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  Emergency and Abnormal Situations (EAS) Symposium  

The Human Systems integration Division of NASA Ames Research Center sponsored The International Symposium on Emergency and Abnormal Situations in Aviation Symposium on June 10th and 11th, 2003


As part of the Emergency, Abnormal, and Off-nominal Situations (EAS) Study at NASA, we are studying the aviation industry's current concerns, problems, and needs relevant to the safe and efficient resolution of emergency and abnormal situations aboard commercial aircraft. We are aware that many others in the field are concerned about these same issues and are working on ways to improve procedures, checklist design, and training for emergency and abnormal situations. The purpose of this symposium was to facilitate communication and the sharing of knowledge across the industry regarding these and related issues, as well as to identify existing gaps and directions for future work.

Program Topics

• The Challenge of Emergency and Abnormal Situations in Aviation
• Emergency and Abnormal Checklists and Procedures - Development, Design, and Certification
• The Human Response to Emergency and Abnormal Situations - Flight Crew, Cabin Crew, ATC, Dispatch, and Maintenance Personnel
• Current Philosophies, Policies, and Practices in Training for Emergency and Abnormal Situations
• How Security Issues Affect Emergency and Abnormal Situations

Symposium Proceedings/Abstracts

* Please click the links below to download the presentations in PDF format (get Adobe Acrobat Reader) *

Welcome Presentation (PDF - 685K) - Barbara Burian, Symposium Chair - SJSUF / NASA Ames Research Center

The Challenge of Emergency and Abnormal Situations in Aviation - Discussion Notes (PDF - 11K)/ Participant Comments and Questions (PDF - 12K)

  > The Scope of the Problem (PDF - 11K) - Immanuel Barshi - NASA Ames Research Center
Abstract: Emergency and abnormal situations represent a unique challenge in aviation operations. They are often time critical and can be complex and/or ambiguous. They cause an increase in stress and workload and require exceptionally high levels of coordination inside and outside of the airplane. The procedures and checklists crews are to use to respond to these situations can be confusing or are problematic in other ways. In this presentation, some of the topics that would be covered in-depth by the speakers at the Symposium were covered, and the stage was set for what was to come over the next two days.
  > The Issues In-Depth: Analysis of an Accident (PDF - 2.9MB) - Ben Berman – SJSUF / NASA Ames Research Center
Abstract: In this session, the significant events of a major airline accident were analyzed in the context of workload, stress, procedural design, crew resource management, crew training, and human cognitive capabilities and vulnerabilities. This discussion raised many of the issues that would be the focus of the rest of the conference.
Emergency and Abnormal Checklist Design, Development, and Certification - Discussion Notes (PDF - 7K)/ Participant Comments and Questions (PDF - 20K)
  > Improving the Boeing Quick Reference Handbook (PDF - 485K) - Barbara Holder- Boeing Co., Commercial Airplanes Group
Abstract: Over the past year Boeing has been engaged in an effort to standardize normal and non-normal procedures across airplane models. Part of this effort involves improving the design of the Boeing Quick Reference Handbook (QRH) and its contents. Because Boeing airplanes are flown world-wide, the QRH must support safe operations anywhere, across a wide range of institutional and cultural settings, and be usable by flight crews with varying experience, knowledge, and English language capability. Our effort to improve the QRH joins knowledge of human performance, technical flight operations, and operational contexts. In this session, Boeings' human-centered approach was discussed, along with the considerations and issues we face as a manufacturer when designing checklists, procedures, and a quick reference handbook.
  > Emergency Checklists from the User’s Perspective (PDF - 28.9MB) - Captain Bill Jones - Central Air Safety Committee Chairman, ALPA
Abtract: Too often emergency and abnormal checklists do not stand up to the realities of the operational environment. Taking the perspective of the user, this presentation highlighted issues that managers, regulators and designers should consider when developing checklists for use in emergency situations.
  > Flight Crew Procedure Development and Modification (PDF - 9.2MB) - Bill McKenzie - Boeing Co., Commercial Airplanes Group
Abstract: This presentation described the process by which an airplane manufacturer develops, validates, and supports the crew procedures and checklists provided to their airline customers. It included the operational design philosophy, key participants, and the role of regulatory agencies.
Pilot Response to Emergency and Abnormal Situations - Discussion Notes (PDF - 15K)/ Participant Comments and Questions (PDF - 9K)

> LOSA Data and Emergency and Abnormal Situations (PDF - 2.5MB)- Captain Don Gunther - Continental Airlines and Chair of ATA Human Factors Committee
Abstract: This presentation showed how the 2000 Line Operations Safety Audit (LOSA) data along with data from the Flight Operations Quality Assurance (FOQA) program, the Aviation Safety Action Program (ASAP), the Advance Qualification Program (AQP) and the Continental Airlines Safety Information System (CASIS) was used to evaluate crew performance during Emergency and Abnormal Operations. All of these programs come under the Continental Safety Change & Training Development Program which is aimed at achieving “a greater level of safety.”

  > Responding to Emergencies and Abnormal Events (PDF - 311K)- Captain Neil Johnston (Ret.) - Aerospace Psychology Research Group, Trinity College, Dublin, Ireland
Abstract: This presentation considered responses to emergency and abnormal events from the pilot's perspective. Some examples of changes to checklist design and allied pilot practices over recent decades were considered from the pilot's point of view. This provided a point of departure for discussing the inter-connectedness of non-normal events, previous training, checklist use and cockpit management. The presentation concluded with a practitioner perspective on principles relevant to the design of checklists and associated pilot training.
  > How Continental is Trying to Deal with Emergency/Abnormal Situations with New Security Guidelines (PDF - 1.5MB)- Captain Don Gunther - Continental Airlines and Chair of ATA Human Factors Committee
Abstract: It is well known that recent events have forced the airline industry to review, and in many cases adapt their security procedures. While working within these guidelines the air carriers must also maintain a continued focus on safety and training. In addition, the ability to respond to an emergency or abnormal situation will inevitably be affected in some way by these stricter guidelines. This presentation detailed the experiences thus far of one airline as it relates to these new challenges. The presenter used the Threat & Error Management (TEM) process as a tool to discuss the issues that have been overcome while outlining those that still lie ahead.
Beyond the Flight Deck - Discussion Notes (PDF - 23K)/ Participant Comments and Questions (PDF - 13K)
  > European Air Traffic Management Programme - Controller Training in the Handling of Unusual Incidents (PDF - 545K) - Pat O’Doherty - Eurocontrol ATC
Abstract: A European approach to the creation of a generic package of Training in the handling of Airborne emergencies. 16 of the most common types of emergencies have been identified and a short self tuition programme useable by individual controllers, with or without supervision, has been created. Each scenario consists of up to six interactive pages of material which also includes a self administered test. The package is an ideal aide-memoire and enables a controller to keep in regular touch with necessary emergency procedures. The package consists of a set of guidelines and an easily useable checklist together with an associated Poster presentation. All of the package is available in hard copy, on a CD-ROM or by direct access to the internet.
  > The Cabin Crew in Emergency and Abnormal Situations (PDF - 2.3MB) - Nora Marshall - NTSB
Abstract: The presentation addressed flight attendant performance during abnormal or emergency situations. Case studies of NTSB accident and incident investigations were used to highlight effective and ineffective flight attendant (F/A) procedures and training. The presentation also discussed successful and unsuccessful communication between the flight deck, cabin crew, and passengers during emergency or abnormal situations. The presentation reviewed NTSB recommendations related to: cockpit/cabin communication and/or coordination, interphones, PA systems, joint cockpit/cabin training, and evacuation alarm systems.
  > The Role of Maintenance Personnel in Emergency and Abnormal Situations (PDF - 93K) - Mark Buechin - United Airlines, System Aircraft Maintenance Control (SAMC) Quality Control Coordinator
Abstract: The role of maintenance personnel in emergency and abnormal situations presentation covered who in maintenance is involved in these situations, what their background and training is and how they become involved. Also discussed was their specific role related to in-flight situations, what tools are available to assist them and who they may liaison with. The presentation concluded with lessons learned and challenges for the future.

> The Dispatcher - Information Central (PDF - 16.2MB) - Jim Jansen - Executive Vice President, Airline Dispatchers Federation
Abstract: In commercial airline operations there are three groups of licensed individuals in the United States that bear responsibility for the safety of flight: the pilot, the air traffic controller, and the aircraft dispatcher. When abnormal or emergency situations occur, the pilot flying at 37,000 feet has limited resources available to him or her. The best resource is the individual who shares responsibility for the safety and operational control of the flight: the dispatcher. He or she is the only individual who has the capability to provide the pilot with information regarding, weather, fuel requirements, performance capabilities, aircraft restrictions, airports, security issues, passenger service requirements, ATC problems and phone patches to maintenance or medical experts. It is similar to the "one-stop shopping" source of information for the pilot. This presentation covered a number of these issues related to dispatchers working with an aircraft in distress.

Training for Emergencies - Discussion Notes (PDF - 28K)/ Participant Comments and Questions (PDF - 14K)
  > The Current State of Flight Crew Training for Emergencies (PDF - 140K) - Chris Reed and Ben Berman - SJSUF / NASA Ames Research Center
Abstract: The NASA Emergency and Abnormal Situations project is working with a number of U.S. passenger and cargo air carriers to identify the current state of the art and critical issues in flight crew training for emergency and abnormal situations. We are conducting extensive interviews with training managers, instructors, and line pilots, and are observing simulation training and evaluation sessions. We are also looking at training conducted under AQP as well as the Part 121 training regulations. The data obtained from these sources has been de-identified (removing both individuals' and air carriers' names), and we are compiling aggregate data for analysis. This was a report and review of our findings from the first several air carriers visited.
Where Do We Go From Here? - Participant Comments and Questions (PDF - 17K)
  > The Emergency and Abnormal Situations Project (PDF - 1.8MB) - Barbara Burian - SJSUF / NASA Ames Research Center
Abstract: For the past two years I, my colleagues at the NASA Ames Research Center, and collaborators from the aviation community have been working on a number of projects and studies as a part of The Emergency and Abnormal Situations (EAS) Project. The purpose of the EAS Project is to bring together an understanding of the nature of emergency situations in aviation, of human learning and performance in high workload situations, and of the operational environment to inform the design, evaluation, implementation and training of abnormal and emergency procedures. We are currently or plan to exam ine a variety of issues and factors that affect the ways in which flight crews respond to emergency and abnormal situations on the flight deck, including those that have been raised by speakers during this symposium.

In this presentation, the studies and projects we are completing as a part of the EAS project were briefly described and feedback was solicited from the audience regarding needs in the operational community and directions our future work should take related to emergency and abnormal situations in aviation.
Closing Remarks - The Honorable Robert Francis's Closing Remarks (PDF - 13K)
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