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    Modelling pilot decision-making errors in New Zealand general aviation : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Social Sciences at Massey University
    (Massey University, 1992) Pitham, Claire
    Accident statistics indicate that the rate of mortality and financial loss associated with general aviation accidents is comparable with that of passenger transport operations. However, general aviation appears under­ represented in literature pertaining to the development of safety interventions. In this thesis, this apparent disparity is addressed in an investigation of pilot error in New Zealand general aviation. Using the precedent of accident modelling developed in industrial safety research, accident models taken from aviation, road transport and industrial settings are reviewed for their representation of human error. The Surry Model (1969), a twelve point sequence representing operator decision making processes, was selected for generalization to aviation. The selection of this model was congruous with research literature identifying poor decision making as a primary causal factor in air accidents. Each of the points in the model represents an opportunity for accident avoidance if certain information processing requirements are met. The model presents accident avoidance as the result of three processes: the correct recognition of stimuli, the correct cognitive processing of avoidance options, and the correct implementation of physiological responses. The accident sequence within which these processes occur is divided into two cycles: the build-up of danger in the system, and its subsequent release. The model was applied to a data base of 84 cases involving fixed wing aircraft engaged in general aviation, selected from 1980 to 1991. The point at which an error in pilot decision making occurred was identified and coded using the twelve points of the Surry Model. These data were combined with information concerning biographic characteristics of the pilots, and the number of passengers on board the flight. All pilots in the sample were male. Two research questions were investigated. The first questions whether the Surry Model is a useful tool in the analysis of information about accident sequences. The model was used as a template, and laid over the time line of accidents, as they had been determined by air accident investigators. The second research questions sought to determine whether the format of the model could be used as a protocol for developing time lines and questioning pilots during accident investigations. A small final sample size resulted in a general dichotomizing of the variables for non-parametric Chi Square statistical analysis. The power and utility of the analysis was limited and could only show that, beyond chance effects, there were no biographic characteristics of pilots that influenced the cycle of the model in which the accident inducing error occurred. No quantitative examination of the twelve error types identified by the model was possible. A low level of inter-rater reliability showed that the model was not as self-contained as anticipated. Raters appeared to use the model in a consistent manner, but modes of use varied between individuals. It is suggested that this may be a function of non-standardised presentation of human factors information in air accident reports, coupled with non­ standardised interpretations of ambiguities in the model. On the basis of the inferential interpretation of the data, two main areas of discussion arise. The first is concerned with 'ambiguities': the structural characteristics of the Surry Model that influenced the fall of data onto the twelve error types. It became apparent that the typical sequence of events in aircrashes differed from the temporal sequence depicted by the model, and that assumptions made in the model about the configuration of the pilot- aircraft interface were inaccurate. Accordingly, modifications to the model are proposed. The second area of discussion is centred on 'antidotes': corrections for pilot errors identified as causal in aircrashes. The results indicate that some aspects of in-flight behaviour could be targeted for intervention. It is suggested that it may be useful to encourage pilots to engage in active information search from external sources in order to ensure that they supplement information available from the aviation system. Self-monitoring before flight may induce voluntary self removal from aviation activities. It is possible that some pilots may abstain from flight if they become aware that their performance has become impaired as a result of their physical or emotional condition. It is also suggested that risk communication techniques could facilitate the development of worst case thinking by pilots who are confronted by potential hazards. Rather than a more traditional emphasis on the implementation of strategies after contact with danger, these antidotes may encourage the active avoidance of danger.
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    Pilot error : cognitive failure analysis : a thesis presented in partial fulfilment of the requirements for the degree of Master in Aviation at Massey University
    (Massey University, 1997) Zotov, Dmitri Victorovitch
    Rasmussen (1982) suggested that there was a need for a taxonomy of human errors based on the operator performing the task, rather than upon the task itself; the "internal human malfunction" (p. 323). This proposal was adopted by O'Hare, Wiggins, Batt & Morrison (1994) in a study of pilot errors derived from the New Zealand official Accident Reports. O'Hare et al. (1994) found differences in the types of errors that led to major and minor accidents. These differences were at variance with the proposition by Billings and Reynard (1981) that the errors in accidents and incidents came from a common population, the outcome being due to chance. The results of O'Hare et al. (1994) cast some doubt on the validity of investigating incidents as a means of forestalling accidents. Some of the accident reports used by O'Hare et al. (1994) had not been the result of independent investigation, but were self-reports by the pilots involved. The inclusion of these reports had the potential to produce the apparent dichotomy between the distributions of error types in major and minor accidents, found by O'Hare et al. (1994). It was therefore decided to revisit their work, using as a database the entire population of New Zealand official Accident Reports since 1965, which had been the subject of official investigation. With the large database available, variability in the distribution of error types was also examined between different classes of aircraft, and between pilots of different levels of experience. Some variability between major and minor accidents was found, but not enough to be of practical significance. No variability was found between pilots of different levels of experience. There was little difference between classes of aircraft, except in the case of fixed-wing agricultural aircraft. In the latter case, the difference in the distribution of error types from other classes of aircraft was marked, and further study to identify the reasons might assist in reducing the accident rate for agricultural aircraft.
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    The role of experience in the susceptibility to confirmation bias in pilots : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University, Albany, New Zealand
    (Massey University, 2012) Rowntree, Jaime
    Confirmation bias refers to the tendency of an individual to prioritise and seek out evidence that confirms their theory or hypothesis and avoid or place little importance on disconfirming information. In the field of aviation, confirmation bias can have disastrous consequences and has been implicated in several aviation disasters. Despite the potentially fatal consequences, little research has systematically explored the underlying causes of confirmation bias in pilots. The following research examined the role of experience in the susceptibility to confirmation bias in pilots utilising an aviation themed location discovery task. To assess the relationship between flying experience and susceptibility to confirmation bias, 53 participants (23 non-pilots with no prior flying experience, 13 novice pilots with between 0-200 hours of logged flight time, and 17 experienced pilots with between 220-15000 hours of logged flight time) were asked to complete an online map-based location discovery task, which required participants to imagine that they were unsure of their location in four aviation themed scenarios. They then had to select, out of three features given, which feature would be the most useful for helping them to decide on their current location. Two out of the three features provided incorrect confirming (positive) tests of the pilot’s hypothesised location and one feature provided the correct disconfirming (negative) test of their hypothesised location. Results indicated that overall, participants primarily utilised a hypothesis-confirming strategy on the task. No relationship between experience and a participant’s susceptibility to confirmation bias was identified. A thematic analysis of the comments provided by participants was completed, which illustrated that participants were fairly consistent in the decision-making strategy that they used when reasoning about their location across each of the four scenarios. Interestingly, non-pilots and novice pilots primarily utilised a hypothesis-confirming approach most regularly in their feature selection. By contrast, it appears that the experienced pilot group primarily utilised a strategy that favoured the selection of manufactured objects and large objects. Future research should focus on discovering the mechanisms underlying confirmation bias and the identification of groups of people who are less susceptible to it. This information can then be used to create a model of confirmation bias outlining interventions that can be used to reduce or eliminate its effects.
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    Developing proficiency in air transport pilots : the case for the introduction on non-technical skills in basic pilot training programmes : a thesis presented in partial fulfilment of the requirements for the degree of PhD Aviation at Massey University, Palmerston North
    (Massey University, 2008) De Montalk, Ritchie James
    This study examines the differences between the skills and competencies of New Zealand flight school graduates and the types of skills and competencies believed to define a proficient air transport pilot. In New Zealand the training of professional pilots is directed towards meeting the requirements laid down by the New Zealand Civil Aviation Authority for the licensing of professional pilots. However, some evidence suggests that competence for licensing purposes does not necessarily meet the requirements of the airlines and the types of skills that they require as a prerequisite to airline training. Although not clearly defined, this shortfall has been recognised for several decades and traditional thinking is that extra flying experience gained as a general aviation pilot will develop the skills necessary for entry into airline pilot training. The importance that pilots of differing experience levels attach to technical and non-technical skills and their perception of the training effectiveness of those skills and how deficiencies in those skills contributed to aircraft accidents was explored by a four stage study including: i) a review and analysis of flight test results obtained from graduate pilots on a university air transport pilot programme; ii) the analysis of responses to questionnaires supplied to three pilot groups within the New Zealand aviation industry; iii) the analysis of air transport aircraft accidents and their primary and contributing causes; and iv) interviews with qualified airline pilots working for New Zealand airlines. The results indicated that throughout the spectrum of experience and qualifications, from student pilot to airline pilot, the technical skill of aircraft handling was highly valued and the training in this skill was considered by all pilots to be satisfactory. In contrast, while non-technical skill deficiencies were found to be primary or contributing factors in many aircraft accidents, less importance was attached to non-technical skills by all pilot groups. The training effectiveness of these skills was rated as only moderately effective or of minimal effectiveness. The findings are discussed and recommendations are made for the improvement of basic flight training. In addition, a model is proposed for the fast tracking of flight school graduates into the airline training schools. Several areas for future research are also proposed.
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    Grappling with complexity : finding the core problems behind aircraft accidents : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Aviation at Massey University, Palmerston North, New Zealand
    (Massey University, 2006) Zotov, Dmitri Victorovitch
    The purpose of accident investigation is the discovery of causal factors, so that they may be remedied, in order to avert the recurrence of accidents (ICAO, 1994). However, experience has shown that the present intuitive methods of analysis do not always achieve this aim. Investigation failure may come about because of failure to discover causal factors, or to devise effective remedies, or to persuade those in a position to act of the need to do so. Each of these types of failure can be made less likely by the use of formal analytical methods which can show whether information gathering has been incomplete, and point to the sources of additional information that may be needed. A formal analysis can be examined by formal logical tests. Also, the use of formal change mechanisms can not only devise changes likely to be effective, but can present these changes in such a way that the case for them is compelling. Formal methods currently available are concerned with what happened, and why it happened. To produce generic remedies which might avert future accidents of similar type, some formal change mechanism is needed. The Theory of Constraints has become widely adopted in business as a way of replacing undesirable effects with desired outcomes. The Theory of Constraints has not previously been used for safety investigation, and a principal object of this thesis is to see whether it can usefully be employed in this area. It is demonstrated that the use of formal methodology can bring to light factors which were overlooked during an official accident investigation, and can ‘tell the story’ in a more coherent manner than is possible with present methods. The recommendations derived from the formal analysis are shown to be generic in nature, rather than particular to the airline involved and the accident studied, and so could have a wider effect in improving safety.