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# The Multitasking Myth: Handling Complexity in Real-World Operations

## Abstract

Despite growing concern with the effects of concurrent task demands on human performance, and research demonstrating that these demands are associated with vulnerability to error, so far there has been only limited research into the nature and range of concurrent task demands in real-world settings. This book presents a set of NASA studies that characterize the nature of concurrent task demands confronting airline flight crews in routine operations, as opposed to emergency situations. The authors analyze these demands in light of what is known about cognitive processes, particularly those of attention and memory, with the focus upon inadvertent omissions of intended actions by skilled pilots. © Loukia D. Loukopoulos, R. Key Dismukes and Immanuel Barshi 2009. All rights reserved.
... According to Loukopoulos et al. (2009), operating an aircraft requires the use of three main cognitive processes: prospective memory, automatic processing, and switching attention between ...
... Instead, they often must shift or divide their attention among tasks. Pilots exposed to multitasking of this type or to new situations tend to commit more errors, sometimes unknowingly, even when they have extensive experience (Loukopoulos et al., 2009). Many such errors tend to be the result of attentional tunneling, an excessive attentional focus on a specific channel of information irrelevant to the task goal (Wickens & Alexander, 2009). ...
... For example, simple tools such as checklists and protocols can be used in the initial stages of a task to ensure that all procedures have been accomplished. This tends to lighten soldiers' workloads because their memory systems are not taxed by having to explicitly recall components of every task (Loukopoulos et al., 2009). Part-task automation, that is the usage of systems designed to carry out part of a task independently from the operator, can also be used to assist workers. ...
Article
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... They are good at resolving unexpected or emergency situations, and at finding ways to make systems work. Although some people pride themselves on their ability to 'multitask' -carrying out several tasks simultaneously -there is evidence that this practice causes errors and omissions which may seriously affect performance (Loukopoulos, 2009). Most systems including operators tend to be 'event-driven' -where operators respond to cues from the system. ...
... Where it is not easy to contact the other controller, communications may be 'saved up' mentally, and several messages passed in one call. Loukopoulos and his colleagues discuss the pitfalls of this situation in their book "The Multitasking Myth" (Loukopoulos, 2009). ...
... It should not be necessary for the controller to leave the action and return to it later. Multi-tasking of this sort risks errors and omissions, and, by the controllers' own accounts, increases the strain on them (Loukopoulos, 2009). ...
Book
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The current Air traffic system is a ‘Kludge’ - an unplanned accumulation of expedients. Tools and equipment have been adopted and adapted from other systems with no strategic oversight. It works, and is safe, but no one really knows how safe it is, where it is weak or how it can be improved. This book describes the current system, showing some of its weak points. It sketches the process of defining a revised system, looking at the human contribution and at possible developments using currently available technology. The product of 32 years of practical study and a further ten years of deeper analysis, it points the way to a cheaper, safer and more humane system. (The views expressed in this book are the author’s own and are not necessarily endorsed by EUROCONTROL or its management.)
... During airborne emergencies, this requires a great deal of attention directed toward resolving the detected hazard that degrades the flight safety by increasing the pilot workload significantly. Research studies [1][2][3][4] address the consequences of multitasking on human brain and the ability to simultaneously deal with several parameters [5] as needed for cockpit monitoring by the human pilot. ...
... The set of Eqs. (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12) provides the combined degree of beliefs for the low, normal, and high grades that are further used for the decision making about a normal or abnormal flight situation. Figure 4 represents a sequential flow of the mathematical steps to measure the combined degree of beliefs for all grades. ...
Article
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During in-flight emergencies, a pilot’s workload increases significantly, and it is often during this period of increased stress that human errors occur that consequently diminish the flight safety. Research studies indicate that many plane crashes can be attributed to ineffective cockpit instrument monitoring by the pilot. This paper entails the development of Flight Guardian¶ system being first of its kind that aims to provide efficient flight-deck awareness to improve flight safety while assisting the pilot in abnormal situations. The system is intended to be used in older aircraft that cannot easily or cost effectively be modified with modern digital avionic systems. One of the important features of the Flight Guardian system is being not physically connected to the aircraft, which avoids any impact on airworthiness or the need for recertification. For the first time, a composite of techniques including video analysis, knowledge representation, and machine belief representations are combined to build a novel flight-deck warning system. The prototype system is tested in both simulation-based laboratory and real flight environments under the guidance of expert pilots. The overall system performance is evaluated using statistical analysis of experimental results that proved the robustness of the proposed methodology in terms of automated warning generation in hazardous situations.
... Several lines of research have shown that individuals with limited cognitive control functions, due to, for example, delayed development, brain damage, pathology or aging, have major difficulties in handling and coordinating multiple tasks and intentions within limited time frames (Burgess et al., 2000;Craik & Bialystok, 2006;Mackinlay, Charman, & Karmiloff-Smith, 2006;Shallice & Burgess, 1991). On the other hand, highly trained experts in diverse fields can monitor and coordinate multiple tasks with seemingly limited effort (Chisholm, Dornfeld, Nelson, & Cordell, 2001;Loukopoulos, Dismukes, & Barshi, 2009;Wickens, 2008), supporting the idea that these control demands of complex task coordination can be offloaded by relying on overlearned action scripts, schemas, and related knowledge structures. ...
... Experts are better than nonexperts in handling multiple tasks (e.g. air traffic control, Loukopoulos et al., 2009; preparing a breakfast in one's own kitchen), and individuals with better executive functions are typically more effective multitaskers than individuals with less competent control functions (Redick et al., 2016;Shallice & Burgess, 1991). However, in many novel or complex situations, overlearned scripts and schematic knowledge structures are not relevant (or even interfering) for handling executively demanding task coordination (cf. ...
Article
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... Simple, rule-like work methods are useful in circumstances of high pressure like those found in cockpits, because reflecting on knowledge and making decisions in a more improvisational manner is extremely hard (Rasmussen, 1983). Yet to manage complex interactions that arise from complex, computerized systems (Leveson et al., 2009), linear procedures are not well-suited (Loukopoulos, Dismukes & Barshi, 2009;Dekker, 2012). Strong sensing practices-that is, sensitivity to dynamics and nonlinearity of socio-technical systemsare required to operate resiliently (Weick et al., 1999). ...
... In this type of work has also been termed concurrent task management. The research on multi-tasking has addressed circumstances in which we divide our attention among multiple tasks or information streams [10]. ...
Conference Paper
A recent survey suggests that 10.2% of software developers work as independent contractors, freelancers, or are self-employed. Whether they fully or only partly depend on gig work for their income, or work in traditional organizations, most software developers must concurrently work on multiple projects with multiple teams across a variety of software development platforms. This creates a complex and fragmented work environment for developers. We refer to this phenomenon as Multiple Team Membership (MTM). Utilizing a multi-method study, our goal is to develop a deeper understanding of MTM in software development by first developing and then empirically testing a research framework that can contribute to the broader context of research on software development challenges in the gig economy.
... Specific interventions can be developed to train operators to make a mental note of their "place" and next step needed in an ongoing task, prior to shifting attention. This intervention supports prospective memory, and is an effective technique for improving interruption management (Dismukes & Nowinski, 2006;Loukopoulos, Dismukes & Barshi, 2009). ...
Article
The operators of unmanned aerial systems (UAS) have multiple screens of information they need to monitor, and numerous interruptions that challenge them in their work. Research on attentional training has revealed that it is possible to train operators to improve their visual scanning, prioritization, and interruption management performance. This paper describes the analyses that were conducted to identify the information processing requirements associated with UAS tasks and the integration of findings into a prototype attentional skills training tool. This tool uses adaptive scenario-based training to improve the attentional management skills of UAS sensor operators.
... O ile jeszcze stosunkowo dobrze można sobie poradzić z przerzucaniem uwagi, to już niemożność skupienia się na jednym z przedmiotów ogranicza zdolność jego poznania, w pamięci pozostają jedynie ślady informacji, z których trudno sensownie odtworzyć obraz rzeczywistości. Tymczasem tylko pełne skupienie uwagi na czynności sprzyja przenoszeniu informacji z pamięci roboczej do pamięci trwałej -długoterminowej (Loukopoulos, Dismukes, Barshi, 2009). Wielozadaniowość sprowadzać może proces uczenia się nie tylko do powierzchownego pozyskiwania danych, ale wręcz popełniania błędów i pogorszenia efektów pracy. ...
Article
Full-text available
The aim of the paper is to present, against the background of current challenges of managing academic didactics, the desired formula of goals in academic teaching, the implementation of which will strengthen the status of higher education institutions on the one hand, and enable their graduates to experience effective professional practice on the other. The essence of academic education is presented, paying attention to the distinction between “transfer of knowledge” and “practicing science”. The main challenges of managing academic didactics faced by higher education institutions are pointed out and discussed. These included: quick obsolescence of knowledge acquired in higher education institutions, inconsistency of the academic teacher-student relationship and developmental disparities of the cognitive abilities of modern students. A new formula of teaching objectives including three dimensions is proposed, namely: (1) development of specialist knowledge and skills; (2) development of general knowledge and formation of attitudes; and (3) training in scientific research and development of cognitive abilities. The presented formula of teaching objectives was based on the assumption that all indicated dimensions should complement each other and create a compendium of coexisting activities. Teaching is not limited to transferring knowledge as the results of earlier research, but makes its deeper understanding and development of individual abilities possible, which in turn allows one to function effectively in a complex, changing reality. The paper was prepared on the basis of literature studies in the field of modern academic education, mainly from the last 10 years. It was shown that to overcome the discrepancy between professional knowledge and the development of individual skills visible in the current syllabuses, it is important to give educational goals a dimension of “science” taking into account the participation of students in scientific research and enabling the achievement of a broader development profile. Keywords: higher education institution, educational process, teaching goals, challenges of managing academic didactics.
... Yet, media multitasking relies on self-report questionnaire which is prone to response bias (Paulhus, 1991) and reflects the respondents' perception of their own multitasking experiences rather than their real multitasking behavior (e.g., Carrier, Cheever, Rosen, Benitez, & Chang, 2009;Lui & Wong, 2012). However, the ubiquitous requirement of multitasking ability is present in many workplaces for numerous occupations, including organization management (Mark, Gonzalez, & Harris, 2005;Sanderson, Bruk-Lee, Viswesvaran, Gutierrez, & Kantrowitz, 2013), medicine (Chisholm, Dornfeld, Nelson, & Cordell, 2001;Ferris & Sarter, 2011), and military/aviation (Loukopoulos, Dismukes, & Barshi, 2009). ...
Article
... Thus, a recall of registered key elements related to a past situation or the direct access to it supports the efficiency of Multitasking [17]. However, it shouldn't be neglected that even well-trained "experts" are accident prone when it comes to Multitasking [18]. Next to task difficulty and training, [19] argue that the performance of Multitasking depends on the task combination. ...
Conference Paper
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Providing air traffic service to more than one aerodrome is a key concept within Remote Tower. So-called Multiple Remote Tower Operations (MRTO) are expected to be more cost-efficient and user-friendly. On the one hand, their anticipated benefit is to maintain smaller airports that are currently non-profitable due to low traffic numbers, high staff- and tower maintenance costs. On the other hand, MTRO offer equally distributed and constant activity for air traffic controllers (ATCOs), with the expectation to lower risks of human error due to boredom or sleepiness at work. However, multiple tasking challenges arise if one ATCO needs to handle traffic at three airports simultaneously. Thus, combinations of visual, audio, vocal and haptic tasks need to be performed for more than just one location. Therefore, this paper addresses the impact of simultaneous movements on perceived safety, workload and task difficulty. Descriptive results show that with the increase of simultaneous movements, providing ATC is perceived as being more efficiency-critical, more demanding in workload and task difficulty increases as well. It was not tested if the differences were significant, since statistical conditions haven’t been met. Results show that no situation containing simultaneous movements was perceived as a threat to safety, good workload or the ability to provide ATC. The discussion shows why the impact of simultaneous movements might not only affect MRTO but also single remote or conventional tower environments.
... Novices tend to appreciate and apply procedures (Nordsteien & Byström, 2018); when they resort to holistic thinking they often lack the experience to do it competently. Conversely, insisting that experts comply with procedures and think analytically may degrade their performance but also help avoid occasional oversights (Hammond et al., 1987;Loukopoulos et al., 2009). ...
Article
Full-text available
Professional work is often regulated by procedures that shape the information seeking involved in performing a task. Yet, research on professionals’ information seeking tends to bypass procedures and depict information seeking as an informal activity. In this study we analyze two healthcare tasks governed by procedures: triage and timeouts. While information seeking is central to both procedures, we find that the coordinating nurses rarely engage in information seeking when they triage patients. Inversely, the physicians value convening for timeouts to seek information. To explain these findings we distinguish between junior and expert professionals and between uncertain and equivocal tasks. The triage procedure specifies which information to retrieve but expert professionals such as the coordinating nurses tend to perform triage, which is an uncertain task, by holistic pattern recognition rather than information seeking. For timeouts, which target an equivocal task, the procedure facilitates information seeking by creating a space for open-ended collaborative reflection. Both junior and expert physicians temporarily suspend patient treatment in favor of this opportunity to reflect on their actions, though partly for different reasons. We discuss implications for models of professionals’ information seeking.
... For these reasons there is a growing body of both laboratory and field research examining PM using air traffic control tasks. These studies have shown that PM produces numerous performance costs, including slower acceptance and hand-off of aircraft, slower detection of conflicts between aircraft, and increased rates of missed conflicts (Loft, Chapman, & Smith, 2016;Loft, Finnerty, & Remington, 2011;Loft, Pearcy, & Remington, 2015;Loft, Smith, & Remington, 2013;Loft & Remington, 2010;Loft, Smith, & Bhaskara, 2011;Loukopoulos, Dismukes, & Barshi, 2009). These costs observed by Loft and colleagues, which affected both accuracy and RT, appear more consistent with resource sharing than increased thresholds, inconsistent with the results from basic PM paradigms in which raised ongoing task thresholds typically allow participants to maintain similar ongoing task accuracy in control and PM blocks (e.g., Ball & Aschenbrenner, 2017;Heathcote et al., 2015;Horn & Bayen, 2015;Strickland et al., 2017Strickland et al., , 2018). ...
Preprint
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... Standardised work tasks in the form of checklists have also introduced higher risks in missing safety critical steps in the work task during time constraints resulting in task deviation (Loukopoulos et al., 2009). Some checklists designed to have high number of steps to be taken in specific order. ...
Article
The high frequency of maritime accidents and incidents occurring at sea has been a major challenge for the maritime industry in the last decades. The majority of these accidents are attributed to seafarers’ poor performance. This, despite the fact that the international maritime domain continues to adopt and update conventions regulating maritime safety to mitigate these accidents from occurring. In this paper, utilising a qualitative research approach, we show through a socio-cultural contextual perspective that time constraints as a major influencing factor in causing task deviations at sea which leads to dangerous situations. We analyse how some of the present barriers in place to prevent accidents at sea are in effect prompt seafarers who are working under time pressure to deviate from their task. Moreover, the paper discusses the social constituents such as job insecurity and the seafarers’ viewpoint towards the ship operators’ commitment to safe ship operations are crucial in motivating seafarers’ deviating from the task at hand when faced with time pressure.
... Coviello et al. (2014) demonstrate a multitasking pheromone existing in an Italian court, in which judges are assigned new cases every morning, and at the same time they need to process cases which are already in the pipe. Loukopoulos et al. (2009) investigate the problem that pilots have to read multiple sources of data over the panel and at the same time listen over his headset the enquiries and instructions from the air traffic control tower to ensure that the plane can safely take off and land. For more results related to multitasking, the reader may refer to Trafton et al. (2003), Watson and Strayer (2010), Seshadri and Shapira (2001), Monsell (2003), Rosen (2008), Ophir et al. (2009), andMayer andMoreno (2003). ...
Article
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This paper addresses a two-agent scheduling problem with due date assignment under multitasking environment, in which the due dates of the jobs from the first agent are decision variables to be determined using the unrestricted (usually referred to as DIF) due date assignment method. Each agent requests the processing of its own set of jobs on a machine and wishes to minimize a certain scheduling criterion related to the completion times of its jobs only. Under multitasking, when a job (primary job) is processed, it is inevitably interrupted by other jobs (waiting jobs) that are available but unfinished, and the amount of time that each waiting job interrupting the primary job is a linear function of the remaining processing time of the waiting job. The overall objective is to determine the optimal primary job sequence along with the due dates of the jobs from the first agent as to minimize the weighted sum of the due date assignment cost and weighted number of late jobs from the first agent, while maintaining the total completion time of the jobs from the second agent not exceeding a given threshold. We show that the problem is $$\mathcal {NP}$$-hard, devise a pseudo-polynomial time dynamic programming algorithm, establishing that it is $$\mathcal {NP}$$-hard in the ordinary sense, and demonstrate that it admits a fully polynomial-time approximation scheme.
... They have to put the primary task into their prospective memory and suspend it to handle the interruption or they have to handle the primary task and interruption simultaneously. However, various accident reports show that people are vulnerable to lapses in prospective memory [102] or unreliable in multi-tasking [103]. It is easy for an individual to reduce attention to the primary task, miss critical changes related to the primary task, or forget the elements of the interrupted primary task and lose situation awareness [101], because of attention conflict or overload. ...
Article
Human reliability analysis (HRA) still heavily relies on expert judgments to generate reliability data. There exists a widely recognized need to validate and justify the reliability data obtained from expert judgments. For demonstrating such effort, we provide a template of how we base expert elicitations and empirical studies to derive the multipliers of performance shaping factors (PSFs). We applied two expert judgment techniques—absolute probability judgment (APJ) and ratio magnitude estimation (RME)—to update the PSF multiplier design in Standardized Plant Analysis of Risk-Human Reliability Analysis (SPAR-H). Licensed operators (N = 17) from a nuclear power plant were recruited. It is found that APJ and RME have acceptable inter-rater reliability and convergent validity between them. The multipliers estimated by APJ and RME were compared with those from empirical studies in the human performance literature. Certain consistencies between these heterogeneous data sources were found. Combining these heterogeneous data, we suggested the multiplier design of PSFs for SPAR-H. We also bridged the relationship between every PSF and its psychological mechanism to trigger human errors. Our work might suggest the appropriateness of expert elicitations in generating useful data for HRA, and strengthen the empirical and psychological foundations of PSF-based HRA methods.
... Much of the research to date has been centered on using attributes from the task domain (Altmann et al., 2014;Iqbal and Horvitz, 2010). However, there are other aspects surrounding the problem of determining when to interrupt a user (Loukopoulos et al., 2009). These other aspects involve the user and environment contexts. ...
Article
... Workload is usually greater on the larger, wide-bodied aircraft, such as the 747, 777, or A340, due to the longer travelling distances from front to rear of the cabin, higher passenger-to-flight attendant ratios, and more stretching across rows of seats (8). ...
Article
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The purpose of the study was to assess the effect of workload on low back pain among Kenyan Airline operating at Jomo Kenyatta International Airport. The research study adopted descriptive research design and tar attendants of Kenyan Airlines operating at JKIA with a sample size of 285 respondents. The data collection tool was questionnaire that was self-administered through drop and pick. Data was analyzed using Stata 13 to aid in th descriptive and inferential statistics. The response rate of 96.1% (274 respondents) was attained. Results should that highest effect on low back pain with a coefficient of 0.068. The main recommendation of the study is that both ICAO reexamine the regulations pertaining to the number of hours a flight attendant should work within a specific period o
... 6 In aviation, changes to cockpit practice successfully eliminated interruptions and multitasking. 7 Understandably then, there is a pervasive assumption among those who study clinical work that interruptions contribute negatively to safety and efficiency of clinical work and that changes could be made to practice to minimize or even eliminate their effects. 8 Read the introduction of just about any interruption study in health care, Fong and Ratwani included and there will be some framing of interruptions as potentially negative, even if the aim is not to assess associations between interruptions and negative outcomes. 2 However, despite well over 100 studies describing and examining various aspects of interruption in clinical work, a critical examination of the literature does not yield a clear evidential consensus in support of negative effects. ...
Article
... The incoming calls through available communication systems on the ship's bridge are identified as one of the important distracting elements influencing an OOW [15][16][17]. The incoming calls, as well as notification of different systems' alerts, demand the immediate attention of the OOW, i.e., in the moment of occurrence, without "choosing" a suitable moment. ...
Article
The tasks of an officer of the watch (OOW) on complex ships during navigation in coastal areas may be very challenging. Almost all the tasks require substantial information processing and timely decision making. Every distracting element should be avoided during navigation. Every call, made through any communication system, activates a new process that the OOW needs to conduct. The new process may interrupt a previously started task. In case of too many incoming calls, the workload of the OOW may increase significantly, thus, their situational awareness may be compromised and the risk of errors may increase. The objective of this research was to analyze the impact of incoming voice calls on the OOW. The research methods used include a questionnaire survey and a series of interviews with experienced officers. The main outcomes refer to the average frequency of incoming calls, duration of conversations and subjective assessment of their influence. The results indicate that, during one watch, an officer needs to answer 14 calls that last 16.19 min altogether. However, the officers consider 45% of calls made during watch keeping as distracting. A possible call management system with the aim to reduce distractions made by low priority calls is proposed in this paper.
... However, it appears that the human mind quickly switches between multiple tasks rather than performing many simultaneously. Switching between tasks creates a cognitive demand that goes beyond performing each task separately [9]. IOP Conf. ...
Article
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To date, autonomous shipping appears to primarily have been about a technology push rather than considering and providing sociotechnical solutions including re-design of work, capturing knowledge and addressing human factors in modern shipping. Autonomous shipping is frequently claimed to reduce human error, whereas in reality, any issue connected to humans will arguably move with the people from ship to shore in that different people will make different mistakes; with possibly more severe consequences. Furthermore, autonomous shipping is likely to require changes to regulation and increased attention to cyber security and other IT human-centred quality factors if it is to succeed. What the HUMANE project is interested in is how (in certain scenarios) the human collaborates with, hands over to, or takes over from the technology/automation to achieve an overall safe state of the system. The aim is to map and investigate a potential gap between current human skills, training and education and an autonomous maritime future, and to provide insight to enable mitigating change. The main project method is expert workshops, performed in a focus group style. Four workshops are planned and to date (mid 2019), two have been performed. The topic of the first was technology, and the second was legal, class and insurance implications. For this paper, we have analysed the data relevant to future skills. Results show that not only is the skill set imagined to be needed very different from that of today, it also contains many contradictory elements and, occasionally, demands for abilities that humans do not possess, and are unlikely to evolve.
... The SOP present idealized picture: tasks are linear, predictable, and under moment-to-moment control of the crew. Whereas, the reality is opposed: execution of procedures is frequently perturbed by interruptions, situations change dynamically, and tasks must be performed concurrently (Loukopoulos et al., 2009). Pilots must juggle multiple tasks concurrently, and always have to remember to perform deferred task or perform task out of normal sequence. ...
Article
Pilot performance reliability is critical to civil air transportation safety. Internal and external factors influencing pilot performance reliability are important elements to estimate human error probability. However, dependencies between these factors, including state dependencies and effect dependencies, are always ignored or only partially considered in most human reliability analysis (HRA) method. This paper attempts to develop a methodology incorporating both state and effect dependencies between contributory factors into HRA for airline pilot tasks based on fuzzy logic and the Cognitive Reliability and Error Analysis Method (CREAM). Anchor points were determined for each common performance condition (CPC) state levels through airline pilot elicitation process and then corresponding state and effect fuzzy sets were constructed for each CPC. The CPC dependency fuzzy inference rules were constructed and transformed with reference to the CPC dependency assessing rule in CREAM. And a cognitive failure probability (CFP) calculation method based on the final CPC effect fuzzy sets and the extended CREAM was proposed. To illustrate the use of the proposed methodology, a case study about commercial airline pilot taxiing task was given. The results demonstrate the validity of the proposed methodology and its capability of representing the ambiguity and fuzziness of expert judgement.
... Interrupting one task to perform another causes delays in resuming the initial task and lowers performance [44][45][46][47][48][49][50][51][52][53] . Multitasking is also associated with decreased overall performance [54][55][56][57] . ...
... Unexpected interruptions and distractions are even more difficult to manage. In their book on the demands for multi-tasking in real-world operations, Loukopoulos, Dismukes, & Barshi (2008) describe the range of assaults on the flight crew, which includes operational demands to keep moving, delays in getting flight information, changes to weather and, therefore, flight planning, disruptions due to passenger behavior or illness, and airplane system failures that need to be addressed. The potential list is long, and each item can require the flightcrew to stop what they are doing and attend to some emerging need. ...
Technical Report
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The commercial aviation industry world-wide has identified a need for improved pilot monitoring and awareness (e.g., FAA, 2013, ICAO, 2016). More specifically, aviation safety data indicate that failures in pilots’ flight path management (FPM) monitoring and awareness have contributed to a range of undesired outcomes: accidents, major upsets, and non-compliance with air traffic control (ATC) guidance. The Federal Aviation Administration (FAA) has further stated that these types of FPM failures are likely to worsen with the increasingly complex air traffic control systems and FPM concepts proposed for NextGen (https://www.faa. gov/nextgen/what_is_nextgen/) operations (e.g., see Hah et al., 2017). Adding to this complexity is the introduction of increasingly automated aircraft systems that can increase monitoring burdens. One potential mitigation for this situation is to enhance pilot training for effective monitoring. NASA Ames Research Center was asked to identify and evaluate training approaches that have the potential to enhance pilots’ ability to effectively monitor for FPM (with the result of improved awareness). The focus of this work is to identify, develop or validate training guidance to improve pilot monitoring/awareness regarding FPM and mitigate the recent trend of accidents and incidents, especially loss of control (LOC) events. The result of this work should be input for improved industry standards and FAA guidance to reduce the risk of incidents and accidents due to inadequate pilot monitoring/awareness. This is the first of three reports that were developed for this project.
... The pilot must manage the interruption and return to the task that was partially completed. Prospective memory-reminding oneself to return to these activities-can be fragile (Loukopoulos, Dismukes, & Barshi, 2009). • Search is strongly biased toward finding an expected target, not an unexpected target. ...
Technical Report
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This report is part of a series of reports that addresses flight deck design and evaluation, written as a response to loss of control accidents. In particular, this activity is directed at failures in airplane state awareness, in which the pilot loses awareness of the airplane’s energy state or attitude and enters an upset condition. Another report in this series of reports speaks directly to flight deck evaluation methods and metrics for the types of attention and awareness issues that were revealed from the airplane state awareness events. In this report, we describe a wide range of flight deck evaluation issues tied to flight crew performance. The objectives are to establish a framework for thinking about how the flight deck interface should support the performance of the flight crew, and to aid the Federal Aviation Administration (FAA) in identifying relevant human performance issues during the evaluation/certification process. Issues are broken out into sections that cover physical ergonomics, design for usability, data integration and display content, attention and task management, flight crew problem solving, and flight crew teaming. For each issue, we recommend specific ways that the flight deck interface should support the flight crew. For each, we also identify existing 14 CFR Part 25 rules and guidance that are relevant to the issue. This allows the FAA to determine what current regulatory materials can support them in raising the issue with the applicant.
... Pilots must identify events with enough precision so that the correct response protocol is followed. The real-world, however, can display a variety of dynamic events not captured in operating manuals or training encounters (Loukopoulos et al. 2009). For example, periodic episodes of stimuli, where cues do not show a continuous, intelligible system state or trend. ...
Article
Full-text available
Some safety events do not stabilise in a coherent state, presenting with transient or intermittent features. Such dynamism may pose problems for human performance, especially if combined with non-typical stimuli that are rarely encountered in everyday work. This may explain undesirable pilot behaviour and could be an important cognitive factor in recent aircraft accidents. Sixty-five airline pilots tested a real-world typicality gradient, composed of two cockpit events, a typical event, and a non-typical event, across two different forms of dynamism, a stable, single system transition, and an unstable, intermittent system transition. We found that non-typical event stimuli elicited a greater number of response errors and incurred an increased response latency when compared to typical event stimuli, replicating the typicality effect. These performance deteriorations were amplified when a form of unstable system dynamism was introduced. Typical stimuli were unaffected by dynamism. This indicates that dynamic, non-typical events are problematic for pilots and may lead to poor event recognition and response. Typical is advantageous, even if dynamic. Manufacturers and airlines should evolve pilot training and crew procedures to take account of variety in event dynamics.
... In clinical applicability view, patients with neurological disorders are greatly benefited from use of hybrid V-BCI for consciously control of devices in their surrounding environment and for their own movements. From the entertainment view, ability to control objects directly using their brain would be fascinating to humans, for example telekinesis [12]. There are numerous factors that affect success of direct control. ...
... Especially problematic was the task of remote manual control; at a time when it is needed it is unlikely that the operator will be able to focus on anything else. This fits with some researchers' models for multitasking which posit that humans are more adept at switching between individual tasks than performing multiple tasks simultaneously, and that this task switching requires cognitive effort [15]. In the case of manual control in the SCC, an unknown amount of time will be needed for this effortful task switching -time that may be safety critical. ...
Conference Paper
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Technology driven innovation has been advancing the development of autonomous ships and their Shore Control Center (SCC) counterpart. We plot a stakeholder map focused on the SCC based on data collected in a workshop and semi-structured interviews containing ten (10) Subject Matter Experts. The results identify key stakeholders and their interconnected relationships. Furthermore, insights from the qualitative data highlight important human factor issues of SCC operators that can be put into organizational context using the stakeholder map. The contribution is a tool designers can use to understand of the business model and the needs of the SCC customer, technology developer, and operators. Considering the operator's stake in autonomous shipping and the human factors issues that are expected in the SCC, the case is made for a Human-Centered Design (HCD) process to run concurrently with the technology innovation.
... Weiterhin kommt hinzu, dass der Operateur nur bei der Bearbeitung der Primäraufgabe an deren hierarchisch sequentielle Struktur gebunden ist. Nach der Handlungsregulationstheorie (Hacker, 1986(Hacker, , 2005 Siegrist et al., 2010;Loukopoulos et al., 2009;Bailey & Konstan, 2006;Salvucci, 2005;Wild et al., 2004). Hervorgerufen werden kann dies z.B. durch erhöhte Arbeitsgedächtnisleistung sowie beeinträchtigtes Situationsbewusstsein (Brumby et al., 2007;Bailey & Konstan, 2006). ...
Conference Paper
Der vorgestellte Ausschnitt einer Forschungsarbeit zentriert die Frage: Wie können schon in der Gestaltungsphase einer Benutzungsoberfläche, unabhängig von der Expertise des Designers, die zusätzlichen informatorischen und arbeitsorganisatorischen Anforderungen durch Mehrfachaufgaben Berücksichtigung finden? Um sich dieser Fragestellung zu nähern, wird eingangs ein Überblick über die daran beteiligten Forschungsfelder gegeben (siehe Abbildung 1), z.B. Task Switching und Ecological Interface Design. Parallel zur Erläuterung des theoretischen Rahmens folgt die Beschreibung des Anwendungskontextes Leitzentralen von Schleusen an Bundeswasserstraßen der Wasser- und Schifffahrtsverwaltung des Bundes. Der Anwendungskontext wird weiterführend mittels Arbeitsgebietsanalyse und Abstraktions-Dekompositions-Matrix beschrieben. Auf die Präsentation dieser Ergebnisse folgen Zusammenfassung und Ausblick.
... According to the researches, the cause of the accidents was the crew error and, in particular, the workload issues and the concurrent tasks. All the pilots were highly experienced, but their performance was undercut by the limited brain ability to switch the attention between concurrent tasks and to remember to perform the postponed tasks [11]. This means that the exposure to high workload could be a major threat for aviation safety, but, on the other hand, low workload leads to boredom and to the decrease of vigilance level. ...
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La présence de sons non pertinents est reconnue pour affecter le fonctionnement cognitif. Plus précisément, la présentation d'un son qui dévie du contexte auditif a le potentiel d'affecter la performance à une tâche réalisée simultanément. Plusieurs études s'intéressant à l'impact délétère des sons déviants sur la performance à une tâche montrent qu'il découle de la réorientation de l'attention déclenchée lorsqu'un son déviant est détecté par l'organisme. Cette capture attentionnelle (ou réponse d'orientation) est également reconnue pour engendrer plusieurs réponses physiologiques associées à l'état d'alerte. Ces réponses physiologiques, sous certaines conditions, sont considérées comme des indices psychophysiologiques de la capture attentionnelle auditive permettant de démontrer l'occurrence d'une réorientation de l'attention de la tâche en cours vers le son déviant. De récentes études suggèrent qu'il existe un lien entre ces indices et la réponse pupillaire, soit l'augmentation rapide du diamètre pupillaire. Quelques études ont tenté d'évaluer si cette réponse pouvait remplir les critères d'un indice valide de la réponse d'orientation; cependant, les résultats de ces études sont parfois contradictoires ou incomplets. La présente thèse propose donc une évaluation systématique de l'utilisation de la réponse pupillaire à titre d'indice psychophysiologique de la capture attentionnelle auditive. Les résultats de la première étude montrent que la réponse pupillaire respecte les critères d'un index valide de la réponse d'orientation, supportant ainsi la validité de cet index. L'Étude 2 montre que cet indice peut être utilisé dans des contextes dans lesquels les sujets effectuent simultanément à l'écoute des sons une tâche visuelle provoquant des changements systématiques de luminosité ou des mouvements oculaires qui affectent la taille de la pupille. Ces expériences appuient ainsi l'utilisabilité de cet index. Enfin, la dernière étude permet d'établir l'utilité de ce proxy puisque ce dernier permet de distinguer l'origine de deux phénomènes de distraction auditive différents. Dans l'ensemble, les résultats de la thèse révèlent que la réponse pupillaire représente un indice psychophysiologique adéquat qui pourrait être intégré aux études sur la distraction auditive ou dans des contextes plus appliqués où les mesures de la capture attentionnelle auditive peuvent s'avérer pertinentes.
Article
Shortcomings of incident‐based metrics such as Total Recordable Incident Frequency Rate (TRIFR) are well‐documented, including the lack of standardization, construct validity, statistical power, and predictive power. A low TRIFR is also no assurance against legal liability. There is considerable overlap between the research literature on safety as the presence of capacities to make things go well, and jurisprudence in labor and workplace safety law. In this paper we suggest an index that merges the two, measuring the capacities to acquire and maintain safety knowledge; to understand the nature of operations; to resource for safety; to respond to risks; to demonstrate engagement and compliance; and the capacity for assurance.
Chapter
Chapter
The high-complexity environment of the flight deck follows the model spoken-heard-understood-applied in the interaction and action of ATC and pilots. Aviation systems require the maximum amount of information expressed with the minimum of effort and consuming the minimum of time. A successful flight is a systemic interactional accomplishment of human performance. This book follows a communication orientation to investigate the knowledge applied; every interaction is based on a first event, time is important, and communication process is a product of what actors have learned, inward, in ways that permit skill and event growth and discovery of knowledge from their awareness. Separation of situation awareness (SA) in types denotes that a practitioner could commit in awareness of any type. ATC needs to sustain GA, for the big picture ahead, while addressing/replying with LA to each flight; TA is necessary for the required separation in the limited airways.
Article
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Efforts have always been deployed to surpass limitations in human cognitive abilities to enhance aspects such as task accuracy, work effectiveness, and error management. Cognitive enhancement is a field aiming at improving human cognition to overcome those limitations. It bears important interest from the human factors community given its potential for reducing errors in complex operational environments, but also for occupational psychology to improve work performance, mitigate risks, and improve job stress/well-being. Yet, cognitive enhancement strategies are still marginally used in practice. The current narrative review presents a brief summary of the literature on human cognitive enhancement and discusses key implications as well as operational applications of the main methods and technologies reported in this field. Using a human factors perspective, the paper also outlines how such techniques could be integrated into intelligent support systems to help operators facing cognitive challenges in complex operational domains, including those experiencing functional limitations preventing them to contribute to the workforce. We also discuss the implications of integrating such techniques into the workplace and the consequences this might incur for workers and stakeholders. Then, we briefly present a five-step guideline to discuss ways of optimally integrating cognitive enhancement methods into the workplace.
Chapter
Silence via storytelling in its multiple dimensions is explained in this chapter, as one of the two pivotal communication phenomena of this study. Ideal flight and actual flight situations are analyzed, experientially, in stages that emphasize silence as a knowledge factor for the flight. Periods of silence are part of the communication process, but the duration of these periods, the way silence breaks into messages, and the consequences of different manifestations of silence are the topics objectified. The protagonists narrate their experiences commenting on scenarios and questions, and the text develops in a dialogic format with conventional alias names: Ikaria Ikaros and Oia Santorinis as ATCs for pilots’ behavior, Eleftherios Venizelos with Ioannis Daskalogiannis as fighter pilots, and Ippokratis Koos as helicopter pilot for the military point of view. All fighter pilots underlined (briefing and) debriefing as an integral part of any mission in the (preflight and) postflight phase. The debriefing is a meta-communication process which retracts the whole flight, provides a mechanism to evaluate human error and safety culture in a systemic way, and cultivates collegiality and leadership. The magic of silence may be needed in some cases, whereas organizational culture and communities practice mindset may dictate corporate fame protection and professional face to be defended. Leadership traits in speaking up and openness in a trusting atmosphere, as well as checklist mnemonics and monitoring with the two-layer redundancy, are explained. Safety culture and situation awareness are also part of the narrative. Knowledge manifestation flows from what is communicated, and actions are knowledge-worthy only when communicated under the circumstances.
Chapter
The exploration of human communication and its consequences to aviation safety delivers a knowledge framework, configuring this chapter. A bottom-up approach from qualitative data gathering to relation identification between actions and interactions with iteration and refinement is described and allows core concepts to emerge with theoretical sensitivity, using a rich depository of data guided by grounded theory (GT). This chapter explains the core concept of situation awareness (local, transitory, and global) as the catalyst of “what we need to know” for aviation safety. Preconceptions, interviews, questioning tools, and an Ishikawa diagram are analyzed, considering operations, cultural, technical, and commercial parameters in aviation realities. A GT approach is the guiding path to knowledge construction through notions of perception, comprehension, projection, sorting, comparing, coding, and reenactment. GT immersion in the data searches for the following knowledge-construction elements: (i) the relevant conditions in which participants act in the various flight-related situations, (ii) how the actors respond to changing conditions and unexpected events, (iii) what are the consequences of their actions or lack of action, and (iv) what is the essence of expertise in critical environments (i.e., the expert complies to the “letter of the rule” and to the “spirit of the rule” or deviates when he/she identifies an exception or exceptional case). Lastly, four schematic figures offer a picturesque description of the above steps of inquiry, depicting the backbone of the study for this book, while cross-references “connect the dots.” The textual aspects found in the experts’ replies are interpreted using with discourse analysis and close reading guidelines.
Chapter
Human communication use of silence and voice in flights and the input both provide in knowledge construction especially in unusual or emergency situations are the core of this book. In addition to voice, the book explores silence (personal, operational, institutional, and regulatory) and its impact towards accomplishing awareness for effective flight communication. Aviation interaction is purposeful, since pilots and controllers develop consciousness of where is the one and where is the other and in what status only when they exchange messages and describe their actions. The voice channel between pilot and controller may contain periods of operating in silence, but voice should restart to have a meaningful exchange of information (with no uncertainty) between their physically distant spaces. Empirical data from this book’s aviation informants include a whole range of instances: from verbal phraseology to truncated messages of hesitation, interrupted messages, and dialogic marking of checklists. So, communication constructs even explicit factual knowledge that must be applied (first perceived) by all participants following SOPs. Human factors analysis is focusing more on conditions and evaluations, whereas in cockpit operation environment, the issue seems to be more on how pilot, crew, and ATC expertise are to be exercised and thus implemented in a dynamic decision-making process.
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Simulations are increasingly popular in employee selection and training. While face valid and engaging, the attributes being assessed are often poorly understood. This study evaluated the extent to which a multitasking assessment based on concurrent memorization, math, visual monitoring, and listening tasks predicted simulated unmanned aircraft vehicle (UAV) mission performance in a military trainee sample (N = 368). Performance was based on accuracy of mission planning, information recall during “Lost Link” conditions, and success in rescuing stranded allies while monitoring the aircraft’s resources. Although scores on the multitasking assessment were only weakly related to performance of pre-flight mission planning tasks completed under static conditions, multitasking was strongly related to overall simulated UAV mission performance, including execution of tasks requiring attending to multiple, dynamic sources of information and shifting attention among concurrent processes and demands. Further, multi-tasking demonstrated substantial incremental validity beyond the traditional measures of cognitive ability that have been used for decades within the US military. Implications, limitations, and recommendations for selection and classification and future research are discussed.
Technical Report
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For some time aircraft manufacturers and researchers have been pursuing mechanisms for reducing crew workload and providing better decision support to the pilots, especially during non-normal situations (Banks & Lizza, 1991; Champigneux, 1995; Matheus et al., 2005). Some of these approaches, such as increasingly autonomous systems, have indeed reduced workload but have also sometimes had the effect of reducing the pilots’ understanding of what the aircraft is doing (Mosier & Skitka, 1996; Sarter, Woods, & Billings, 1997). So too, previous attempts to develop task managers or pilot decision support tools have not resulted in robust and fully functional systems (Banks & Lizza, 1991; Miller & Hannen, 1999). However, the increasing sophistication of sensors and automated reasoners, and the exponential surge in the amount of digital data that is now available create a ripe environment for the development of a robust dynamic task manager and decision support tool that is context sensitive and integrates information from a wide array of onboard and off aircraft sources—a tool that monitors systems and the overall flight situation, anticipates information needs, prioritizes tasks appropriately, keeps pilots well informed, and is nimble and able to adapt to changing circumstances. In this report, we explore fundamental issues associated with the development of such a system. We discuss information automation and associated human factors issues and review the current state of the art of pilot information management and decision support tools. We explore team behavior and expectations to determine how characteristics of effective human-human teams may be operationalized in teams involving humans and automation or autonomous systems. This report includes a review of critical literature and provides the scientific basis and foundation for the development of a truly robust and highly functional dynamic flight, automation, and information management system. Although much of the report is thus, focused on aviation automation, much of our discussion has relevance for automation and autonomous systems in other domains such as sophisticated clinical decision supports (CDS) systems for use in medicine.
Chapter
This chapter reviews Sohlberg and Mateer's classifications and addresses the following attentional components: arousal, selective attention, sustained attention/vigilance, alternating/shifting attention, and divided attention and multitasking. Psychologists have been considering the role of attention in cognition since the end of the nineteenth century when William James distinguished between two modes of attention. The 'active' mode involves top‐down processing related to a person's goals and expectations, and the 'passive' mode is reaction to external stimuli in a bottom‐up way. The Society for Cognitive Rehabilitation has recommended the early identification and rehabilitation of attention deficits. Evidence indicates that there is a high prevalence of attentional deficits across a number of different health conditions and that they often persevere. The chapter suggests that both remediative and compensatory interventions may have positive effects upon attention.
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The goal of this in-the-wild study was to understand how different patient, provider, and environment contexts affected the use of a tablet-based checklist in a dynamic medical setting. Fifteen team leaders used the digital checklist in 187 actual trauma resuscitations. The measures of checklist interactions included the number of unchecked items and the number of notes written on the checklist. Of the 10 contexts we studied, team leaders’ arrival after the patient and patients with penetrating injuries were both associated with more unchecked items. We also found that the care of patients with external injuries contributed to more notes written on the checklist. Finally, our results showed that more experienced leaders took significantly more notes overall and more numerical notes than less experienced leaders. We conclude by discussing design implications and steps that can be achieved with context-aware computing towards adaptive checklists that meet the needs of dynamic use contexts.
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Objective We conducted a systematic review of peer-reviewed articles aimed at the evaluation of certified flight instructors’ (CFI) performance in a training context and a scoping review of potential research avenues given the previously identified gaps. Background As the demand for pilots will continue to grow significantly in the coming decades, so will the demand for CFIs, and for ways to improve their existing performance. Understanding performance factors of CFIs could benefit their training and help meet the increasing demand for pilots. Method State-of-the-art research on the subject was surveyed via a systematic review of performance factors of CFIs and a scoping review to identify areas where other fields of research could inform CFI performance evaluation. Result Only 20 articles since 1965 have directly assessed performance factors of CFIs. Their focus has mostly been on communication and educational processes. The scoping review brings forward concepts from cognitive psychology and psychophysiology as means of improving the current understanding of CFI situation awareness and task management. Conclusion Very little work has been done on CFI situation awareness and task management. These are the two main domains in which psychophysiological tools could provide a clear understanding of the attentional and decisional processes at play while developing situation awareness in a dynamic environment and quantify the task load affecting it.
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Many factors come together probabilistically to affect clinician response to critical events in the operating room; no 2 critical events are alike. These factors involve 4 primary domains: (1) the event itself, (2) the individual anesthetist(s), (3) the operating room team, and (4) the resources available and environments in which the event occurs. Appreciating these factors, anticipating how they create vulnerabilities for error and poor response, and actively addressing those vulnerabilities (before events occur as well as during) will help clinicians manage critical event response more effectively and avoid errors.
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Face aux limites, bien documentées, des indices de sécurité au travail habituels, axés sur la fréquence des incidents, et alors que la jurisprudence a fait valoir une obligation de diligence raisonnable de l'employeur, de nombreux chercheurs préconisent de mesurer, plutôt que les échecs, les ressources – ou capacités – qui font que tout se déroule de façon harmonieuse en temps ordinaire. Les auteurs proposent dans cet esprit un indice des capacités qui englobe six dimensions: la connaissance des enjeux de sécurité, celle des processus opérationnels, les moyens alloués, le suivi des risques, la mise en conformité et les garanties de sécurité.
Conference Paper
In der Planungsphase von Leitwarten werden neben der Gestaltung der Arbeits-mittel und der Arbeitsumgebung auch die Aufgaben geplant. Hierbei ist die Gewährleistung der zeitlichen Vereinbarkeit, unter Berücksichtigung von Sicher-heitszuschlägen, ein erster Schritt in der Aufgabenallokation. Für die Bearbeitung komplexer Aufgabenzusammenhänge müssen die durch nicht planbare, intrans-parente, umfangreiche, dynamische und sich untereinander beeinflussende Aufgabeninhalte entstehenden psycho-mentalen Anforderungen Berücksichtigung finden. Das gelingt mit zeitlichen Sicherheitszuschlägen nur unzureichend, da in Multitaskingsituationen die parallel ablaufenden Prozesse auch parallele Informa-tionsverarbeitung in Echtzeit erfordern können. Der folgende Beitrag zentriert die Frage, wie viel Multitasking ist unter welchen Umständen in der Prozess-überwachung und-steuerung zweckmäßig. Dafür wird das Modell zur Prognose der mentalen Beanspruchung (cognitive task load model) vorgestellt und auf diese Fragestellung angepasst. Anpassungen des Originalmodells werden ausführlich hergeleitet und betreffen die theoretischen Grundlagen sowie die Prognose des Beanspruchungswertes mittels Fuzzy Logik. Um das angepasste Modell zu validieren, wurden die Ergebnisse mit 450 Beanspruchungswerten einer Feldstudie in Verkehrsleitzentralen gegenübergestellt und statistisch ausgewertet.
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A new paradigm was developed to examine prospective memory performance in a visual-spatial task that resembles some aspects of the work of air traffic controllers. Two experiments examined the role of workload (number of aeroplanes that participants directed), delay (between receipt of prospective instructions and execution), and phonological rehearsal. High workload increased prospective memory errors but increasing delay from 1-3 or 5 minutes had no effect. Shadowing aurally presented text reduced prospective memory performance, presumably because it prevented verbal rehearsal of the prospective instructions. However, performance on the foreground task of directing aeroplanes to routine destinations was affected only by workload and not by opportunity for rehearsal. Our results suggest that ability to maintain performance on a routine foreground task while performing a secondary task--perhaps analogous to conversation--does not predict ability to retrieve a prospective intention to deviate from the routine.
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In this study, we developed a framework for the study of interruptions in distributed team environments from the perspectives of distributed cognition and activity theory. The core of this framework is the Action Coding System (ACS) that provides a language for the description, representation, categorization, and analysis of interruptions at the level of activities that are meaningful for team performance. We demonstrated the practical utility and theoretical significance of ACS in an its application to a real-world, complex, dynamic, and mission critical environment--the Biomedical Engineer (BME) console in the Mission Control Center at NASA's Johnson Space Center. We discussed the potentials of our framework for the design of interruption management systems that could potentially eliminate some interruptions by information redesign, delegate others to autonomous agents, and help human agents to better manage the rest.
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In 3 experiments, the authors examined the role of memory for prior instances for making relative judgments in conflict detection. Participants saw pairs of aircraft either repeatedly conflict with each other or pass safely before being tested on new aircraft pairs, which varied in similarity to the training pairs. Performance was influenced by the similarity between aircraft pairs. Detection time was faster when a conflict pair resembled a pair that had repeatedly conflicted. Detection time was slower, and participants missed conflicts, when a conflict pair resembled a pair that had repeatedly passed safely. The findings identify aircraft features that are used as inputs into the memory decision process and provide an indication of the processes involved in the use of memory for prior instances to make relative judgments.
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The role of aviation safety measures concerned with the crew monitoring and cross-checking based approaches is discussed. Monitoring and cross-checking achieve the functions of apprising the crew with the current status of the aircraft and also help them catch their own errors. The affects of inqdequate monitoring and the involvement of human factors are also discussed.
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This report, using illustrations from the taxi-out phase of flight, is part of alarger study of the cognitive demands of concurrent task management. We also discuss potential countermeasures
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Cockpit task management (CTM) is the management level activity pilots perform as they initiate, monitor, prioritize, and terminate cockpit tasks. To better understand the nature and significance of this process, we conducted 3 empirical studies: a review of National Transportation Safety Board aircraft accident reports, a review of Aviation Safety Reporting System aircraft incident reports, and a simulator experiment. In the accident report study, we determined that CTM errors occurred in 76 (23%) of the 324 accidents we reviewed. We found CTM errors in 231 (49%) of the 470 incident reports we reviewed. In the simulator study, we found that CTM performance was inversely related to workload. We conclude that CTM is significant to flight safety and recommend that this realization be reflected in pilot training, in cockpit procedures, and in research to develop pilot aiding systems.
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