans observe, process, and react to surrounding events. The purpose of this qualitative, archival case study was to explore the use of Situated SA (SSA) as an accident investigation tool capable of explaining the sociotechnical system within the cockpit during aircraft overrun events. The research questions had a threefold purpose: identify outliers within the scenarios that may have led to SA shortfalls within the overrun scenarios, evaluate the efficacy of SSA as an accident analysis tool, and provide additional information to support or conflict with SSA theory. This researcher examined official accident reports, transcripts of cockpit voice recorders, and transcripts of interviews conducted by NTSB investigators with the aircrew involved shortly after the accidents. The majority of outliers in each scenario were attributed to human error. The most common outliers across the scenarios were a failure of the pilot to take appropriate action and the lack of training for events dealing with snowy runways and poor visibility. There were no unexplained phenomena using the SSA model. Despite the differences between scenarios, the consistent reporting method by the NTSB and the structured tenets of the SSA model allowed for the categorization and comparison of the cognitive processes of the accident pilots. However, data offloading (a key tenet of SSA) was difficult to assess based on the chosen data sources, calling into question whether pilots download information from the environment during time critical, off-nominal situations such as runway overruns. Based on this case study, it is recommended that pilots prepare for overrun scenarios prior to landing, and system failures during deteriorating weather conditions should be added to pilot training syllabi. Also, other SA models should be assessed for their capability to explain cognitive processes within the cockpit of overrun scenarios. Finally, conducting similar studies for accidents in other phases of flight would build a more holistic picture of the capabilities of the SA models in the aviation context.