Dissertation: Situational Awareness: High Reliability or Normal Accidents

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High Reliability or Normal Accidents: A critical examination of situational awareness and its value in reducing human errors in aviation ground operations


The concept of situational awareness

Level 1 SA -- Perception Of The Elements In The Environment.

Level 2 SA -- Comprehension Of The Current Situation.

Level 3 SA -- Projection Of Future Status.

Situation Awareness Requirements

Theories of Situational Awareness

Three-level model

Interactive sub-systems

The perceptual cycle

Summary of the theories

Preparing for thematic synthesis


Qualitative assessment

Extracting data from studies

Thematic synthesis

Stages one and two: coding text and developing descriptive themes

Stage three: generating analytical themes

Context and rigor in thematic synthesis

Study quality and sensitivity analyses


SA Measurement Devices

SA requirements analysis

SA resource analysis

SA resources: personnel

SA resources: technologies


Three Levels of SA


Task management

Development of comprehension

Projection (Level 3 SA) and planning

Information seeking and self-checking activities

SA training

Shared mental models

Verbalization of decisions



A conceptual model to aid understanding of the critical decision making complexities arising out of transient situation awareness in aviation has been attempted in this paper. The cognitive processes of the brain as affected by rapidly changing situations have been analyzed. This paper also tries to factor in the various factors that have significant effect on decision making in this time sensitive and critical profession.

The limitations of attention spans, concentration issues and the working memory part of the brain have been addressed in this paper to seek a solution holistic behavioral orientation and methodology that will make situational awareness easier to perceive.

Two classes of factors, human brain and technology have contributed to limiting the SA capabilities. These are chiefly; incessant demands put on the brain by way of magnitude, quality and response time on one hand and rapidly evolving complex technology and level of mechanization on the other.

The two approaches that have gone into development of the model presented herein are based on; one, the causes of errors in decision making and two, a comparison of the successful vs. The unsuccessful pilots based on their tackling of situational cognition. With the continually increasing demands of complexity, continuity and frequency of decision making on the human brain in the last fifty years specially, it has become necessary that due attention is paid to this avenue of human performance. The situation awareness capability of the human interface is under increasing pressure and this paper considers these critical factors while trying to attend to them to help improve performance.


ATC -- Air Traffic Control

ATM -- Air Traffic Management

SA -- Situation Awareness

CFIT -- Controlled flight into terrain

GA -- General Aviation

RCTs -- Randomized Controlled Trials

LSZ -- Launch Success Zone

SART -- Situational Awareness Rating Technique

SAGAT -- Situation Awareness Global Assessment Technique

AMT -- Aviation Maintenance Technician

SABARS -- Situation Awareness Behaviorally Anchored Rating Scale

PSAQ -- Participant Subjective SA Questionnaire

OCCs -- Operations Control Centers

"High Reliability or Normal Accidents: A critical examination of situational awareness and its value in reducing human errors in aviation ground operations"

Chapter 1: Introduction

The sustained levels of awareness cognition demanded in aviation puts a lot of stress on those required to take decisions based on the rapidly changing scenario. A correlation between the changing environmental and other conditions has to be understood, picturized and analyzed to arrive at a line of action to be taken. Seen from this perspective, the fighter pilots face a more challenging situation with the added parameters of identification of allies' and enemy's aircraft are also to be accounted for. The skill of navigating the aircraft thus involves the proper evaluation of shifting ambient conditions and factors in addition to following the rules, procedures and other technicalities of flying and aircraft maneuvering. The complexity cannot be overemphasized. To top it, it should be noted that an assertion of the factors at hand have to be recognized to also assess and anticipate developing possibilities in light of the data available. All the above discussion goes on to show the importance and criticality of situation awareness. SA plays a significant role in the operability of flying industry and due importance to it has been given by those studying the human brain for cognitive capabilities and limitations (Kilingaru et al., 2013). The recurrent mishaps and incidents owing to inadequate SA practices have inspired many studies in related fields. In order to improve the operating costs of aviation owing to operational difficulties in flying in turn causing disrupted schedules, mishaps and material damage to equipments and facilities, SA training has to be streamlined. Best practices to improve SA have to be imbibed in the aircrew (Thatcher & Kilingaru, 2012). This training structure has to be approached at two levels, personal and at the team level, with each aiding the other. This has to be further augmented by improving existing systems with an eye on improving SA cognition. It is pertinent to note that the pilots need to learn and unlearn practices by adapting to newer systems to best incorporate situational awareness. A very critical factor that leads to success in aviation is improvement in situational awareness. The clarity of inter-play between the technology, capabilities of the brain, and other factors that make flying successful has to be the cornerstone of any system that aims at improving SA (Strybel et al., 2011).

Objectives of the study


Comprehend the effect of SA and its capability to reduce incidents in ground operations


Understand the effect of SA on people in lessening human lapses in flying


Understand the role of communication in SA


Understand the effect of different measures of SA


Recognize significant activities imperative to SA

Purpose of the study

The aim of this work is to discern the importance of SA and hence to propose a model that would improve SA. It is also proposed hereby that the work already done in this area will be further explored.

Significance of the study

It will be brought out that SA is not the sum total of the information available on the instrument panels alone. SA is much more than that. It involves the capability to anticipate situations and hence decision making will have to me made based on those premises and impending possibilities too. Unlike in other spheres, where data can be solely depended upon for critical decision making aviation success depends on much more that analysis of data available. As long back as the WW1, the importance of SA was deemed critical for the fighter aircraft operations. The aircraft itself, whether in military, commercial or day-to-day civilian use, has undergone radical changes owing to the singular importance of SA in flying it successfully. The design parameters have been altered to make it more congenial for the purposes of improving SA of those flying it. The main factors that the pilot manning the aircraft encounters are those of the incessantly and rapidly changing aircraft parameters, conditions prevailing outside, the data provided by navigational systems as also the presence of other aircrafts and any other intruding condition (Thatcher and Kilingaru, 2012; Kilingaru et al., 2013). A complete and precise scenario has to be ingrained and updated continuously by the aircrew to safely achieve his goals. The smallest of error or oversight can result in disastrous situations (Durso, and Manning, 2009). On the ground the SA capabilities of the Air Traffic Controllers is called upon to navigate the aircraft movement while taking-off and landing procedures. The parameter of minimum safe distance from other aircrafts has to be assured while keeping in perspective the destination and speed of other aircrafts (Endsley, 1995; Durso, and Manning, 2009). The increasing traffic has made the task even more reliant on the SA capabilities of the ATC personnel. The job of safety becomes even more complex given the 3D nature of cognition required for assessing the dynamics involved.

The concept of situation awareness

Endsley (1988) chose to define Situation awareness as the assimilation of individual components within the confines of time and space, their significance to the whole system and the estimation of their values in foreseeable future.

Thus the three stages in which SA can be grouped under are level 1: understanding all critically important factors; level 2: the relative contribution of each factor to the aim of safe operation and Level 3: anticipating changes in the system based on anticipating variations in the independent factors known thus far. A better operational success rate can be achieved only by a better decision making based on these higher SA levels (Endsley, n.d.).

Level 1 SA - Perception of the Elements in the Environment.

The primary step in practices of effective decision making is the SA of the status displayed on the aircraft, its relevance to the overall picture and the inter-play of the data thus obtained. The pilot needs to be aware of the terrain, other planes and other indicating lights and sign ages. The pilot faces an overwhelming assortment of… [END OF PREVIEW]

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