Civil Aerospace Medical Institute

Report No: DOT/FAA/AM-06/21

Title and Subtitle: A Human Factors Review of the Operational Error Literature

Report Date: August 2006

Authors: Schroeder D, Bailey L, Pounds J, Manning C

Abstract: This report reviews available documents concerning research and initiatives to reduce operational errors (OEs). It provides a brief history of OE investigation and reporting. It describes 154 documents published from 1960-2005 and 222 OE reduction initiatives implemented from 1986 to 2005. Materials are classified by 1) type of study and 2) human and other contributing factors (using the JANUS taxonomy).

An analysis of the literature identified several consistent findings. OEs were related to the amount of traffic (measured nationally rather than by position, early time on position, and pilot/controller miscommunications (especially hearback/readback errors). Initiatives included developing national and local QA activities, providing resources to supervisors to help them perform their jobs, and skills training to address controller mental processes.

Many ATO initiatives involved controller training, teamwork, and communications. Research and operations seemed to focus on the same 6 areas: a) training and experience, b) teamwork, c) pilot-ATC communications, d) Human Machine Interaction (HMI) and equipment, e) airspace/surface, and f) traffic.

This review concluded that, historically, much (sometimes redundant) research was conducted that generated little new information about why OEs occurred. Similarly, many initiatives were implemented, but the lack of a systematic follow-up prevented us from learning which were effective. This cycle will continue unless relevant data are obtained that can address underlying causal dimensions typically associated with human errors. Better data will allow conducting more informative, theory-based analyses.

ATO must also continually assess the effectiveness of OE mitigation strategies. Research efforts, operational initiatives, and program outcomes must be monitored to avoid wasting resources by repeatedly conducting the same analyses, re-discovering the same intervention strategies, and addressing only the easy problems. Development of a safety culture requires obtaining better data about circumstances surrounding OEs; identifying individual, supervisory, and organizational contributions; and measuring the effectiveness of interventions.

Key Words: ATC, Air Traffic Control, Operational Errors, OEs, Causal Factors, Incidents, Human Factors, Contextual Factors, Contributing Factors, Quality Assurance, Human Error, Error Mitigation, Controller Performance

No. of Pages: 66