diff --git a/pub/dissertation/chapters/background.tex b/pub/dissertation/chapters/background.tex index 57bdd2b..ee2c152 100644 --- a/pub/dissertation/chapters/background.tex +++ b/pub/dissertation/chapters/background.tex @@ -16,6 +16,7 @@ \end{itemize} + %%%%% SAFETY %%%%% \section{Safety in Aviation} \subsection{History} @@ -25,62 +26,141 @@ % - Rates of accidents \begin{itemize} \item 70-80\% of aviation accidents are attributed to human factors~\cite{faa:reasons} + \item The first use of a checklist was in 1935 after the crash of a prototype plane known + back then as the Model 299 (known as the Boeing B-17 today), due to the complex procedures + required to operate the aircraft normally and forgetting a step resulting in + lack of controls during takeoff~\cite{manifesto} + \item It was found that because of the complicated procedure to operate the aircraft + that the pilots would forget steps, and hence the concept of checklists was tested, + and found to minimize human errors~\cite{manifesto} \end{itemize} \subsection{Checklists} -\begin{itemize} - \item Checklists are defined by the Civil Aviation Authority (CAA) as: - \blockquote{A set of written procedures/drills covering - the operation of the aircraft by the flight - crew in both normal and abnormal - conditions.~\ldots~The Checklist is - carried on the flight deck.}~\cite{caa:design} +% \begin{itemize} +% \item Checklists are defined by the Civil Aviation Authority (CAA) as: +% \blockquote{A set of written procedures/drills covering +% the operation of the aircraft by the flight +% crew in both normal and abnormal +% conditions.~\ldots~The Checklist is +% carried on the flight deck.}~\cite{caa:design} - \item Checklists have been shown to aid in minimizing human errors~\cite{manifesto} +% \item Checklists have been shown to aid in minimizing human errors~\cite{manifesto} - \item However, according to the Civil Aviation Authority (CAA), the UK's aviation regulator: - \begin{itemize} - \item Checklists can be misleading and compromise the safety of the aircraft - due to them being either too confusing or taking too long to complete~\cite{nasa:design} - \item Other problems may include the crew skipping a step either unintentionally or by interruption, - or just failing to complete the checklist outright - \item The crew may also not be alerted to performance issues within the aircraft, - that running the checklist may cause~\cite{caa:design} - \end{itemize} +% \item However, according to the Civil Aviation Authority (CAA), the UK's aviation regulator: +% \begin{itemize} +% \item Checklists can be misleading and compromise the safety of the aircraft +% due to them being either too confusing or taking too long to complete~\cite{nasa:design} +% \item Other problems may include the crew skipping a step either unintentionally or by interruption, +% or just failing to complete the checklist outright +% \item The crew may also not be alerted to performance issues within the aircraft, +% that running the checklist may cause~\cite{caa:design} +% \end{itemize} - \item However, it is important to note that checklists does not prevent the human - factor of failure to use a checklist, like in the case of Northwest Airlines - Flight 255, where the National Transportation Safety Board (NTSB), an investigatory board - for aviation accidents in the United States, determined that - \enquote{the probable cause of the accident was the flight crew's failure - to use the taxi checklist to ensure that the flaps and slats were extended for takeoff.}~\cite{ntsb:NWA255} +% \item However, it is important to note that checklists does not prevent the human +% factor of failure to use a checklist, like in the case of Northwest Airlines +% Flight 255, where the National Transportation Safety Board (NTSB), an investigatory board +% for aviation accidents in the United States, determined that +% \enquote{the probable cause of the accident was the flight crew's failure +% to use the taxi checklist to ensure that the flaps and slats were extended for takeoff.}~\cite{ntsb:NWA255} - \item These checklists can be bundled into a Quick Reference Handbook (QRH) - which the CAA defines it as: - \blockquote{A handbook containing procedures which - may need to be referred to quickly and/or - frequently, including Emergency and - Abnormal procedures. The procedures - may be abbreviated for ease of reference - (although they must reflect the procedures - contained in the AFM\footnote{ - Aircraft Flight Manual - \enquote{The Aircraft Flight Manual produced by the - manufacturer and approved by the CAA. - This forms the basis for parts of the - Operations Manual and checklists. The - checklist procedures must reflect those - detailed in the AFM.}~\cite{caa:design} - }). - The QRH is often - used as an alternative name for the - Emergency and Abnormal Checklist.~\cite{caa:design}} +% \item These checklists can be bundled into a Quick Reference Handbook (QRH) +% which the CAA defines it as: +% \blockquote{A handbook containing procedures which +% may need to be referred to quickly and/or +% frequently, including Emergency and +% Abnormal procedures. The procedures +% may be abbreviated for ease of reference +% (although they must reflect the procedures +% contained in the AFM\footnote{ +% Aircraft Flight Manual - \enquote{The Aircraft Flight Manual produced by the +% manufacturer and approved by the CAA. +% This forms the basis for parts of the +% Operations Manual and checklists. The +% checklist procedures must reflect those +% detailed in the AFM.}~\cite{caa:design} +% }). +% The QRH is often +% used as an alternative name for the +% Emergency and Abnormal Checklist.~\cite{caa:design}} - \item Therefore, as there may be a need for the checklist to be - referenced quickly and potentially in emergency situations, - these checklists should be tested for flaws -\end{itemize} +% \item Therefore, as there may be a need for the checklist to be +% referenced quickly and potentially in emergency situations, +% these checklists should be tested for flaws +% \end{itemize} + +Checklists are defined by the Civil Aviation Authority (CAA), +the UK's aviation regulator, as: +% +\blockquote{A set of written procedures/drills covering + the operation of the aircraft by the flight + crew in both normal and abnormal + conditions.~\ldots~The Checklist is + carried on the flight deck.}~\cite{caa:design} +These checklists as a result has shown to be a crucial tool in aviation +to minimize human errors.~\cite{manifesto} + +There are multiple checklists that are designed for aircraft for the use of +normal operation and potential problems that could arise during the flight. +These checklists are stored in a Quick Reference Handbook (QRH) which is +kept in the cockpit of each aircraft for use when needed. The definition +of a QRH by CAA is: +% +\blockquote{A handbook containing procedures which + may need to be referred to quickly and/or + frequently, including Emergency and + Abnormal procedures. The procedures + may be abbreviated for ease of reference + (although they must reflect the procedures + contained in the AFM\footnote{ + Aircraft Flight Manual - \enquote{The Aircraft Flight Manual produced by the + manufacturer and approved by the CAA. + This forms the basis for parts of the + Operations Manual and checklists. The + checklist procedures must reflect those + detailed in the AFM.}~\cite{caa:design} + }). + The QRH is often + used as an alternative name for the + Emergency and Abnormal Checklist.~\cite{caa:design}} + +However, checklists themselves can have design flaws as noted by researchers at +the National Aeronautics and Space Administration (NASA) where checklists +can be misleading, too confusing, or too long to complete, as a result +having the potential of compromising the safety of the aircraft.~\cite{nasa:design} +An example of this is what happened on Swiss Air Flight 111, where an electrical fault +was made worse by following the checklist, resulting in the aircraft crashing in the ocean. +This was as the flight crew was unaware of the severity of the fire caused by the +electrical fault. Following the steps in the checklist, one of the steps was +to cut out power to \enquote{non-essential} systems, which increased the +amount of smoke in the cockpit. +Simultaneously, the checklist itself was a distraction as it was found to take +around 30 minutes to complete in testing during the investigation.~\cite{tsb:SWR111} +This incident shows that checklists need to be tested for these flaws, and considering +the original checklist for Swiss Air Flight 111 would have taken 30 minutes +to theoretically complete, this could be time-consuming for checklist designers, +and this would be something to note whilst working on this project. + +There are other potential problems with checklists, +noted by the CAA, where the person running through the checklist could skip a step +either unintentionally, by interruption, or just outright failing to complete the +checklist. Or the crew may also not be alerted to performance issues within the aircraft, +which would be a result of running the checklist.~\cite{caa:design} Therefore, +this would be useful to add for features when testing checklists, such as +adding the ability to intentionally skip a step of a checklist or gathering +statistics on how the performance of the aircraft has been affected as a result +of using the checklist. + +Another problem to note about checklists is the human factor where the crew +may fail to use the checklist, like in the case of Northwest Airlines Flight 255, +where the National Transportation Safety Board (NTSB), an investigatory board +for aviation accidents in the United States, determined that +\enquote{the probable cause of the accident was the flight crew's failure +to use the taxi checklist to ensure that the flaps and slats were extended for takeoff.}~\cite{ntsb:NWA255} +This shows that even though checklists have shown to improve safety of the aircraft, +there are other measures that aviation regulatory bodies are required implement, to avoid +situations where the crew may completely ignore safety procedures and systems. %%%%% FORMAL METHODS %%%%% diff --git a/pub/dissertation/dissertation.pdf b/pub/dissertation/dissertation.pdf index 61f72ba..355f871 100644 Binary files a/pub/dissertation/dissertation.pdf and b/pub/dissertation/dissertation.pdf differ diff --git a/pub/dissertation/dissertation.tex b/pub/dissertation/dissertation.tex index 7276041..75e5703 100644 --- a/pub/dissertation/dissertation.tex +++ b/pub/dissertation/dissertation.tex @@ -8,6 +8,7 @@ \usepackage{csquotes} \usepackage{babel} +\usepackage{parskip} \usepackage{xcolor} diff --git a/pub/dissertation/references.bib b/pub/dissertation/references.bib index 82b1c40..1b26692 100644 --- a/pub/dissertation/references.bib +++ b/pub/dissertation/references.bib @@ -22,6 +22,21 @@ url = {https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR8805.pdf}, } +@report{tsb:SWR111, + author = {{Transport Safety Board of Canada}}, + shortauthor = {TSB}, + number = {A98H0003}, + title = {Aviation Investigation Report + In-Flight Fire Leading to Collision with Water + Swissair Transport Limited + McDonnell Douglas MD-11 HB-IWF + Peggy's Cove, Nova Scotia 5 nm SW + 2 September 1998}, + year = {2003}, + month = {02}, + url = {https://www.tsb.gc.ca/eng/rapports-reports/aviation/1998/a98h0003/a98h0003.pdf}, +} + @article{nasa:checklist, author = {Burian, Barbara}, year = {2006},