It is highly questionable whether total system safety is always enhanced by allocating functions to automatic devices rather than human operators, and there is some reason to believe that flight-deck automation may have already passed its optimum point.
Archives For Psychology
Human psychology and the role it plays in decision making under uncertainty.
If you want to know where Crew Resource Management as a discipline started, then you need to read NASA Technical Memorandum 78482 or “A Simulator Study of the Interaction of Pilot Workload With Errors, Vigilance, and Decisions” by H.P. Ruffel Smith, the British borne physician and pilot. Before this study it was hours in the seat and line seniority that mattered when things went to hell. After it the aviation industry started to realise that crews rose or fell on the basis of how well they worked together, and that a good captain got the best out of his team. Today whether crews get it right, as they did on QF72, or terribly wrong, as they did on AF447, the lens that we view their performance through has been irrevocably shaped by the work of Russel Smith. From little seeds great oaks grow indeed.
The search for MH370 will end next tuesday with the question of it’s fate no closer to resolution. There is perhaps one lesson that we can glean from this mystery, and that is that when we have a two man crew behind a terrorist proof door there is a real possibility that disaster is check-riding the flight. As Kenedi et al. note in a 2016 study five of the six recorded murder-suicide events by pilots of commercial airliners occurred after they were left alone in the cockpit, in the case of both the Germanwings 9525 or LAM 470 this was enabled by one of the crew being able to lock the other out of the cockpit. So while we don’t know exactly what happened onboard MH370 we do know that the aircraft was flown deliberately to some point in the Indian ocean, and on the balance of the probabilities that was done by one of the crew with the other crew member unable to intervene, probably because they were dead.
As I’ve written before the combination of small crew sizes to reduce costs, and a secure cockpit to reduce hijacking risk increases the probability of one crew member being able to successfully disable the other and then doing exactly whatever they like. Thus the increased hijacking security measured act as a perverse incentive for pilot murder-suicides may over the long run turn out to kill more people than the risk of terrorism (1). Or to put it more brutally murder and suicide are much more likely to be successful with small crew sizes so these scenarios, however dark they may be, need to be guarded against in an effective fashion (2).
One way to guard against such common mode failures of the human is to implement diverse redundancy in the form of a cognitive agent whose intelligence is based on vastly different principles to our affect driven processing, with a sufficient grasp of the theory of mind and the subtleties of human psychology and group dynamics to be able to make usefully accurate predictions of what the crew will do next. With that insight goes the requirement for autonomy in vetoing of illogical and patently hazardous crew actions, e.g ”I’m sorry Captain but I’m afraid I can’t let you reduce the cabin air pressure to hazardous levels”. The really difficult problem is of course building something sophisticated enough to understand ‘hinky’ behaviour and then intervene. There are however other scenario’s where some form of lesser AI would be of use. The Helios Airways depressurisation is a good example of an incident where both flight crew were rendered incapacitated, so a system that does the equivalent of “Dave! Dave! We’re depressurising, unless you intervene in 5 seconds I’m descending!” would be useful. Then there’s the good old scenario of both the pilots falling asleep, as likely happened at Minneapolis, so something like “Hello Dave, I can’t help but notice that your breathing indicates that you and Frank are both asleep, so WAKE UP!” would be helpful here. Oh, and someone to punch out a quick “May Day” while the pilot’s are otherwise engaged would also help tremendously as aircraft going down without a single squawk recurs again and again and again.
I guess I’ve slowly come to the conclusion that two man crews while optimised for cost are distinctly sub-optimal when it comes to dealing with a number of human factors issues and likewise sub-optimal when it comes to dealing with major ‘left field’ emergencies that aren’t in the QRM. Fundamentally a dual redundant design pattern for people doesn’t really address the likelihood of what we might call common mode failures. While we probably can’t get another human crew member back in the cockpit, working to make the cockpit automation more collaborative and less ‘strong but silent’ would be a good start. And of course if the aviation industry wants to keep making improvements in aviation safety then these are the sort of issues they’re going to have to tackle. Where is a good AI, or even an un-interuptable autopilot when you really need one?
1. Kenedi (2016) found from 1999 to 2015 that there had been 18 cases of homicide-suicide involving 732 deaths.
2. No go alone rules are unfortunately only partially effective.
Kenedi, C., Friedman, S.H.,Watson, D., Preitner, C., Suicide and Murder-Suicide Involving Aircraft, Aerospace Medicine and Human Performance, Aerospace Medical Association, 2016.
The Sydney Morning Herald published an article this morning that recounts the QF72 midair accident from the point of view of the crew and passengers, you can find the story at this link. I’ve previously covered the technical aspects of the accident here, the underlying integrative architecture program that brought us to this point here and the consequences here. So it was interesting to reflect on the event from the human perspective. Karl Weick points out in his influential paper on the Mann Gulch fire disaster that small organisations, for example the crew of an airliner, are vulnerable to what he termed a cosmology episode, that is an abruptly one feels deeply that the universe is no longer a rational, orderly system. In the case of QF72 this was initiated by the simultaneous stall and overspeed warnings, followed by the abrupt pitch over of the aircraft as the flight protection laws engaged for no reason.
Weick further posits that what makes such an episode so shattering is that both the sense of what is occurring and the means to rebuild that sense collapse together. In the Mann Gulch blaze the fire team’s organisation attenuated and finally broke down as the situation eroded until at the end they could not comprehend the one action that would have saved their lives, to build an escape fire. In the case of air crew they implicitly rely on the aircraft’s systems to `make sense’ of the situation, a significant failure such as occurred on QF72 denies them both understanding of what is happening and the ability to rebuild that understanding. Weick also noted that in such crises organisations are important as they help people to provide order and meaning in ill defined and uncertain circumstances, which has interesting implications when we look at the automation in the cockpit as another member of the team.
“The plane is not communicating with me. It’s in meltdown. The systems are all vying for attention but they are not telling me anything…It’s high-risk and I don’t know what’s going to happen.”
Capt. Kevin Sullivan (QF72 flight)
From this Weickian viewpoint we see the aircraft’s automation as both part of the situation `what is happening?’ and as a member of the crew, `why is it doing that, can I trust it?’ Thus the crew of QF72 were faced with both a vu jàdé moment and the allied disintegration of the human-machine partnership that could help them make sense of the situation. The challenge that the QF72 crew faced was not to form a decision based on clear data and well rehearsed procedures from the flight manual, but instead they faced much more unnerving loss of meaning as the situation outstripped their past experience.
“Damn-it! We’re going to crash. It can’t be true! (copilot #1)
“But, what’s happening? copilot #2)
AF447 CVR transcript (final words)
Nor was this an isolated incident, one study of other such `unreliable airspeed’ events, found errors in understanding were both far more likely to occur than other error types and when they did much more likely to end in a fatal accident. In fact they found that all accidents with a fatal outcome were categorised as involving an error in detection or understanding with the majority being errors of understanding. From Weick’s perspective then the collapse of sensemaking is the knock out blow in such scenarios, as the last words of the Air France AF447 crew so grimly illustrate. Luckily in the case of QF72 the aircrew were able to contain this collapse, and rebuild their sense of the situation, in the case of other such failures, such as AF447, they were not.
With the NSW Rural Fire Service fighting more than 50 fires across the state and the unprecedented hellish conditions set to deteriorate even further with the arrival of strong winds the question of the day is, exactly how bad could this get? The answer is unfortunately, a whole lot worse. That’s because we have difficulty as human beings in thinking about and dealing with extreme events… To quote from this post written in the aftermath of the 2009 Victorian Black Saturday fires.
So how unthinkable could it get? The likelihood of a fire versus it’s severity can be credibly modelled as a power law a particular type of heavy tailed distribution (Clauset et al. 2007). This means that extreme events in the tail of the distribution are far more likely than predicted by a gaussian (the classic bell curve) distribution. So while a mega fire ten times the size of the Black Saturday fires is far less likely it is not completely improbable as our intuitive availability heuristic would indicate. In fact it’s much worse than we might think, in heavy tail distributions you need to apply what’s called the mean excess heuristic which really translates to the next worst event is almost always going to be much worse…
So how did we get to this? Simply put the extreme weather we’ve been experiencing is a tangible, current day effect of climate change. Climate change is not something we can leave to our children to really worry about, it’s happening now. That half a degree rise in global temperature? Well it turns out it supercharges the occurrence rate of extremely dry conditions and the heavy tail of bushfire severity. Yes we’ve been twisting the dragon’s tail and now it’s woken up…
2019 Postscript: Monday 11 November 2019 – NSW
And here we are in 2019 two years down the track from the fires of 2017 and tomorrow looks like being a beyond catastrophic fire day. Firestorms are predicted.
The first fatality involving the use of Tesla’s autopilot* occurred last May. The Guardian reported that the autopilot sensors on the Model S failed to distinguish a white tractor-trailer crossing the highway against a bright sky and promptly tried to drive under the trailer, with decapitating results. What’s emerged is that the driver had a history of driving at speed and also of using the automation beyond the maker’s intent, e.g. operating the vehicle hands off rather than hands on, as the screen grab above indicates. Indeed recent reports indicate that immediately prior to the accident he was travelling fast (maybe too fast) whilst watching a Harry Potter DVD. There also appears to be a community of like minded spirits out there who are intent on seeing how far they can push the automation… sigh. Continue Reading…