Archives For Psychology

Human psychology and the role it plays in decision making under uncertainty.

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.

 

Black Saturday fires (Image source: ABC)

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 a post I wrote 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?  Well 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 heavy tail of bushfire severity. Putting it even more simply it look’s like we’ve been twisting the dragon’s tail and now it’s woken up…

Joshua Brown screen grab

Keep your eyes on the road, and your hands upon the wheel…

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…

A requirements checklist that can be used to evaluate the adequacy of HMI designs in safety critical applications. Based on the work of Nancy Leveson and Matthew Jaffe.

qantas-vh-vzr-737-838-640x353

Deconstructing a tail strike incident

On August 1 last year, a Qantas 737-838 (VH-VZR) suffered a tail-strike while taking off from Sydney airport, and this week the ATSB released it’s report on the incident. The ATSB narrative is essentially that when working out the plane’s Takeoff Weight (TOW) on a notepad, the captain forgot to carry the ‘1’ which resulted in an erroneous weight of 66,400kg rather than 76,400kg. Subsequently the co-pilot made a transposition error when carrying out the same calculation on the Qantas iPad resident on-board performance tool (OPT), in this case transposing 6 for 7 in the fuel weight resulting in entering 66,400kg into the OPT. A cross check of the OPT calculated Vref40 speed value against that calculated by the FMC (which uses the aircraft Zero Fuel Weight (ZFW) input rather than TOW to calculate Vref40) would have picked the error up, but the crew mis-interpreted the check and so it was not performed correctly. Continue Reading…

To err is human, but to really screw it up takes a team of humans and computers…

How did a state of the art cruiser operated by one of the worlds superpowers end up shooting down an innocent passenger aircraft? To answer that question (at least in part) here’s a case study that’s part of the system safety course I teach that looks at some of the casual factors in the incident.

In the immediate aftermath of this disaster there was a lot of reflection, and work done, on how humans and complex systems interact. However one question that has so far gone unasked is simply this. What if the crew of the USS Vincennes had just used the combat system as it was intended? What would have happened if they’d implemented a doctrinal ruleset that reflected the rules of engagement that they were operating under and simply let the system do its job? After all it was not the software that confused altitude with range on the display, or misused the IFF system, or was confused by track IDs being recycled… no, that was the crew.

Matrix (Image source: The Matrix film)

The law of unintended consequences

There are some significant consequences to the principal of reasonable practicability enshrined within the Australian WHS Act. The act is particularly problematic for risk based software assurance standards, where risk is used to determine the degree of effort that should be applied. In part one of this three part post I’ll be discussing the implications of the act for the process industries functional safety standard IEC 61508, in the second part I’ll look at aerospace and their software assurance standard DO-178C then finally I’ll try and piece together a software assurance strategy that is compliant with the Act. Continue Reading…