FF LL II GG HH TT SS AA FF EE TT YY FF OO UU NN DD AA TT II OO NN MARCH–APRIL 2003 FLIGHT SAFETY D I G E S T The Human Factors Implications for Flight Safety Of Recent Developments In the Airline Industry FLIGHT SAFETY FOUNDATION Flight Safety Digest For Everyone Concerned With the Safety of Flight OFFICERS AND STAFF Vol. 22 No. 3–4 March–April 2003 Hon. Carl W. Vogt Chairman, Board of Governors In This Issue Stuart Matthews President and CEO The Human Factors Implications for Flight 1 Robert H. Vandel Safety of Recent Developments in the Executive Vice President James S. Waugh Jr. Airline Industry Treasurer ADMINISTRATIVE Worldwide Apron Accident/Incident 78 Ellen Plaugher Rates for 2001 Show Increase Special Events and Products Manager Data from 353 airports showed that damage to equipment Linda Crowley Horger and facilities was more frequent than damage to aircraft on Manager, Support Services the apron, and that apron accident rates and incident rates FINANCIAL were highest in the European Region and at larger airports. Crystal N. Phillips Director of Finance and Administration Report Outlines Procedures for First 81 Millicent Wheeler Responders at Aircraft-accident Sites Accountant TECHNICAL Police, firefighters and medical personnel are usually the first to arrive at an accident scene. Australian civil and military James M. Burin safety authorities have issued jointly a report outlining Director of Technical Programs procedures to ensure the safety of these emergency-services Joanne Anderson personnel, aid survivors and preserve information for accident Technical Programs Specialist investigators. Louis A. Sorrentino III Managing Director of Internal Evaluation Programs Robert Feeler Airplane Strikes Vehicle 83 Q-Star Program Administrator Parked Near Gate Robert Dodd, Ph.D. Manager, Data Systems and Analysis The flight crew believed that the area was clear of obstructions Darol V. Holsman when they taxied the airplane to the gate at an airport in Manager of Aviation Safety Audits England after a night flight from Germany. After the incident, the airport operator planned to publish warnings to drivers MEMBERSHIP of airside vehicles not to leave unattended equipment at the Ann Hill gates. Director, Membership and Development Ahlam Wahdan Membership Services Coordinator PUBLICATIONS Roger Rozelle Director of Publications Mark Lacagnina Senior Editor Wayne Rosenkrans Senior Editor Linda Werfelman Senior Editor Rick Darby Associate Editor Karen K. Ehrlich Cover photo: © Copyright 2003 Corbis. Web and Print Production Coordinator Ann L. Mullikin Flight Safety Foundation is an international membership organization dedicated Production Designer to the continuous improvement of aviation safety. Nonprofit and independent, the Foundation was launched officially in 1947 in response to the aviation Susan D. Reed industry’s need for a neutral clearinghouse to disseminate objective safety Production Specialist information, and for a credible and knowledgeable body that would identify Patricia Setze threats to safety, analyze the problems and recommend practical solutions to Librarian, Jerry Lederer Aviation Safety Library them. Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Today, the Foundation provides Jerome Lederer leadership to more than 910 member organizations in more than 142 countries. President Emeritus The Human Factors Implications for Flight Safety of Recent Developments in the Airline Industry A Research Study for the Joint Aviation Authorities Contents Executive Summary ..................................................................................................................................................4 1. Introduction ........................................................................................................................................................7 1.1 Background to the Study..............................................................................................................................7 1.2 Scope of the Study........................................................................................................................................7 1.3 Methodology.................................................................................................................................................8 1.4 Layout of Report...........................................................................................................................................8 2. Culture ................................................................................................................................................................9 2.1 Professional Culture......................................................................................................................................9 2.2 Organizational Culture .................................................................................................................................9 2.3 National Culture..........................................................................................................................................10 2.4 Managing Cultural Issues on the Flight Deck............................................................................................13 2.5 Conclusions.................................................................................................................................................13 3. Errors Arising From the Performance of Team Tasks ..................................................................................13 3.1 Introduction ................................................................................................................................................13 3.2 Information Acquisition..............................................................................................................................15 3.3 Information Sharing....................................................................................................................................16 3.4 Decision Making.........................................................................................................................................19 3.5 Latent Failures ...........................................................................................................................................20 3.6 Summary of Factors Infl uencing Flight Deck Errors ................................................................................20 4. Commercial Developments in the Airline Industry ......................................................................................20 4.1 Historical Perspective.................................................................................................................................20 4.2 Effects of Deregulation...............................................................................................................................23 4.3 Privatization ...............................................................................................................................................24 4.4 Alliances ....................................................................................................................................................24 4.5 Mergers and Acquisitions ..........................................................................................................................25 4.6 Low-cost Carriers.......................................................................................................................................26 5. Effects on Flight Crew of Commercial Developments...................................................................................26 5.1 Multicultural Flight Crews .........................................................................................................................26 5.2 Merging of Company Cultures ..................................................................................................................29 5.3 Commercial Pressure..................................................................................................................................32 FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 1 6. Mitigating Factors.............................................................................................................................................35 6.1 Crew Resource Management (CRM).........................................................................................................35 6.2 Standard Operating Procedures (SOPs)......................................................................................................38 6.3 Professional Culture....................................................................................................................................40 6.4 Safety Regulation .......................................................................................................................................42 7. Effectiveness of Mitigating Factors on Human Factors Problems Arising From Commercial Developments ......................................................................................................44 7.1 Teamwork...................................................................................................................................................44 7.2 Communication ..........................................................................................................................................45 7.3 Fatigue........................................................................................................................................................46 7.4 Morale and Job Satisfaction .......................................................................................................................46 7.5 Experience and Competence.......................................................................................................................47 7.6 Situational Awareness ................................................................................................................................48 7.7 Safety Auditing and Internal Oversight .....................................................................................................49 7.8 Summary of Mitigation Effectiveness........................................................................................................50 8. Comparison With the Marine Industry..........................................................................................................50 8.1 Introduction ................................................................................................................................................50 8.2 Differences Between Aircraft Cockpit and Bridge Navigation Operations................................................51 8.3 Multicultural Crews ...................................................................................................................................51 8.4 CRM and Professional Culture...................................................................................................................51 8.5 Safety Regulation .......................................................................................................................................51 8.6 Conclusion .................................................................................................................................................52 9. Approaches to Human Factors in Other Safety-critical Industries .............................................................52 10. Conclusions........................................................................................................................................................53 10.1 CRM...........................................................................................................................................................54 10.2 SOPs...........................................................................................................................................................55 10.3 Professional Culture....................................................................................................................................55 10.4 Overall .......................................................................................................................................................56 11. Recommendations.............................................................................................................................................56 12. References..........................................................................................................................................................57 Appendix A: Postal Questionnaire.........................................................................................................................60 Appendix B: Interview Questionnaire...................................................................................................................66 Appendix C: Comparison With the Marine Industry..........................................................................................74 C.1 Introduction.................................................................................................................................................74 C.2 Globalization...............................................................................................................................................74 2 FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 C.3 Economics of Change in Merchant Shipping ............................................................................................74 C.4 Characteristics of the Merchant Shipping Industry....................................................................................74 C.5 Regulation of the Shipping Industry...........................................................................................................75 C.6 Differences Between Aircraft Cockpit and Bridge Navigation Operations................................................75 C.7 Multicultural Crews in Shipping.................................................................................................................77 C.8 SOPs ..........................................................................................................................................................77 C.9 Crew Resource Management .....................................................................................................................77 C.10Professional Culture....................................................................................................................................77 C.11Reference....................................................................................................................................................77 FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 3 Executive Summary literature on possible human factors impacts. The following paragraphs provide a very short summary of the principal dimensions in which commercial developments potentially Introduction have a human factors impact. The study was carried out during 2000, on behalf of the Joint Culture Aviation Authorities (JAA), by a team led by Icon Consulting and including Human Reliability Associates, International Air Transport Association (IATA) Aviation and Research1 and The impacts of national, professional and organizational experienced pilots. The aim of the study is to consider the cultures were investigated. human factors implications of recent commercial developments in the airline industry and to assess their potential impact, if A link between national culture and potential flight-deck any, on flight-deck safety. behavior was established. National differences were identified in the dimensions of individualism/collectivism (achieving individual desires as opposed to group harmony), power Approach distance (relationship between subordinates and superiors) and uncertainty avoidance (tolerance to risk and uncertainty). The overall approach was as follows: These differences may result in different attitudes to following standard operating procedures, (SOPs) to the use of automation (cid:127) To investigate whether there is a theoretical possibility and to relationships and management on the flight deck. of commercial developments having a safety impact on the flight deck — it was concluded that there is a In terms of globalization, therefore, flight deck crews composed possibility; of individuals from different cultural backgrounds might experience conflict in the dimensions identified. (cid:127) If there is a theoretical possibility, to identify whether the conditions exist for a safety impact to occur — it was The professional culture of the flight crew is strong. However, concluded that the conditions do exist and that continuing the satisfaction level achieved is largely determined by the changes in the industry are increasing the likelihood of organizations that they work for and the conditions under their occurrence; which they work. In addition, the sense of professional pride can result in an unrealistic denial of vulnerability to factors (cid:127) If the conditions exist, to seek evidence on whether such as fatigue. incidents are occurring as a consequence — relevant incidents were identified, but it was concluded that there A link between a negative organizational culture and negative is insufficient evidence to link them directly to this cause; attitudes and behavior was established which would not and, necessarily be mitigated by the high level of professionalism of flight crews. (cid:127) To identify any mitigating factors that could be used to reduce the threat — it was concluded that there are factors Flight Deck Error and that they should be enhanced to deal with this threat. A wide range of people were consulted for the study, including Researchers have recorded that errors were made on 68 percent airline management, management pilots, line pilots, safety of flights they observed, with an average of two errors per flight. regulators, an airframe manufacturer, a flight crew agency Not all crew errors will lead to adverse consequences. This and pilot-representative organizations. The airlines consulted report identifies the types of errors and their causes. included national, regional and cargo carriers, charter airlines and new entrants in the low-cost sector. The countries represent Direct causes of failures are primarily due to a breakdown a broad cross section of the whole of the JAA region and are in crew-related interactions such as decision making, verbal not biased toward any one part of Europe. communication, team organization and workload distribution, rather than a lack of technical proficiency. Team skills are All contributions to the study are confidential to the study therefore vital to a safe flight. The indirect or latent causes team. of failures can be due to inadequate training, supervision, resources or oversight, and faulty procedures and policies. At the beginning of the study, the team reviewed commercial developments in the air transport industry and the published Commercial Developments The report describes past, recent and possible future 1 International Air Transport Association Aviation Information and Research developments in the air transport industry that have been (IATA-AIR) input was related to describing and analyzing commercial trends in the industry. motivated by deregulation, liberalization and privatization. 4 FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 Alliances are formed partly to improve market access and partly effect on interpersonal relations during off-duty periods, which to reduce cost. Cost-reduction mechanisms include: will reduce the likelihood of the crew building up a shared knowledge base and a shared set of assumptions about how (cid:127) Management contracts, leading to the reduction in the the team should work together. management head count of members; Other factors that are thought to cause difficulties are different (cid:127) Joint ventures in areas such as ground handling and religious beliefs, membership in different trade unions, different aircraft maintenance, which allow alliance members safety or crew resource management (CRM) philosophies and to enjoy the benefits of bulk purchasing from key concerns over flying skills and technical knowledge. suppliers; Commercial Pressure (cid:127) Sharing of facilities such as training, maintenance and aircraft spares; and, In some instances, there is strong pressure to increase flying hours up to the legal limits. Many airlines treat the legal limit as (cid:127) Higher utilization of aircraft. a performance target to be achieved if utilization of flight crew is to be maximized and operational costs reduced. In addition, Cost efficiency does not automatically mean a loss of safety, some airlines allow very little, if any, reduction in flying hours particularly as all carriers are subject to the same regulation. for management pilots, some with critical responsibilities such However, the emergence of numerous new-entrant airlines, as flight safety. each of which requires specific regulatory effort, may stretch the resources of the regulators. While previous airline Unsympathetic rostering increases fatigue, upsets sleep patterns, mergers generally took place between airlines within the reduces morale and has a detrimental effect on the personal life same country, mergers that cross national boundaries are of crew. In some cases, this is combined with a reduced ratio becoming increasingly common. This is likely to give rise of crew per aircraft, leading to a loss of flexibility and pressure to a more complex mix of cultural factors to be dealt with to fly despite personal welfare. by the new companies. Further mixing is likely to result from an increase in the number of pilots from the former Many pilots interviewed in a wide range of airlines observed Soviet Bloc seeking improved employment conditions in that there is a tendency for business people with no flying Western airlines. experience to fill senior operational positions. Their concern was that these managers might not understand the implications The growth of the low-cost carriers has generated new demand of their decisions. for air travel, a new market sector and new commercial pressures. Not all low-cost carriers have survived, and those Training is an expensive activity, and there is a fear that training that have face increased costs, not least because they now have budgets might be reduced to achieve cost savings. to compete in the marketplace for the considerable number of pilots they require. Overall, they have contributed toward an Captains are increasingly being required to make economic increase in volatility in the employment of pilots. decisions, which is often counter to their traditional role of safely flying the aircraft. There is sometimes a dilemma between safety and economics: A captain has the responsibility The Effect of Commercial Developments for the safety of a flight but may be blamed by management if he or she is thought to have taken a commercially detrimental The consequences of recent developments have the potential to decision. If a pilot succumbs to commercial pressure and as a affect flight deck performance. Airline mergers and alliances will result is involved in an incident, he cannot, in law, defend his change the organizational culture in which individuals work, and position by saying that the company pressured him to take the this in turn may influence individual performance. They are likely, actions that he did. Some pilots find this dilemma difficult to also, to increase the incidence of multinational flight crews. As resolve on a day-to-day basis. more flexibility is required of airline staff, effects such as changes in morale and increased fatigue may be seen. Mitigating Factors Of all the potential problems arising from multinational flight crews, differences in language are an obvious concern, and During the research, a number of factors that might mitigate an increase in mixed-language operations is likely to have the effects of globalization were identified. These factors have a negative effect on safety. Language is also a social issue been classified into three categories: CRM training, SOPs and affecting both duty and off-duty time. Social interaction may professional culture. Safety regulation is also available as a help to reduce fatigue, maintain alertness between the crew and controlling measure. The report identifies to what extent each contribute to teamwork during flights. A lack of conversational category is likely to produce effective mitigation and whether or colloquial ability in a common language may have an adverse other control measures can be brought to bear. FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 5 CRM training is the approach used within aviation to tackle Several airlines stressed the highly proceduralized nature of issues of teamwork among flight crew. Whereas benefits have the flying task, claiming that procedures existed for every been claimed by the industry from the use of CRM, there is eventuality. However, crews working in highly proceduralized little hard evidence that CRM has a measurable effect on safety. environments may encounter difficulties when faced with a There are particular concerns that behavior in training sessions situation that is not covered by a procedure. Furthermore, is not correlated with behavior under real circumstances. In crews who normally use SOPs when working for an airline addition, CRM cannot deal with other causes of error such as that strongly adheres to procedures may experience difficulties fatigue, poor interfaces, cockpit automation issues and problems should they then operate in an airline which allows a greater related to SOPs quality and compliance. degree of individual interpretation of SOPs. The use of a standard, outsourced CRM “product” that has not been Airline personnel display strong ownership toward their own adapted for the particular culture in which it is applied may also SOPs. It would appear that new-entrant airlines tend to adopt reduce its effectiveness. There appears to be no process in place manufacturers’ SOPs with little, if any, modification, whereas in the industry to spread to others either the experience gained in established airlines will often have adapted these SOPs quite developing appropriate CRM training or best practices. considerably. Problems may arise if there are differences in the degree of compliance with SOPs by flight crews from different The scope of CRM is being extended in some airlines. airlines. While the previous emphasis was on team-building skills and communication, other aspects are now being introduced, Safety regulators do not allow the operation of mixed SOPs such as monitoring skills and the management of time and within a single aircraft type under an aircraft operating workload. Some airlines run CRM training for mixed groups certificate (AOC). Therefore, it would be difficult to mix of cabin and flight deck crew, and in one case also maintenance crewmembers within an alliance unless all partners of the personnel. alliance were using the same SOPs. However, there is a serious danger that CRM will be seen as The professional culture in aviation is strong and distinctive, the solution to all human factors issues in commercial aviation. and this is particularly apparent in the professional culture This is reflected in the fact that the human factors departments among pilots. of airlines are often staffed by CRM specialists rather than by human factors professionals. Flight crew were described as intelligent, although not necessarily formally educated, with a high degree of self-confidence. Strong The emphasis on CRM may in some cases lead to a culture in self-discipline and self-motivation were said to be essential to which all errors are considered to arise (and be contained) in the cope with the working environment. Flight crew tend to be cockpit environment. However, many factors that may adversely conservative in nature and are generally uncomfortable with influence flight safety originate, as in all other industries, from change unless it is long-term and gradual. management and organizational failures that occur deeper in the system and are outside the control of individual flight A strong professional culture has both strengths and crewmembers. High levels of flight crew training, experience or weaknesses. On the positive side, pilots take great pride in personal capability will not automatically mitigate the adverse their profession and have a strong motivation to perform to effects of such factors. the best of their ability. On the negative side, there may be an unrealistic denial of vulnerability to factors such as fatigue, The CRM industry is responding to changes due to globalization, stress or personal issues. Given the great responsibility of and no doubt the more recent versions of such training will pilots, this may be a psychological defense mechanism to improve its effectiveness. avoid performance anxiety. SOPs form the basis for the operation of the aircraft, and There is a danger that globalization may degrade those aspects it is thought by the whole industry that very few incidents of professional culture that do act as a control mechanism. would occur if SOPs were adhered to rigidly. However, it For example, the movement of crew between countries is clear that, in common with most safety-critical industries, and companies may diminish the perception of a common absolute compliance with the letter of all written procedures identity. is not regarded as feasible. The extent of the noncompliance is influenced by the prevailing safety culture in the company. Safety regulation in Europe is not yet harmonized. Differences In addition, pilots who have experience with more than one among member states mean that European airlines are not set of procedures may inadvertently revert to a previously overseen by a coherent legal entity, unlike the situation in the familiar procedure, particularly under conditions of duress. In United States. Given that overall regulation is the remaining a multicultural environment, a flight crewmember’s knowledge control mechanism to deal with conditions not controlled by of an SOP may lead him to interpret ambiguous communication the other three identified mitigating factors, this has to be a in terms of SOPs with which he is familiar. matter of concern to the JAA. 6 FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 Some regulators are taking a less active role in enforcing Hawkins (1993) states that, despite the low level of accidents standards by allowing airlines to take greater responsibility per passenger carried or hours flown, the current accident rate for their own oversight by means of self-audits. However, it is is still too high for the comfort of the public. The Final Report apparently becoming increasingly difficult for airlines to recruit of the (U.S.) White House Commission on Aviation Safety suitably experienced people as nominated post-holders to carry and Security (1997) states that if the current accident rate is out this important role. maintained, the expected growth in air transport means that by 2015 there will be one major accident somewhere in the Conclusions world each day, a situation which would be totally untenable. Therefore, the accident rate must be reduced to ensure that the total number of accidents per annum is no greater, and hopefully The aviation industry in Europe is developing rapidly, and lower, than current figures. As a part of this improvement a number of human factors effects that can arise from these process, human factors issues need to be addressed. commercial developments have been identified. Some of these effects have the potential to impact negatively on flight safety, The global nature of aviation means that issues of and this threat is likely to increase as the pace of commercial communication and interaction between cultures are of developments increases. particular interest, perhaps more so than in any other industry, apart from international shipping (see Chapter 8). The constant There is a belief in the industry that the control measures of drive for cheaper and more flexible travel may lead airlines to CRM, SOPs and professional culture will mitigate these threats. look further afield for their flight crews and to increase their This report suggests that these measures may not be fully use of multicultural crews. effective in preventing or controlling the issues. An evaluation of the extent to which the three measures are thought to be However, it would be a mistake to assume that issues arising effective is presented in Table 1. from differences in national cultures are the only or even the 1. Introduction most important flight safety issues arising from commercial developments in the airline industry. Mergers between airlines also involve a merger of the individual cultures and practices 1.1 Background to the Study that have existed in the previously independent companies. The aim of this study is to consider the human factors implications To remain competitive, airlines will also seek more efficient for flight safety, if any, of recent commercial developments in and cheaper ways of doing business, which is likely to result in the airline industry. In particular, the study focuses on recent greater flexibility being required of flight crew and may increase tendencies for airlines to merge and form global alliances, and their sense of commercial pressure. The rapid expansion in low- the growth in new entrants with different business models. cost carriers and the future movement of flight crew between these airlines and more conventional carriers with very different The functional reliability of aircraft has improved beyond company cultures may also have human factors implications. all recognition over the course of the last century. This improvement, however, has drawn attention to the importance of the human element in determining system safety (David, 1.2 Scope of the Study 1997). It has been suggested that around 70 percent of aviation incidents and accidents are attributable to human error on the The scope of the study is countries in the JAA area. No flight deck (Foushee, 1984). organizations were consulted from outside this area, although, Table 1 Tabulation of Human Factors Issues and Mitigating Factors Mitigation Effectiveness Crew Resource Standard Operating Human Factors Issue Management Procedures Professional Culture Teamwork/power gradient Medium Medium Medium Communication Medium Medium Low Fatigue Low Medium Low Morale and job satisfaction None Low Low Experience/competence Medium Medium None Situational awareness and mental models Medium Low Medium Source: Icon Consulting, Human Reliability Associates and International Air Transport Association Information and Research. FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003 7 during the course of the study, some examples were provided Using the output from this research, two questionnaires were of airlines based beyond the boundaries of the JAA that have developed to elicit relevant information from airlines. The experienced and resolved human factors issues that are relevant first was a postal questionnaire that could be sent to selected to this study. Some of these examples are referred to in this airlines to obtain some preliminary information. The second report. was a list of follow-up questions that could be used by members of the team in a face-to-face, structured interview. The main thrust of the study has been in obtaining the The interview questionnaire provided a framework for the views, concerns and experience of a variety of stakeholders meeting but was used flexibly to ensure that all matters in European aviation. Table 2 shows the sample of different relevant to the study could be pursued as they arose. The types of organizations that were consulted by means of either a postal questionnaire appears in Appendix A, and the interview questionnaire or a face-to-face interview, and their geographic questionnaire in Appendix B. spread. These two questionnaires were particularly suitable for interviewing management and management pilots in airlines, Table 2 and a less structured approach was taken with line pilots and safety regulators. In particular, questions that were asked at Dimensions of Representation meetings with regulators were based on issues that had already In the Study emerged from the airline interviews. Number Countries Much of the content of the main part of this report is derived Organization Type Consulted Represented from an analysis of the information collected at meetings and Airline 21 14 from questionnaires. Safety Regulator 4 4 Airframe Manufacturer 1 1 The human factors issues identified are not only being Flight Crew Agency 1 1 experienced in the aviation industry but also occur in other Pilots’ Representative Association 1 Europe safety-critical industries where globalization is taking place. The study team has used its prior experience of the marine Source: Icon Consulting, Human Reliability Associates and International Air industry to compare it with aviation to determine if there are Transport Association Information and Research. lessons that can be learned. The airlines consulted include national, regional and cargo 1.4 Layout of Report carriers, charter airlines and new entrants in the low-cost sector. Airline managers, management pilots and line pilots Chapter 2 puts the remainder of this report into context were interviewed. The countries represent a broad cross section by reviewing previous work that has been carried out on of the whole of the JAA region and are not biased towards any cultural factors in aviation. It discusses three types of culture one part of Europe. To preserve confidentiality, neither the — professional, organizational and national — and explores organizations nor the countries are named. how flight crew attitudes are influenced by these cultures. It also considers how cultural issues might be managed on the It should be noted that in this report, “flight crew” refers to flight deck. all those members of the crew who work on the flight deck, including captains, first officers and flight engineers. It does Chapter 3 reviews different types and causes of human error on not include cabin crew. the flight deck. It provides a framework model of flight deck error based on the acquisition of information, the sharing of 1.3 Methodology this information between flight crew and its use for decision making. A summary table is provided to illustrate the type of To set the scene at the beginning of the study, two pieces of error that can occur during each stage of the framework and research were carried out: relates each error type to possible cultural causes. (cid:127) A review of significant historical and current developments Chapter 4 highlights some of the significant historic and in the structure of the air transport industry, together with current structural changes in the air transport industry of a look at likely future developments; and, particular relevance to this study. It considers the effects of deregulation, its impact on different types of carriers, the rapid (cid:127) A review of published literature relating to the professional growth in global airline alliances and the emergence of low- culture of pilots, the mixing of national and organizational cost carriers. cultures, the management of culture on the flight deck and the causes of flight deck errors. Chapters 5 to 7 are based on the results of the interviews. 8 FLIGHT SAFETY FOUNDATION (cid:127) FLIGHT SAFETY DIGEST (cid:127) MARCH–APRIL 2003