AIR TRAFFIC CONTROL: HUMAN PERFORMANCE FACTORS

This book is for all those air traffic controllers, past, present and future to
whom excellence is the minimum.

The operator sits in the light of the lamp,

dutifully setting down figures; the mechanic
ticks offpoints on his chart; the pilot swerves
in response to the drift of the mountains as
quickly as he sees that the summits he intends
to pass to the left have deployed straight ahead
of him in a silence..... and below on the ground
the watchful radio men in their shacks take
down submissively in their notebooks the
diction of their comrade in the air "12.40am
enroute 230, all well".

Antoine de Saint-Exupery, 1939.

Air Traffic Control: Human
Performance Factors

ANNE R. ISAAC
with
BERT RUITENBERG
First published 1999 by Ashgate Publishing

Published 2016 by Routledge

2 Park Square, Milton Park, Abingdon, Oxon 0X14 4RN
711 Third Avenue, New York, NY 10017, USA

Routledge is an imprint of the Taylor & Francis Group, an informa business

Copyright © Anne R. Isaac with Bert Ruitenberg 1999

All rights reserved. No part of this book may be reprinted or reproduced or

utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.

Notice:
Product or corporate names may be trademarks or registered trademarks, and
are used only for identification and explanation without intent to infringe.

British Library Cataloguing in Publication Data

Isaac, Anne R. ReP
Air traffic control : human performance factors
1.Air traffic control 2.Aircraft accidents - Human factors
3.Aircraft incidents - Prevention
I.Title II.Ruitenberg, Bert
387T40426

Library of Congress Cataloging-in-Publication Data

Isaac, Anne R ., 1953-
Air traffic control : human performance factors / Anne R. Isaac
with Bert Ruitenberg.
p. cm.
Includes bibliographical references and index.
ISBN 0-291-39854-5
1. Air traffic control-Psychological aspects. 2. Aeronautics-
-Human factors. 3. Human engineering. I. Ruitenberg, Bert.
II. Title.
TL725.3.T7I83 1999
629.136’6’0 19~dc21 98-53849
CIP

ISBN 13: 978-0-291-39854-3 (hbk)

Contents

List of Figures vii

List of Tables ix
Preface X
Acknowledgements xu
Foreword xiii

The Need for Human Factors 1

1.1 The Past 1
1.2 The Present 4
1.3 Applied Human Factors in Air Traffic
Control 5

2 Human Error 11
2.1 The Nature of Human Error 11
2.2 The SHELL Model 13
2.3 Modelling Error 17
2.4 Levels ofBehaviour 20
2.5 Sources of Error 25
2.6 Managing Human Error 30
2.7 Individual Blame or Systemic Causal
Factors 32

3 Liveware : The Controller 39

3.1 Information Processing 39
3 .2 The Senses 53
3.3 Situation Awareness 95
3.4 Decision Making and Judgement 105
3.5 Selection and Training 124

4 Liveware- Liveware: Social Psychology and the

Controller 131
4.1 Communication 131

v
vi Air Traffic Control: Human Performance Factors

4.2 Communication in the ATC

Environment 145
4.3 Teams and Teamwork 161
4.4 Working with Other Teams 186

5 Liveware - Software: Procedures, Documentation and

the Controller 189
5.1 Procedures 190
5.2 Checklists 199
5.3 Software Display 201

6 Liveware - Hardware: Equipment and the Controller 211

6.1 Human - Machine Systems 211
6.2 Operational Complexity Versus
Functional Capability 215
6.3 Future Changes in the Controlling
Environment 224

7 Liveware - Environment: Other Factors and the Controller 253

7.1 Stress 254
7.2 Post Traumatic Stress Disorder 266
7.3 Sleep and Fatigue 277
7.4 Shiftwork 286
7.5 Safety Management 297
7.6 Company Risk Management 315

Appendices
A Test of the Blind Spot 326
B Task/Relationship Questionnaire 327
c Key to the Countries in the Hofstede
Model 335

Bibliography 337
Index 357
List of Figures

2.1 Hull loss accidents 12

2.2 Levels of performance 20
2.3 Classification of human errors 25
2.4 Reasons systemic failure model related to ATC 34
3.1 A simple model of information processing 40
3.2 The inverted U principle for different tasks 45
3.3 The rate of forgetting over a month 48
3.4 The hierarchical organisation of memory 50
3.5 The structure of the eye 54
3.6 Illustration of the laws of perspective 59
3.7 Size constancy played a part in the Air New Zealand
crash on Mt. Erebus 60
3.8 The Muller-Lyer illusion 63
3.9 The Ponzo illusion 64
3.10 The Circle illusion 64
3.11 The Necker cube 65
3.12 The Penrose impossible triangle 65
3.13 The Kanizas triangle 66
3.14 Height and depth cues in landing 69
3.15 Runways of the same length and width 69
3.16 Time to impact and angular size of oncoming aircraft 72
3.17 Imagery and visualisation as a proactive system 75
3.18 The structure of the ear 81
3.19 Actual and perceived sensation during acceleration 93
3.20 A tri-modular system of imagery 97
3.21 Important variables which make up the controllers
Situation Awareness 100
3.22 Pattern matching in Air Traffic Control 108
3.23 The Task-Relationship Matrix indicating the
results from a group of controllers 122
4.1 A model of communication 135
4.2 Percentage of time spent communicating in
different modes 141

vii
viii Air Traffic Control: Human Performance Factors

4.3 Analysis of hearback/readback errors, Seattle

Centre, 1995 151
4.4 Power Distance and Individualism-Collectivism
plot for a number of countries in 3 regions 180
4.5 Submission and self-assertiveness in the team 183
6.1 Picture of Flight Progress Board with Flight
Progress Strips in the Santa Maria Oceanic Control
Centre, Azores 219
6.2 Problems with the interim OCS (Auckland) 228
6.3 Sources of variance in air traffic management data 237
6.4 Separation standards versus type of ATC service 245
7.1 The effect of stress on ATC performance 258
7.2 A model of stress and coping 264
7.3 Factors associated with Post Traumatic Stress
Disorder 267
7.4 Circadian rhythm of a day worker's body
temperature 280
7.5 Graph indicating a normal circadian rhythm and
effectiveness of performance 281
7.6 Graph indicating a night shift circadian rhythm
and effectiveness of performance 287
7.7 Relationship of circadian factors, sleep factors
and domestic factors to an individual's coping
ability 293
7.8 Elements common to complex working groups
and technologies 302
7.9 An event involving the penetration of the systems
defences 304
7.10 The causal pathway of the Mount Erebus disaster 305
7.11 A matrix for locating specific defensive failures 308
7.12 Proposed proactive model for investigation
of incidents 311
7.13 Types of organisational practice 321
List of Tables

2.1 Analysis of action slips 28

2.2 Classifying the stages of error opportunity 29
2.3 The abilities ofhumans and machines 30
3.1 Sample sound levels in decibels 84
3.2 Controller-pilot communication failures 87
3.3 Sample of auditory alerts used on the Boeing
74 7 aircraft 88
3.4 Results of a radar failure simulation 99
7.1 Advantages and disadvantages of afternoon,
night and rotating shifts 291
7.2 Countries which have ATS separated from the
Civil Service 318

ix
Preface

The motivation for writing this book comes from a long standing belief
that Air Traffic Service personnel are rarely represented in the aviation
literature. There are few references to Air Traffic Control in any of the
increasing numbers of books written for pilots and about pilots. This is
also observed at all the main conferences held both in Australasia and
Internationally, although since 1994 things have gradually improved. I also
hope that the past sixteen years working with and for many of the New
Zealand and Australian air traffic control centres has given me sufficient
insight to redress the balance in the aviation industry.
This book has been written for all in air traffic services, from the ab initio
through to the boardroom. It is probably more important in some ways that
the men and women in these senior management positions have some
knowledge and awareness of the fundamental problems that limit and
enhance human performance. I have tried to present the information in this
book as logically as possible and having followed ICAOs lead in their
model of human performance, I hope I have succeeded in presenting the
material as clearly as possible.
I firstly examine the reason for the study of human factors, including the
past developments and how this discipline impacts on the present ATC
environment. Secondly, and probably most importantly, the issue of
human error is considered. It is perhaps this area alone which has
accounted for the continued and growing presence of human factors in the
aviation industry and is therefore the basis on which the rest of the book is
referenced. The introduction of the SHELL and Reason models allows a
logical progression of the various issues which affect the controller in their
working environment. A study of the strengths and weaknesses of the
controller themselves is followed by discussions regarding the interaction
of the controller with other people within the system, their use of
equipment (particularly in advanced technologies), the use of procedures
within ATC, and the more physiological issues within the working
environment itself.
Finally the topic of safety and risk management is tackled in the hope that
the system can learn from previous errors.

X
 Preface xi

I have endeavoured to be as explicit as possible with the use of ATC

examples, but typically in some cases I have had to revert to the pilots
perspective. I have also included some issues which may not be considered
the domain of the Air Traffic Controller. However I believe that there are
certain issues, such as loss of situation awareness, visual illusion, sleep,
fatigue and risky decision making in which the controller, knowing and
recognising these issues from the pilots perspective, will be better able to
do their job.
There are also certain issues I do not tackle in depth in this text, mainly
because of the speed in which the technology is developing. My plea in
this regard comes from my scientific roots: when there has to be a change
in the system, firstly plan the human in the equation and then test it for its
validity. Too often I have heard that those who change a system in ATC do
so because they perceive it did not work not because it had some evaluated
problem.
I hope those who read this book will learn something and be encouraged
to challenge the decision makers - I hope that together we can make a
difference.

Cambridge, England, 1998.

Acknowledgements

A book such as this is never a solo effort. There are many people who
need to be acknowledged for their professional help, guidance and support.
Air Traffic Control is both a science and an art and I believe that rarely are
these two aspects addressed. It is for this reason that I needed professional
Air Traffic Control personnel (and the odd pilot!) to help.
Firstly I would like to thank my co-contributor and collaborator, Bert
Ruitenberg, without whose help and witty repartee, as well as his writing,
this book would never have been completed. I have known Bert for many
years and his professional attitude and tolerance for, and applied work
with, the human factors specialists is somewhat unique. It is often difficult
and frustrating to get the message across to those who work in air traffic
services, but Bert has made my contribution much easier.
Thanks must also go to Dan Maurino for his faith in Bert and I and this
book.
There are several senior managers in both Australia and New Zealand
who I have to thank for their tolerance of my work over the years; from
the N. Z. Airways Corporation, Jack Frost, Ken McLean, Brian Hay and
Dave Rollo and John Guselli in AirServices Australia. Also from N. Z. the
many controllers, in training and in the field, in particular, Don Hamilton,
Fred Hansen and Mal Sole, who was brave enough to allow me dual
control with real traffic.
Lastly, but not least, the many pilots who have influenced my thinking,
Ron Raymond, Gordon Vette, Mark Woodhouse and Jim Rankin from
N.Z. and Mike O'Leary and Neil Johnston from British Airways and Aer
Lingus respectively.
I would also like to thank the many ab initio pilots and instructors,
particularly Leigh Signal, from Massey University School of Aviation who
have tolerated my experiments, simulations and demand to do things my
way, in the belief of training safer pilots. In a similar way I would like to
acknowledge the influence of Ken Lewis, Head of Safety and Environment
for QANTAS airways. His passion for safety in aviation is renown; I wish
all managers in this industry felt the same way.

xii
Foreword

Indecision is the precursor offlexibility

Canadian politician, circa 1990.

Introduction

There is a big difference between a philosophy and a slogan. The first

clearly enunciates precise guidance, is based in sound knowledge and
provides an all-encompassing statement of how to conduct a particular
endeavour. The latter articulates oblique reference, derives conventional
and sometimes questionable popular wisdom, and more often than not is a
misleading representation of how to tackle an issue. It would appear
beyond sensible reason to pursue a critical endeavour such as safety in
aviation - in which life and property are at stake - based on sloganism.
However, scratching the surface of the history of aviation safety might
reveal otherwise - for all the accomplishments that have turned aviation
into the safest mass transportation industry in the history of humankind. In
fact, my first argument in this foreword is that on occasion we - as an
industry - have been led by convention and slogans and allowed them to
define the way to proceed, safety-wise. That in spite of this faux pas
aviation's safety record remains unparalleled by other production
industries, is proof evident of the strength of the aviation safety process.
Nevertheless I am among those who fear that, unless change takes place,
the future might hold something other than what we might wish.
Therefore, my second argument in this foreword is about the need for well
thought out change in the ways in which we conduct business about
aviation safety - in air traffic control and elsewhere - in the year 2000 and
beyond. Such change should be guided by a clear safety philosophy. But
before I present my case, let me first review (and attempt to destroy) five
of aviation's most cherished safety slogans.

xiii
xiv Air Traffic Control: Human Performance Factors

Five slogans which are indeed falsehoods

Safety is the number one priority. Organisations in production systems are

formed to pursue - as the systems' name clearly suggests - some
production goal, such as manufacturing automobiles, extracting oil or
transporting people and goods by air. They need to make money as a
consequence of their endeavours, so they can secure the necessary
resources to continue pursuing their production goals. It is therefore hard
to see how safety could possibly be the first priority in aviation; one would
rather think that money is first. In the simplest terms, safety in aviation is a
question of sensible, coordinated prioritization of production and
protection goals, and of course organisations in aviation can make money
safely. However, the mix-up of priorities embodied by this slogan has
occasionally led to aberrant endeavours. In fact, the most frequent
argument advanced by pathogenic organisations when caught with their
hands in the cookie jar is that, notwithstanding evidence to the contrary,
they do not know how could they have possibly been involved in the bad
outcome in question, since "in our company, safety is first". It is a matter
of historical record that organisations which have hidden behind this
slogan - and have not backed it up with appropriate action - are among the
worst safety offenders in the trade.

Safety is no accident (also If it ain't broke, why fix it?). The proposal here
is that there is no need to be concerned about safety as long as there are no
accidents, that the system is safe as long as people are not hurt, metal is
not bent, and the organization is not exposed to criticism and
embarrassment. In other words, that accidents - or the lack thereof - are
reliable indicators of system safety. This school of thought has recently
been under fire. An alternative view proposes that, if structures and
processes afforded by state-of-the-art knowledge are in place to keep the
system under continuous surveillance for signals of hazards, accidents are
merely like "noise in the system". Beyond other falsehoods underlying this
slogan, waiting until the system breaks down before attempting to address
its flaws might tum out to be onerous beyond reason. Furthermore, when
the system breaks down, human life is at stake, which raises ethical
questions in relation to this approach. Since the financial and human costs
associated with waiting for accidents before undertaking remedial action
are inevitably high, there are compelling economic and ethical reasons to
fix the system before it breaks. However, too often is the case in aviation
 Foreword xv

at large that we continue to wait until we experience accidents before we

take preventive action.

If you believe safety is expensive, try an accident. The popular belief

reflected here is that it is possible to anticipate all flaws in the system
which might eventually lead to accidents, namely by observing
professional behaviours, exercising discipline and adhering to the rules.
Simply put, regulatory compliance and "going by the book" are guarantee
enough. Unfortunately, the real world does not operate like this. It is
possible - and sensible - to perform proactive checks of system
performance, in a similar manner as humans visit family physicians and
engage in fitness programms. However, as already mentioned, once state-
of-the-art structures and processes are in place, accidents, like illness and
death, become ultimately a matter of statistical chance. If the objective is
to avoid accidents exclusively, organisations indulge themselves by
gambling (and in the process delude themselves and their customers). If
the objective is to monitor the processes engaged by the organisation while
pursuing its production goals in order to ascertain their intrinsic resistance
to the hazards inherent to aviation, then organisations exercise prevention.
Even if sound prevention is exercised, it is impossible to cancel all sources
of hazards inherent to aviation (gravity being the best example!). The
window of opportunity for accidents, small as it might hopefully be, will
always be open: in spite of politicians' aspirations, accidents- like income
taxes - will continue to occur every year. The window of opportunity will
be almost closed if an "organisational fitness" programme is exercised, but
if organisations aim exclusively at avoiding accidents, then maintaining
the organisational fitness will not be promoted and safety indeed becomes
an accident. Accidents are noise in the system, and the record shows that
quite healthy organisations manned by sensibly trained personnel,
equipped with resources commensurate to their production goals and with
well-designed procedures can suddenly find themselves involved in nasty
occurrences. By opposition, crummy outfits with doubtfully-qualified
personnel, seriously under-resourced, with substandard practices and a
record of close-calls large enough to fill a telephone directory manage to
stay away from harm's way simply because of the luck of the draw.

Safety is everyone's business. This one is quite puzzling. When we feel

sick; we visit a physician. When we need legal counsel, we consult an
attorney. If water does not come out of the faucet, we call the plumber.
xvi Air Traffic Control: Human Performance Factors

However, when facing safety problems, all of us in aviation presume to be

subject-matter experts, particularly if we have a vast experience in the
trade. The truth of the matter is that all this slogan does is blow smoke,
since only trained specialists can address present-day safety problems in a
context-relevant, intelligent manner. The best run organisations in aviation
have dedicated safety personnel, professionally qualified, with specific job
descriptions and with defined responsibilities and organisational access.
These professionals assume responsibility as the safety conscience of the
organisation. They devise plans to assess and reinforce the organisation's
intrinsic resistance to the potential hazards inherent to aviation, for the rest
of the personnel to follow. They do not point fingers when they discover
unmanaged hazards and safety problems, but develop solutions. Crummy
outfits dilute this responsibility among all sectors and all personnel, and as
a consequence few, if any, take an active stance in safety matters. Blowing
smoke is however convenient because it provides for a cover screen when
the fallacy in this slogan is uncovered by the proverbial trail of wreckage.
As it turns out to be, everybody's office at corporate headquarters is rather
difficult to find in the aftermath of an accident, and "a scapegoating" of
operational personnel is the inevitable follow up.

Seventy percent of accidents are caused by human error. This one has
been saved for the end because it epitomises how misleading the armchair
wisdom underlying conventional wisdom and slogans can be, and because
it becomes the natural bridge for the balance of my argument. Consider the
aviation system: humans conceive what the system should look like, and
once they are satisfied with what they conceived they set upon to design it.
Humans then build the system and when the system is functional, humans
make it work. In order to exhibit the behaviours necessary to achieve the
system's objectives, humans train other humans who are going to make the
system work day after day. Humans make strategic and tactical decisions
about system performance, and when dangers are anticipated, humans
devise and deploy the necessary countermeasures to protect the system
from such dangers. Simply put, humans design, manufacture, train,
operate, manage and defend the system. Therefore, when the system
breaks down, it is of necessity that human error is a foregone conclusion,
that some human flaw of one kind or another must be underlying the
occurrence. From this perspective and depending upon the level of
observation, it is arguable that virtually one hundred percent of accidents
 Foreword xvii

are caused by human error. If there is any contribution to protect the

system through the re-iteration of this slogan, it is quite difficult to see.

On error and Human Factors in real-life environments

Be it as it may, the "70% factor" underlies most justifications for the

integration of Human Factors knowledge into aviation. It is a very
"marketable" slogan because it is supported by tons of data, although
many would argue that not very much intelligence or information has been
extracted from these data. This discussion therefore takes considerable
exception to this clause. It is suggested that we need to incorporate
Human Factors knowledge into aviation operations because error is a
normal component of human behaviour, and only through the judicious
and informed application of Human Factors knowledge will we be able to
deploy the necessary countermeasures to keep human error under control.
Error is the other side of the coin of human intelligence, the price we
humans pay for our ability to think on our feet and adapt to unanticipated
situations. Error is a consequence of a cognitive load-shedding
mechanism which allows us to operate under very demanding operational
conditions for prolonged periods of time without unduly draining our
limited mental batteries.
From the practical perspective which must necessarily underpin error and
Human Factors in real-life endeavours, the problem in aviation operations
does not lie with error itself but with its negative consequences, with those
consequences of error which might pose a threat to safety. The point is
simple: if an error in operational circumstances does not have negative
consequences, for safety purposes such error does not exist. In applied
terms, we face two options: one, we might try to overextend past
endeavours conceptually aimed at error-free human performance - an
unattainable illusion. Alternatively, we could seek to build, through the
integration of Human Factors knowledge in aviation, operational contexts
embedding "error buffer zones" which allow operational personnel
second, third and nth-chances to recover the negative consequences of
their errors.
It is furthermore suggested that it would be as unwise to attempt to
eliminate error as it would be, for example, to completely eliminate pain.
Pain is a human defence and warning mechanism. If we were to eliminate
pain, then when placing a hand over a fire we would certainly feel no
discomfort, but we would bum our hand beyond hope of recovery. Pain
xviii Air Traffic Control: Human Performance Factors

can thus be considered an early-warning device. Likewise, error in

aviation is an early-warning and protection device, both to avoid
operational cognitive breakdowns as well as to flag deficiencies in the
architecture of the system which are the breeding grounds for error.
Beyond the fact that it would be a cognitive absurdity, if we eliminate -
rather than control- error, we would be squandering a fundamental source
of protection and proaction.
Aviation history has characterized humans as a safety liability, as the
weak link in the system. From the perspective of cognitive science, one
can but take strong. exception to this view, leaning rather to believe in
human reliability. It is wrong and misleading to consider the human
condition beyond hope, vis-a-vis error and safety; in fact, error - if
properly managed - is what makes humans reliable and dependable by
allowing them to learn and develop. When considering human
performance per se, devoid of surrounding artefacts, we discover that
humans are extremely reliable performers. In spite of living in an
aggressive environment, in spite of societal and self-inflicted aggressions,
human life expectancy surpasses presently seventy years, ranking topmost
amongst living species. One of the reasons for this is the adaptability and
feedback provided by error to human intelligence. When by themselves,
humans cope well. When supported- or hindered- by technology, human
error adaptation mechanisms degrade because the opaqueness of linking
interfaces which subsume human performance to machine performance.
Let there be no mistake about it: in contemporary aviation, Human Factors
issues arise when humans interact with the products of the technological
society.
The notions of error tolerance and error management are not new, and
they are well established and accepted in engineering dogma. They are an
integral part of engineering design. However, when critically analysing
aviation interfaces between humans and technology, we discover that such
notions have not always been successfully translated into practice. Herein
lies the real contribution of aviation Human Factors in terms of control and
management of error, and therefore to the safety and efficiency of the
aviation system: Human Factors knowledge should ensure that intrinsically
error-resistant technology and reliable human beings are interfaced by
error-tolerant interfaces. Adversarial interfaces will inevitably defeat
human performance and generate error, whilst co-operative interfaces will
enhance human performance and tolerate error. At the end of the day, the
quest for human error control in aviation is largely a question of interfaces.
 Foreword xix

Safety 2000, air traffic control

Air traffic control (ATC) - like all of aviation - is and will remain a
technology-intensive system. People (controllers) must harmoniously
interact with technology to contribute to achieve the aviation system's
goals of safe and efficient transportation of passengers and cargo.
Maintaining and advancing safety in technology-intensive systems
demands a continuous evaluation of the strategies we adopt and the
resources we deploy to achieve the system's goals. Should this constant re-
evaluation be absent, or should our endeavours be guided by slogans, then
we might at best attack the symptoms rather than the causes of safety
deficiencies. At worst, we would be squandering limited and precious
resources in misdirected endeavours.
In specific, ATC- related terms, there are three fundamental aspects over
which we need to maintain a watchful eye to make sure that the integration
of Human Factors knowledge contributes its full potential to "safety 2000"
in air traffic control. Conceptually speaking, it aH starts by making sure
that human-technology interaction in ATC remains human-centred. The
widespread adoption of a philosophy of human-centred automation for
workstation design and supporting procedures is the only safeguard
against unco-operative human-technology interfaces which hold potential
for human error and therefore safety breakdowns. In order to design
human-centred technology, the tendency to include formally educated
Human Factors practitioners into design teams, slowly but surely being
adopted by the two major aircraft manufacturers, must be echoed by others
as well as by equipment manufacturers. This is a much needed
development if we are to design technology which is a tool rather than an
end in itself.
Practically speaking, we must tackle the challenge of integration from a
broad system's perspective. A critical observation of the deployment of
technology over the years suggests that aviation has pursued human-
technology interaction in a piecemeal fashion. We have paid considerable
attention to the design of individual technological components but not
equal or enough attention to the design and integration of the whole. We
have designed technology which, by and of itself, would more often than
not prove adequate. But we have not sufficiently scrutinized the interaction
between technology, humans, and the constraints of the operational
contexts into which technology is deployed. This largely explains the
mismatches in human-technology interaction recorded in accident
xx Air Traffic Control: Human Performance Factors

investigation reports. Mode confusion - a problem which only exists at the

intersection of human and technology when the interface linking them is
not co-operative - is a prime example of these mismatches. There is no
justification for unco-operative interfaces other than mind-sets and
professional biases. We know enough about Human Factors with regard to
design and integration. The step is then obvious: we must include Human
Factors requirements (beyond knobs-and-dials ergonomics) into the
certification process of technology and supporting procedures. Human
capabilities and limitations and operational constraints must be taken into
account when we define the blueprint of our systems, before systems
become operational. Human capabilities and limitations and operational
constraints must also be integrated during procedures design. Experience
has too often shown that, once technology is deployed, it is too late to
address Human Factors issues arising from unfriendly human-technology
interfaces, because the costs involved in re-design are astronomic. Such
issues become endemic flaws and hinder the optimum utilization of
technology. Worst of all, unfriendly interfaces are too frequently mis-
diagnosed in accident investigation reports as pilot or controller error.
Lastly, we must acknowledge the global village. International aviation
may not recognise boundaries, however boundaries do exist. Within
national boundaries, people involved in aviation conduct their daily
business in seemingly similar ways. Yet, ways of doing business encode
significant cultural preferences, making each way unique and distinct. The
bottom-line: the deployment of technology, and the design of
human-technology interfaces in particular, must take into account national
cultures. We cannot assume that technology will work with the same
effectiveness everywhere; in fact, it would be a grave mistake to think that
simply exporting technology which works in one cultural context will
bring the same benefits in another. Each and every culture has important
built-in strengths and weaknesses in relation to aviation safety, all of
which have to be carefully calibrated. The purpose of this cultural
calibration of technology is to define human-technology interfaces which
build upon cultural strengths while attenuating weaknesses. In fact, unless
cross-cultural issues are duly considered, trading culturally uncalibrated
technology across contexts might simply address symptoms of safety
deficiencies, leaving causes largely untouched.
 Foreword xxi

Wanted: a contemporary safety philosophy

The watchful evaluation of strategies discussed in the previous section

would be facilitated if conducted under the overarching statement provided
by a contemporary safety philosophy. Without suggesting to have found
the Holy Grail, my vision of the building blocks of the philosophy
necessary to sustain the safety process in ATC and elsewhere in the year
2000 and beyond includes:

• the need to consider safety as an outcome, an "ideal state" we want to

achieve, rather than as a process as we do today. Safety is the outcome
of the proactive process of hazard evaluation and risk management. In
this sense, safety could be considered an additional system production
goal;
• the need to shift the focus of the safety process from ritualistic reaction
to dynamic proaction . There will always be room and need to learn
about the past, and protect aviation's safety corporate memory, through
the rather funereal protocol of accident investigation. There will be,
however, a greater need to remain ahead of the game by continuously
monitoring - through "fitness programmes"- the system's vital signs
(the processes it engages in while pursuing its production goals),
seeking to anticipate deficiencies to keep the system healthy;
• the need to acknowledge that World War II ended in 1945. The safety
practices which served aviation well then and dictated safety dogma for
the ensuing fifty years belong in the past, and the gains possible
through that older approach have been realised. To make additional
gains, we need a new, creative approach. We need to dis-enthral
ourselves from mind-sets and professional biases and progress towards
normal operations monitoring and incident reporting and investigation,
replacing accident investigation as the main prevention tool;
• the need to revisit prevailing views on human error, moving on to
consider error as a symptom which warns about deficiencies in the
deeper architecture of the system.

Education is a fundamental requisite for change, and several excellent

books published in the recent past have been appropriate vehicles to
pursue the educational process underpinning change. This book joins such
select company. It conceptually embodies the fundamental premises upon
which the change this foreword argues for must build, it considers human
xxii Air Traffic Control: Human Performance Factors

error and Human Factors from a contemporary and operational

perspective, and it discusses the parts as well as the whole, moving
towards the necessary systemic view of human performance in aviation.
Furthermore, its timing is quite appropriate: I wholeheartedly agree with
the authors that progress on Human Factors - and safety - in ATC has been
slower when compared with the flight deck and I fully share their
understanding of the reasons for this difference. But now is the time to
move forward. Here is this book: I hope you enjoy reading it as much as I
did.

Daniel Maurino, Montreal, June 1998.

1 The Need for Human Factors

IT WAS SO OBVIOUS- so painfully obvious- but most

of those engaged in commercial aviation couldn 't see it,
or wouldn 't. Human beings engaged in a human enterprise
are subject to human failures. Pilots and controllers and
maintenance people err and cause accidents because they
are human, and we imperfect humans are all prone to make
such mistakes. Discovering that a human error- pilot or
otherwise - has occurred is merely the starting point. To
have any hope ofpreventing such an error from causing
such an accident again and again, the reason the error
was made in the first place must be discovered, and the
underlying cause of that human failure must be revealed
and addressed in future operations.

JJ. Nance, 1986.

1.1 The Past

Human factors has become a major concern in aviation, especially since

the International Civil Aviation Organization (ICAO) adopted a resolution
on Flight Safety and Human Factors at its 1989 Assembly. From this
meeting the Air Navigation Commission formulated the following
objective for the task

To improve the safety in aviation by making States more

aware and responsive to the importance of human factors
in civil aviation operations through the provision of practical
human factors material and measures developed on the basis
of experience in States. ICAO, 1989.

ICAO has described human factors as a concept of people in their living

and working situations; about their relationship with machines, with
procedures and with the environment; and also about their relationships
2 Air Traffic Control: Human Performance Factors

with other people. In aviation, Human Factors involves the consideration

of personal, medical and biological variables for optimal flying and Air
Traffic Control operations (ICAO, 1989). Many people have discussed the
concepts within the Human Factors area and most agree on the main
objectives. These are to enhance the effectiveness and efficiency with
which work and other activities are carried out by people, and also to
maintain and enhance certain desirable human values such as safety,
health and wellbeing. The main approach of human factors is the
systematic application of relevant information about human abilities,
characteristics, behaviours and motivation and communication patterns in
the execution of work and social interactions.
Human factor activity has exploded in the last 250 years. This
development can be viewed during several phases. The time between 1750
and 1890 was characterized by new inventions such as the harnessing of
steam power to machinery which could be applied to specific applications,
most notably the textile industry.
During 1870-1945 a major expansion in the use of power in
manufacturing, transportation, and agriculture was seen. The first part of
this phase also saw the development of the science ofbehaviourism. Early
developments in this field included elementary 'time and motion' studies
in which actual and ideal work practices were analysed in order to
determine more optimum ways of achieving greater efficiencies in work
outputs.
During 1921 in the United Kingdom, the National Institute for Industrial
Psychology was established to undertake experimental studies regarding
the benefits to be gained in industry and commerce. Some of the findings
of this Institute, later confirmed in World War II, found that some
machines could not be operated safely or effectively by many people. In
the United States from 1924-1930 a major research programme was
undertaken at the Hawthorne Works of Western Electric. This study
concluded that work effectiveness could be favourably influenced by
psychological factors not directly related to the work itself. This
psychological effect has come to be known as the 'Hawthorne' effect.
During the Second World War an even greater stimulus for human factor
developments was established. New technology, especially radar and
advanced aircraft systems, appeared to be exceeding the abilities of
ordinary people. At Oxford University a Climatic and Working Efficiency
Research Unit was established to investigate the requirements for
optimising the interface between humans, the physical environment and
 The Need for Human Factors 3

machines. At Cambridge University, Professor Sir Frederick Bartlett was

requested in 1939 by the Medical Research Council to undertake research
regarding the problems with military aviation. A simulator built around a
Spitfire cockpit was constructed to test how pilot performance could be
improved by changing the design, layout and interpretation of displays and
controls. This early simulator, known as the 'Cambridge Cockpit',
generated significant information relating to aircrew selection, pilot
training, the effects of sleep loss and fatigue and various aspects of visual
perception and display design. One of the earliest studies (Drew, 1940)
demonstrated that when pilots suffered significant loss of sleep and were
fatigued, their ability to maintain a complex array of tasks was reduced.
Undue attention tended to be paid to one or two instruments while other
activities such as checking fuel contents were overlooked. These studies
provided firm evidence that machines, systems and procedures needed to
be made to match the characteristics of humans, rather than humans being
made to fit the characteristics of machines with their inherent systems and
procedures.
From 1946 to 1960, the development of human factors (or ergonomics)
as a technology in its own right was established. At this stage it should be
noted that the term ergonomics which was first used by Professor Murrell
in 1949, derives from the Greek words ergon (work) and nomos (natural
law). Thus the derivations led to the definition 'a study of human
behaviour in work'. In the United States and Europe ergonomic societies
were formed to provide more systematic ways of developing and
disseminating the mounting scientific studies. In the United Kingdom, the
Ergonomics Research Society, formed in 1949, became the International
Ergonomics Association in 1959. In the United States, where the preferred
name was human factors rather than ergonomics, the Human Factors
Society was founded in 1957 and affiliated with the European branch.
It was first calculated in 1940 that three out of four aircraft accidents
were due to human failures of one kind or another. This figure was
confirmed by the International Air Transport Association (lATA) at their
Istanbul conference in 1975, where it is well recognised that the initial
development of Human Factors within aviation began.
An example of such human failing occurred in 1977 when two aircraft
collided on the runway at Tenerife airport killing 583 people and creating
the greatest disaster in aviation history. One of the two aircraft which
collided was from the Dutch carrier KLM. It is perhaps not surprising that
4 Air Traffic Control: Human Peiformance Factors

within a year of this accident, that airline had launched the first 'Human
Factors Awareness Course' for its staff.
If the focus of human factors in World War II was primarily on
correcting systems that were obviously faulty, the current phase of
thinking is moving to consider the limitation of the human operator prior
to building a system so that a more effective allocation of functions can be
made between human and system and thus reducing the limitations in both.
An early example of this approach was a study undertaken by Fitts and
Jones (1947) which described the types of errors being made by pilots
through the misinterpretation of instrument information. Today Boeing
lead the way with their developments on the 777 series aircraft, but what
of the developments in Air Traffic Control?

1.2 The Present

The development of human factors issues within Air Traffic Control

(ATC) has advanced a little more slowly than within the pilot performance
area. Although the catagorisation of ATC errors in air incidents is not
new, the analysis as to their cause has not always been well recognised or
researched. Another reason is the low profile of the ATC personnel
themselves. Unlike the pilots who are visable to the flying public, Air
Traffic Control is less visable and, to many, a mystery. However, perhaps
the tragedy which occurred over Zagreb in 1976 changed this. Since this
time, and as a result of other air accidents, the performance and the
limitations of those in ATC have been scrutinised more closely.
Edwards (1988) has provided a useful definition of human factors. He
has suggested

Human factors (or ergonomics) may be defined as the

technology concerned to optimize the relationship between
people and their activities by the systematic application of
human sciences, integrated within the framework of systems
engineering. (p.9)

This definition suggests not only that human factors and ergonomics
should be regarded synonymously, but that all human sciences should be
considered in this relationship. It also implies that those working in these
environments are now represented by both genders and that the interaction
of these people is just as important as their relationship with the
 The Need for Human Factors 5

technology they work with. The optimisation of this relationship also

suggests two sets of criteria. That is, that the human factors approach must
not only be concerned with the level of 'well being' of the individual, but
also with the effectiveness of the systems performance. Often in the past
organisations have been very concerned about the second factor
mentioned, particularly as it affects profit, and little about the first.
Before we define, elaborate and investigate each of the aspects
mentioned by Edwards throughout the remaining chapters, let us consider
the following accident.

1.3 Applied Human Factors in Air Traffic Control

Part One: The Circumstances

In the early hours of an Autumn Monday morning, a twin-engined jet

transport with 5 crew members and 63 passengers on board, while in its
take-off run at Anyfield Airport collided with a small twin-engined
propellor driven aircraft, with a single crew member, that had intruded the
departure runway. Both aircraft were severely damaged as a result of the
collision. The subsequent fire destroyed both aircraft and was the cause of
death for most of the passengers.
Anyfield Airport is a medium sized airport, with a single runway which
can be accessed (or vacated) by a number of intersections. It is a
controlled aerodrome, the control tower is located 400 metres north of the
middle of the runway. Traffic numbers are on the rise as quite a few
commuter type airlines have started operating to and from Anyfield.
Although the airport is in a region in which several foggy days a year are
common, it is not equipped with a Surface Movement Radar (SMR), nor
does it have special taxiway lighting facilities for use under low visibility
conditions.
Air Traffic Control at Anyfield is slightly understaffed, but thus far it had
not been thought necessary to impose restrictions on operations to and
from Anyfield. There is a discrete frequency to handle taxiing aircraft -
'Groundcontrol'.
At the time of the collision, the average visibility was around 700 metres
with fog banks, which was just sufficient to allow the Tower controller to
see the middle part of the runway. The controllers' view at the intersection
where the intruding aircraft entered the runway however was obstructed by
a newly constructed extension to the terminal building at Anyfield Airport.
6 Air Traffic Control: Human Performance Factors

The Air Traffic Control Officer (ATCO) was a very experienced

controller. He had been working in Air Traffic Control for many years at
several major facilities, and had been transferred to Anyfield to act as an
OJT instructor 8 months before the date of the accident. At the time of the
collision, the ATCO was alone in the control tower, as his
Assistant/Ground controller (of far less experience) had briefly left the
tower to answer a call of nature. They were both completing their third
consecutive nightshift, and had come on duty at 22:00 hours the previous
evening. They were due to be relieved within 30 minutes when the
accident occurred.
The crew of the jet aircraft were experienced operators to and from
Anyfield. From their point of view, on the morning of the accident, there
was nothing unusual in the way their flight was handled by Air Traffic
Control. They taxied to the runway with the extra caution required by the
fog conditions, and after being cleared for take-off they made certain they
were lined up correctly on the runway centreline before applying take-off
power.
The pilot of the twin-engined piston driven aircraft was unfamiliar with
Anyfield Airport, having been sent there at short notice to collect an
aircraft that had to divert into Anyfield two days earlier for weather
reasons.

Part Two: Background Details- The Human Factors

Although the ATCO was very experienced, he had only worked a limited
number of solo shifts in Anyfield Tower. Having validated his Tower
rating in early summer, he had been involved in giving OJT instruction on
most of his shifts since that time. As a consequence of the staff shortage he
was required, like all other controllers, to work his share of nightshifts.
The shift in which the accident occurred was only his second in which he
had worked at Anyfield Tower under foggy/low visibility conditions; the
first had been the previous night, when there was hardly any traffic as it
was the mid weekend shift.
A number of years ago there had been an incident at Anyfield involving
runway intrusion by a vehicle, under similar meteorological conditions as
in this case. One of the recommendations at that time was the installation
of an SMR, together with stop bars at all runway intersections. The
authorities decided that in view of the limited number of days (with fog)
that would warrant the use of an SMR, the benefit of having an SMR did
 The Need for Human Factors 7

not match the costs of having one installed. The same argument applied
with regard to the installation of stop bars, but in lieu of those, painted
signs had been put in the grass next to the runway intersections, informing
those who noticed them there was a "runway ahead".
As the early morning traffic began to increase, the ATCO and his G/C
were each working an independent R/T frequency. When the G/C
announced he had to visit the men's room for a second, the ATCO told
him to go ahead, intending to work both frequencies by himself. In order
to do so, the ATCO had to physically move between 2 control positions in
the tower that were about 3 metres apart. Anyfield Tower was not
equipped with a frequency coupling installation and transmissions on one
frequency could not be heard by stations on the other frequency.
The pilot of the piston engined aircraft had arrived in Anyfield late the
night before. After a short sleep he went to the airport in order to waste as
little time as possible as his company wanted the aircraft back at its
homebase as soon as possible. After the minimum of preparation, he went
to his aircraft and called Air Traffic Control for approval to taxi to the
runway. He obtained the clearance and began taxiing, but soon found
himself lost at the foggy, unfamiliar airport. The fact that there were no
signs indicating the various taxiway intersections did not help.
The R/T tapes showed that the pilot of the piston aircraft then called G/C
(by RJT) and asked for "progressive taxi instructions". G/C replied by
asking his position. The pilot said: "I believe I'm approaching Foxtrot
intersection", to which G/C answered: "At Foxtrot taxi straight ahead". In
fact the pilot had already passed Foxtrot, and should have turned onto the
parallel taxiway. The instruction from G/C, though technically correct,
caused the pilot to taxi onto the runway where the jet was in its take-off
roll. Since the communications to both aircraft took place on different
frequencies, neither pilot was aware of what was happening.
After the collision, it took the ATCO several minutes to realise something
was wrong. Of course he had not observed the departing jet passing on the
section of the runway that was visible to him, but he initially blamed that
on the fogpatches and/or being distracted by traffic on the G/C frequency.
Apart from the fog, the ATCO was also unable to see the part of the
runway where the collision had taken place because of the newly built
extension of the terminal building blocking his view. So it was not until he
wanted to transfer the departing jet to the next controller (Departure
Control) that he became aware things were not as they should be; his
transmissions to the jet remained unanswered. His G/C, who returned
8 Air Traffic Control: Human Performance Factors

shortly after the accident, also reported having no contact with the taxiing
twin prop. The ATCO then decided to alert the fire brigade, but as he had
no idea where to send them, more precious time was lost as the rescue
vehicles tried to make their way across the foggy airport. When they
finally arrived at the accident site, they found there was little they could do
as the wreckage of the aircraft had already completely burnt out.

Part Three: Preventive Measures

Had a SMR been installed following the recommendation after the

previous incident, this would have provided the following lines of defence:

• proper taxi instructions for the 'lost' aircraft;

• the ATCO would have observed the runway intrusion;
• easy identification of the collision site;
• adequate instructions for the rescue vehicles.

This also relates to the stop bars. Had they been installed, the twin prop
may have been less likely to have entered the runway.
At the very least, special procedures for Low Visibility Operations at
Anyfield should have been developed and in place, limiting the number of
movements at the field. The ATCOs should have been trained in working
with these special procedures, ideally on a simulator, to help them cope
with the unusual situation once they occurred.
In their talks with the airport authorities, ATC management should have
firmly opposed the plans for extensions to the terminal building. As a
result of not having any input from the operational ATCOs (who were not
available to attend the meetings due to staff shortage), management was
not even aware it would constitute a line of vision problem from the
Tower.
The ATCO should not have found himself in a position where he was
forced to work two positions by himself. At all times ATC positions
should be sufficiently staffed to allow the traffic to be handled in a safe
manner.
The installation of a frequency coupler might have helped prevent the
collision from occurring. As it was, these systems are considered
'optional' by the aviation authorities, so only few ATC facilities had them.
Management should have ensured that OJT instructors were given the
opportunity to stay current at the positions where they were expected to
 The Need for Human Factors 9

teach. This could have been done by scheduling the instructor for duties
without trainees at regular intervals. Such duties should be sufficiently
challenging to allow an instructor to practise their skills (in other words:
shifts without traffic may look good in a roster, but are of no value for
currency maintaining purposes!).
Had there been a well devised training curriculum, that was correlated
with the duty roster, management would have recognised that the ATCO,
although qualified, had not been able to acquaint himself with working at
Anyfield Tower under low visibility conditions. Ideally, they should not
have scheduled him for unsupervised duty when low visibility was
forecast. Dedicated low-visibility operations training would have made the
ATCO aware of the dangers involved, alerting him to be more positive in
guiding the lost taxiing pilot. At the very least he probably would not have
given the pilot irrelevant information.
It is a scientific fact that when consecutive nightshifts are worked, the
performance of persons engaged in cognitive tasks (such as ATC)
decreases dramatically in the second and later nights, especially between
03:00 hours and 07:00 hours. The ATCO at Anyfield was on his third
nightshift in a row. This could explain why he failed to recognize a
potentially dangerous situation that he may not have missed under other
circumstances. When designing shift rosters for ATCOs, it is advisable to
keep the number of consecutive nightshifts to an absolute minimum.
Based on the Met. forecast, and taking into account that the propellor
aircraft's pilot was unfamiliar with Anyfield, it may be argued that the
operator would have been better to send two pilots to collect the aircraft.
Even with limited knowledge of crew resourse management, a second pilot
could have prevented the lone pilot from acting the way he did.

Epilogue

Of course it is understood that the accident which is described could never

happen at the facility or airport where you work!
To this end ICAO has mandated that all controllers should have
knowledge relating to human performance and limitations relevant to the
Air Traffic Control environment; the main principles of which appear
throughout the following chapters.

No matter how well equipment is designed, no matter how

sensible regulations are, no matter how much humans can
10 Air Traffic Control: Human Performance Factors

excel in their performance, they can never be better than

the system which bounds them.

Captain Daniel Maurino, ICAO Flight Safety Human

Factors Programme Manager.
References

Contents

Index 7.1 Stress 7.2 Post Traumatic Stress Disorder 7.3

Sleep and Fatigue 7.4 Shiftwork 7.5 Safety Management
7.6 Company Risk Management A B c Test of the Blind
Spot Task/Relationship Questionnaire Key to the Countries
in the Hofstede Model 145 161 186 189 190 199 201
211 211 215 224 253 254 266 277 286 297 315 326
327 335 337 357
Bibliography

Annett, J. and Duncan, K. D. (1967) 'Task analysis and training design'.

Occupational Psychology. 41: 211-221.
Ash, S. (1952) 'Effect of group pressure upon the modification and
distortion of judgement' in (eds) Maccoby, Newcomb & Hartly.
Reading in Social Psychology. NY: H. Colt.
Baddeley, A.D. (1976) The Psychology ofMemory. New York: Harper and
Row.
Baiada, R. M., Boyd, M.J. and Watts, N.W. (1994) 'Free Flight-
Reinventing Air Traffic Control- The Economic Impact'.
Presentation to the Committee on Government Operations,
Subcommittee on Employment, Housing and Aviation. USA.
Baldwin, R. (1991) Training requirements for automated ATC in Wise,
J.A., Hopkin, V.D. and Smith, M.L. (eds)Automation and Systems
Issues in air traffic control pp 469-479 Berlin: Springer- Verlag.
NATO ASI Series Vol F 73.
Beck, A. (1976) Cognitive therapy and the emotional disorders.
International Universities Press: New York.
Billings, C.E. (1991) 'Human Centered aircraft automation: A Concept
and guidelines' NASA TM 103885 Moffett Field, CA: NASA-
Ames Research Centre.
Billings, C. E. and Cheaney, E.S. (1981) (eds) Information transfer
problems in the aviation system. Technical Paper NASA- TP-
1875. Moffett Field. CA: National Aeronautics and Space
Administation.
Blake, M. J. F. (1967) 'Time of day effects on performance in a range of
tasks'. Psychonometric Science, 9, 349-350.
Blake, R.R. and Mouton, J.S. (1962) 'Overvaluation of own groups
product in intergroup competition'. Journal ofAbnormal and
Social Psychology. 64: 237-238.
Bloom, F. E. and Lazerson. A. (1988) Brain, Mind, and Behaviour. New
York: W. H. Freeman and Company.

337
338 Air Traffic Control: Human Performance Factors

Braverman, M. (1992) 'Stress and Well Being at Work' in J.C.Quick.,

L.R. Murphy and J.J. Hurrell (eds) Stress and Well Being at Work:
Assessment and Interventions for Occupational Mental Health.
Washington: AP A.
Broadbent, D.M.(1958) Perception and Communication. London:
Pergamon Press.
Broome, K. (1997) 'Trainingfor, CNSIATM: a New Zealanders
perspective'. Presentation at ATC Asia Pacific '97, Bali.
Brown, L.M. (in press) Risk and risk assessment: Software applications in
safety-critical systems.
Brown, L.M. (1988) Human-computer interface design guidelines.
Norwood, N.J:Ablex.
Bryan, L.A. (1989) 'The Human Factor: implications for engineers and
managers'. Professional Safety. 34 (11): 15-18.
Buck, O.D. and Walker, J.I. (1982) 'Post traumatic stress disorder in
Vietnam veterans: A review'. Southern Medical Journal75: 704-
706.
Bureau of Air Safety Investigation, (1994) Piper PA31-350 Chieftain,
Young, NSW 11 June 1993. Investigational Report 9301743,
BASI, Canberra.
Cardosi, K.M. (1997) 'IQ- Test Your Communication'. Flight Deck.
British Airways Safety Services.
Cardosi, K.M. and Murphy, E.D. (1995) 'Human Factors in the Design
and Evaluation ofAir Control Systems'. U.S. Department of
Transportation: Federal Aviation Administration, Washington,
DC.
Chapanis, A. (1965) 'On the allocation of functions between men and
machines'. Occupational Psychology. 39: 1-11.
Chase, W.G. and Simon, H.A. (1973) 'Perception in chess'. Cognitive
Psychology. 4: 55-81.
Chopra, V., Bovill, J.G., Spierdijk, J. and Koornneef, F. (1992)
'Reported significant observations during anaesthesia: A
prospective analysis over an 18 month period'. British Journal of
Anaesthesia. 68:13-17.
Clark, N., Sharp, C., Johnson, B., Lyon, J.D., Trautmann, K and
Spurgeon, P. (1987) 'Review ofAir Traffic Services training
program '. Unpublished report submitted by Nicolas Clark: Ottawa
Canada.
 Bibliography 339

Cobb, B.B., Mathews, J.J., and Nelson, P.L. (1972) 'Attrition- retention
rates ofair traffic controller trainees recruited during 1960 - 1963
and 1968 -1970'. Washington DC: federal Aviation
Administration Report No. FAA- AM- 72-33.
Colquhoun, W. P., Blake, M. J. F., and Edwards, R. S. (1968a)
'Experimental studies of shift-work I: A comparison of of
"rotating" and "stabilised" 4-hour shift systems'. Ergonomics,
11, 437-453.
Colquhoun, W. P., Blake, M. J. F., and Edwards, R. S. (1968b)
'Experimental studies of shift-work II: "Stabilised" 8-hour shift
systems'. Ergonomics, 11, 527-546.
Colquhoun, W. P., Blake, M. J. F., and Edwards, R. S. (1969)
'Experimental studies of shift-work III: "Stabilised" 12-hour
shift systems'. Ergonomics, 12, 865-882.
Committee on the Regulation of Air Traffic Controllers' Hours (1990)
'Report ofa Committee on Regulation ofAir Traffic Controllers'
Hours (CRATCOH) to the UK Civil Aviation Authority'.
Cheltenham: Civil Aviation Authority.
Cooper, C. L. and Payne, R. (1989)(eds) Personality and Stress:
Individual Differences in the Stress Process. Wiley: Chichester.
Costa, G., Lievore, F., Ferrari, P., and Gaffuri, E. (1987) 'Usual meal
times in relation to age, sex, work activity and morning-
eveningness'. Chronobiologia, 14,383-391.
Crump, J. H., Cooper, C.L. and Maxwell, V.B. (1981) 'Stress among air
traffic controllers: occupational sources of coronary heart disease
risk'. Journal of Occupational Behaviour. 2: 293-303.
Cruz, C. and Della-Rocco, P. (1995). 'Investigation of sleep patterns
among air traffic specialists as a jUnction of time off between
shifts in rapidly rotating work schedules' in R. S. Jensen and L. A.
Rakovan (eds.), Proceedings of the Eighth International
Symposium on Aviation Psychology Vol. 2, pp. 974-979. Ohio:
Ohio State University.
Cushing, S. (1995) 'Pilot-Air Traffic Control Communications. It's not
(only) what you say, it's how you say it'. Flight Safety
Foundation, Flight Safety Digest.
340 Air Traffic Control: Human Performance Factors

Dailey, J.T. and Pickrel, E W. (1984) 'Development of the air traffic

controller occupational knowledge test.' in Sells.S.B., Dailey. J.T.
and Pickrel (eds) Selection ofAir Traffic Controllers, pp 299-
322. Washington, DC: Federal Aviation Administration Report
No. FAA - AM - 84-2.
Davis, P.R. (1983) 'Human Factors contributing to slips, trips and falls'.
Ergonomics. 26: 51-60.
Degani, A.S. and Wiener, E.L. (1990) 'Human Factors offlight-deck
checklists: The normal checklist'. NASA Report 177549. Moffett
Field, CA: NASA- Ames Research Centre.
Dewe, P., Cox, T. and Ferguson, E (1993) 'Individual strategies for
coping with stress at work: a review'. Work and Stress. 7: 5-15.
Duckworth, D. (1986) 'Psychological problems arising from disaster
work'. Stress Medicine. 2:315-323.
Dunn, B. (1995) 'Not only the sharp end: a flight attendant's viewpoint'.
In R. Fuller, N. Johnston, and N. McDonald. (eds) Human Factors
in Aviation Operations. Aldershot:Avebury.
Edwards, E. (1972) 'Man and machine: systems for safety' in: proceedings
of The BALPA Technical Symposium, London.
Edwards, E. (1985) 'Human factors in aviation'. Aerospace. 12, 7:20-22.
Ehert, C. F. (1981) 'New approaches to chronohygiene for the shift worker
in the nuclear power industry'in A. Reinberg, N. Vieux, & P.
Andlauer (eds.), Night and Shift Work: Biological and Social
Aspects pp. 263-270. Oxford: Pergamon Press.
Endsley, M.R. (1995) 'A taxonomy of situational awareness errors' in R.
Fuller. N. Johnston. & McDonald, N. (eds) Human Factors in
Aviation Operations. Avebury Aviation:U.K.
Farah, M.J. (1985) 'Psychophysical evidence for a shared representation
medium for mental images and percepts'. Journal of Experimental
Psychology: Generall14: 91-103.
Farah, M. J., and Smith, A. F. (1983) 'Perceptual interference and
facilitation with auditory imagery' .Perception and Psychophysics,
33, 475-478.
Farmer, E.W. (1984) 'Personality factors in aviation'. International
Journal ofAviation Safety. 2, 2: 175-179.
Federal Aviation Administration (1990) 'The National plan for aviation
human factors'. Washington, DC: Author.
Fitts, P.M. (1947) (ed) 'Psychological research on equipment design'.
Washington, D.C.: US Government Printing Office, Army Air
Forces Aviation Psychology Program, Research Report 19.
 Bibliography 341

Fitts, P.M. (1951) 'Human engineering for an effective air-navigation and

traffic-control system'. Washington, D.C.: National Research
Council, Committee on Aviation Psychology.
Fitts, P.M. and Jones, R.E. (1961) 'Psychological aspects of instrument
display: I. Analysis of 270 "pilot-error" experiences in reading and
interpreting aircraft instruments' in H. W. Sinaiko, (ed) Selected
papers on human factors in the design and use of control systems.
New York: Dover.
Fleishman, J. A. ( 1984) 'Personality characteristics and coping patterns'.
Journal of Health and Social Behaviour. 22: 229-244.
Folkard, S. (1975). 'Diurnal variation in logical reasoning'. British Journal
of Psychology, 66, 1-8.
Folkard, S. (1990) 'Circadian performance rhythms: some practical and
theoretical implications' in D. E. Broadbent, J. Reason, and A.
Baddeley (eds.) Human Factors in Hazardous Situations Vol.
327B, pp. 543-553. London: Philosophical Transcript Royal
Society of London.
Folkard, S. and Condon, R. (1987) 'Night shift paralysis in air traffic
control officers'. Ergonomics, 30 : 1353-1363.
Folkman, S. (1984) 'Personal control and stress and coping processes: a
theoretical analysis'. Journal of Personality and Social
Psychology. 46: 839-852.
Folkman, S. and Lazarus, R.S. (1988) 'Coping as a mediator of emotion'.
Journal of Personality and Social Psychology. 54: 466-475.
Frese, M. and Semmer, N. (1986) 'Shiftwork, stress and psychosomatic
complaints: a comparison between workers in different shiftwork
schedules, non-shiftworkers, and former shiftworkers'.
Ergonomics, 29: 99-114.
Frey, R. and Safer, P. (1980) (eds) Disaster Medicine: Types and Events
ofDisasters Organization in Various Disaster Situations. New
York: Springer-Verlag.
Gaiotti, V.P. (1997) The Future Air Navigation System (FANS) England:
Avebury, Ashgate.
Galton, F. (1879) 'Psychometric experiments'. Brain 2: 149-162.
Galton, F. (1883) Inquiries into Human Faculty and its Development.
London: MacMillan.
342 Air Traffic Control: Human Performance Factors

Gander, P. H., Myhre, G.,Graeber, R. C., Anderson, H. T. and Lauber, J.

K. (1985) 'Crew Factors in Flight Operations: l Effects of9-hour
time-zone changes on Fatigue and the Circadian Rhythms of
Sleep/Wake and Core Temperature' Technical Report No. 88197.
Moffett Field, California: National Aeronautics and Space
Administration.
Ganse, L. ( 1997) 'Atterrissage a Bruxel/es au lieu de Francfort '. Securite
des Vo1s. Air France.
Gibson, J.J. (1966) The Senses Considered as Perceptual Systems. Boston,
Mass: Houghton Mifflin.
Glendon, A. I., and McKenna, E.F. (1995) Human Safety and Risk
Management. London: Chapman and Hall.
Goodstein,L.P., Andersen, H.B. and Olsen, T. (1988) Tasks, Errors and
Mental Models. London: Taylor and Francis.
Gordon, N. P., Clearly, P. D., Parker, C. E. and Czeisler, C. A. (1986).
'The revalence and health impact of shiftwork'. American Journal
of Public Health 76:1225-1228.
Grandjean, E (1980) Fitting the Task to the Man: an ergonomics
approach. Taylor and Francis: London.
Great Britain: Department of Transport. (1987) 'MV Herald of Free
Enterprise Report of Court No. 8074: Formal Investigation'.
HMSO London.
Great Britain: Department of Transport. ( 1988) 'Investigation into the
Kings Cross Underground Fire', Chairman D. Fennell. HMSO
ondon.
Great Britain: Department of Transport. (1989) 'Investigation into the
Clapham Junction Railway Accident'. Anthony Hidden QC Cm
820. HMSO London.
Green, B.L. (1994) 'Psychosocial research in traumatic stress: An update'.
Journal of Traumatic Stress. 7 (3): 341-362.
Green, R. G., Muir, H., James, M., Gradwell, D. and Green, R.L.
(1991) Human Factors for Pilots. Hants, England: Avebury
Technical.
Gregory, R.L. {1966) Eye and Brain. London: Weidenfeld and Nicolson.
de Groot, A. {1965) Thought and Choice in Chess. The Hague: Mouton.
Hale, A.R. and Glendon, A. I. ( 1987) Individual Behaviour in the Control
ofDanger. Elsevier: Amsterdam.
Hale, A.R. and Hale, M. (1970) 'Accidents in Perspective'. Occupational
Psychology. 44:115-122.
Hartley, J. (1985) Designing Instructional Text. London: Kogan Page.
 Bibliography 343

Harwood, K. and Sandford, B. (1994) 'Evaluation in Context: ATC

Automation in the Field' in J.Wise, V.D. Hopkin and D.J. Garland
(eds) Human Factors Certification ofAdvanced Aviation
Technologies. Embry-Riddle Aeronautical University Press.
Hawkins, F.H. (1984) 'Human factors education in European air
transport operations ' in: Breakdown in Human Adaptation to
Stress Towards a multidisciplinary approach, Vol.l for the
Commission of the European Communities. The Hague: Martinus
Nijoff. '
Hawkins, F.H. (1987) Human Factors in Flight. Aldershot: Gower
Publishing Company.
Hawkins, F.H. (1993) Human Factors in Flight. 2nd Edition. (ed) Orlady,
H.W.Aldershot: Ashgate.
Hayward, B. J. and Lowe, R.L.(1996) (eds) Applied Aviation Psychology:
Achievement, Change and Challenge. Avebury: Hants, England.
Helmreich, R.L. and Merritt, A. (1998) Culture at Work in Aviation and
Medicine. Aldershot: Ashgate.
Helmreich, R.L., Merritt, A., Sherman, P., Gregorich, S., and Wiener, E.
(1993) 'The Flight Management Attitude Questionnaire'.
NASNUT/FAA Technical Report 93-4. Austin, TX: NASNUT.
Hillenberg, J.B. and Wolf, K.L. (1988) 'Psychological impact oftraumatic
events: implications for employee assistance intervention'.
Employee Assistance Quarterly. 4(2): 1-13.
Hodgkinson, P.E. and Stewart, M. (1991) Coping with Catastrophe: A
handbook ofdisaster management. Routledge: London.
Hofstede, G. (1980) Culture's consequences: International differences in
work-related values. Beverly Hills, CA: Sage.
Hofstede, G. (1983) 'The cultural relativity of organizational practices
and theories'. Journal ofInternational Business Studies. 75-89.
Hofstede, G. (1984) Culture's consequences. Newbury Park, CA:Sage.
Hofstede, G. (1991) Cultures and organizations: Software of the mind.
Maidenhead, England: McGraw-Hill.
Hollnagel, E. (1993) Human Reliability Analysis: Context and Control.
London: Academic Press.
Holmes, T.H. and Rahe, R. (1967) 'The Social readjustment rating scale'.
Journal of Psychosomatic Research. 11: 180-213.
Hopkin, V.D. (1980) 'The measurement of the air traffic controller'.
Human Factors 22: 547-560.
Hopkin, V.D. (1982) 'Human Factors in Air Traffic Control'. Paris:NATO
AGARDograph No. 275.
344 Air Traffic Control: Human Performance Factors

Hopkin, V.D. (1989) 'Implications of automation on air traffic control' in

R. Jensen (ed) Aviation Psychology Aldershot England: Gower.
Hopkin, V.D. (1991) 'Organisational and team aspects of air traffic control
training' in G.E. Bradley and H.W. Hendrick (eds) Human
Factors in organisational design and management- IV
Amsterdam: North Holland.
Hopkin, V.D. (1994) 'Automated flight strip usage: lessons from the
functions ofpaper flight strips' in Proceedings of
AIAA/NASA/F AAIHFS Symposium on Challenges in Aviation
Human Factors: The National Plan.
Hopkin, V.D. (1995) Human Factors in Air Traffic Control. London:
Taylor & Francis Ltd.
Horowitz, M.J. (1986) 'Stress response syndromes: A review of post
traumatic and adjustment disorders'. Hospital and Community
P!.ychiatry. 37: 241-249.
Hudson, P.T.W., Reason, J., Wagenaar,W., Bentley, P., Primrose, M. and
Visser, J. (1994) 'Tripod Delta: Proactive approach to enhance
safety'. Journal of Petroleum Technology. 46:58-62.
Hurst, R. and Hurst, L.R. (1983) (eds) Pilot Error- The Human Factors.
Granada Publishing: UK.
ICAO (1993) 'Human Factors in Air Traffic Control'. ICAO Circular:
241-AN/145. ICAO: Montreal.
ICAO ( 1994) 'Human Factors, Management and Organisation' ICAO
Circular 247-AN/148. ICAO: Montreal.
ICAO (1994) 'Human Factors in CNSIATM systems'. ICAO Circular:
249-AN/149. ICAO: Montreal.
Isaac, A.R. ( 1990) 'Imagery for Movement'. Unpublished Doctoral thesis,
University of Otago.
Isaac, A.R. (1994) 'Mental imagery in Air Traffic Personnel'. Aviation,
Space and Environmental Medicine, 65, (2) 95-99.
Isaac, A.R. (1994) 'Imagery ability and Air Traffic Control'. The Journal
ofAir Traffic Control34, (1) 22-25.
Isaac, A.R. (1995) 'Short-term memory and advanced technology: the use
of Imagery in Air Traffic Control' in N.Johnston., R.Fuller., and
N.McDonald, (eds.) Aviation Psychology: Training and Selection.
Aldershot: Avebury Aviation.
Isaac, A.R. (1998) 'Situation Awareness in ATC: creating the mental
picture'. International Journal ofAviation Psychology (submitted).
 Bibliography 345

Isaac, A.R.and Hamilton, D. (1994) 'Operation Group Human Factors

Analysis Project'. Unpublished Report: Airways Corporation of
New Zealand.
Isaac, A.R. and Marks, D.F. (1994) 'Individual differences in mental
imagery experience: developmental changes and
specialization'. British Journal of Psychology. 85, 479-500.
Isaac, A.R. and Ruitenberg, B. ( 1996) 'Air traffic control workshop
report' in Hayward, B.J. and Lowe, A.R. (eds) Applied Aviation
Psychology: Achievement, Change and Challenge. Aldershot:
Avebury Aviation.
James, W. (1890) The Principles of Psychology. New York: Holt Rinehart
and Wilson.
Janis, I. (1982) Groupthink. Boston: Houghton Mifflin.
Janis, I. and Mann, L. (1977) Decision Making: A Psychological Analysis
of Conflict, Choice and Commitment. New York: Free Press.
Jensen, R.S. (1982) 'Pilot Judgement training and evaluation'. Human
Factors, 24, 61-73.
Jensen, R.S. (1989) (ed) Aviation Psychology. Aldershot: Gower Technical
Press.
Jensen, R.S. (1995) Pilot Judgement and crew resources management
Aldershot: Ashgate publishing.
Jensen, R.S and Benel, R. (1977) 'Judgement evaluation and instruction in
civil pilot training'. FAA Report No FAA-RD-78-24 Savoy II, U
of Illinois Aviation Research Laboratory.
Johnson-Laird, P.N. (1983) Mental Models. Cambridge: Cambridge
University Press.
Johnston, N. (1993) 'CRM: Cross-Cultural Perspectives' in E. Wiener, B.
Kanki and R. Helmreich (eds) Cockpit Resource Management.
New York: Academic Press.
Johnston, N., McDonald, N. and Fuller, R. (1994) Aviation Psychology in
Practice. Aldershot:Ashgate Publishing
Kantowitz, B.H. and Sorkin, D. (1983) Human Factors. New York: John
Wiley Publications.
Kerns, K. (1995) 'Human Factors in ATC/Flight Deck Integration:
implications of data link simulation research' in R.S. Jensen and
L.A. Rakovan. (eds) Proceedings of the Eighth International
Symposium on Aviation Psychology. The Ohio State University.
Klein, G.A. ( 1987) 'Applications of analogical reasoning'. Metaphor and
Symbolic Activity. 2: 201-218.
346 Air Traffic Control: Human Performance Factors

Klein, G.A., Calderwood, R.and Clinton-Cirocco, A. (1986) 'Rapid

decision making on the fire ground'. Proceedings of the Human
Factors Society 30th Annual Meeting 1: 576-580.
Klein, G.A., Orasanu, J.and Calderwood, R., (1993) Decision making in
action: models and methods. Ablex, Norwood N.J.
Kogi, K. (1985) 'Introduction to the Problems of Shiftwork' inS. Folkard,
and T. H. Monk (eds.) Hours of Work: Temporal Factors in Work
Schedulingpp. 165-184 New York: John Wiley and Sons.
Kolk, B. van der (1987) (ed) Psychological Trauma. New York:American
Psychological Press.
Kosslyn, S.M. (1980) Image and Mind. Harvard University Press:
Cambridge Massachusettes.
Krieger, D. T. (1988) 'Abnormalities in circadian periodicity in
depression' in D. J. Kupfer, T. H. Monk, and J.D. Barchas (eds.)
Biological Rhythms and Mental Disorders pp. 177-196 New York:
The Guilford Press.
Lashley, K.S. (1917) 'The accuracy of movement in the absence of
excitation from the moving organ'. The American Journal of
Physiology, 43: 169-194.
Lautman, L.G. and Gallimore, P. L. (1987) 'Control of the crew caused
accidents'. Flight Safety Foundation Safety Digest. Arlington,
VA: Flight Safety Foundation.
Lewis, K. (1993) 'The Price of Safety: The QANTAS philosophy'.
Unpublished paper at the ASASI meeting. Wellington, NZ.
Loftus, G.R. (1977) 'Short-term memory factors in Ground
Controller/Pilot communication'. Human Factors. 21 (2): 169-181.
Loftus, G.R., Dark, V.J. and Williams, D. (1979) 'Short-term memory
factors in ground controller/pilot communications'. Human
Factors, 21, 169-181.
Logsdon, E.W. (1995) 'Cockpit data link technology andjlight crew
communication procedures' in R.S. Jensen and L.A. Rakovan.
(eds) Proceedings of the Eighth International Symposium on
Aviation Psychology. The Ohio State University.
Lovell, J. and Kluger, J. (1994) Apollo 13. Hodder and Stoughton:
London.
Luna, T. D., French, J., Mitcha, J. L. and Neville, K. J. (1992) 'Forward
rapid rotation shiftwork in USAF air traffic controllers: Sleep,
activity, fatigue and mood analyses' Technical Report No. AL/CF-
TR-1994-0156 Brooks Air Force Base, Texas.
 Bibliography 347

Mackworth, J. F.(1963) 'The duration ofthe visual image'. Canadian

Journal of Psychology. 71: 62-81.
Mackworth, N.H. (1950) 'Researches on the measurement of human
performance'. MRC Special Report Series 268, HMSO. London.
Mahon, P. (1984) Verdict on Erebus. Auckland: William Collins Publishers
Ltd.
Marks, D.M. (1984) 'The new structural approach to image formation.
Psychophysiology and Psychopathology'. Journal of Mental
Imagery. 8: 95-104.
Marks, D. F. (ed). (1986a). Theories ofImage Formation. New York:
Brandon House.
Marr, D. (1982) Vision. SanFrancisco: W.H. Freeman.
Marrison, C. and Harris,T. (1991) 'The long-term psychological
consequences of a major aircraft accident' in E. Farmer (ed) Stress
and Error in Aviation. Avebury Technical: England.
Martiniuk, R.G. (1976) Information Processing in Motor Skills. New
York: Holt, Rinehart and Winston.
Maurino, D.E., Reason, J., Johnston, N. and Lee, R.B. (1995) Beyond
Aviation Human Factors. Aldershot: Avebury Aviation.
Merritt, A, (1996) 'Facing the issue: Indirect communication in aviation'
in B.J. Hayward. and R.L. Lowe. (eds) Applied Aviation
Psychology: Achievement, Change and Challenge. Avebury:
Hants, England.
Merritt, A.,and Helmreich, R.L. (1996) 'CRM in 1995: Where to from
here?' in B.J. Hayward. and R.L. Lowe. (eds) Applied Aviation
Psychology: Achievement, Change and Challenge. Avebury:
Hants, England.
McCann, I.L., Sakheim, D.K. and Abrahamson, D.J. (1988) 'Trauma and
Victimization: A model of psychological adaptation'. The
Counselling Psychologist. 16 (4); 531-594.
McCormick, E.J. (1976) Human Factors in Engineering and Design.
McGraw-Hill: NJ.
Miller, G.A. (1956) 'The magical number seven, plus or minus two: Some
limits on our capacity for processing information'. Psychological
Review, 63:81-97.
Minors, D.S. and Waterhouse, J.M. (1987) 'Circadian Rhythms and
Aviation', Aviation Medicine Quarterly 1: 9-26.
Minors, D. S. and Waterhouse, J. M. (1990) 'Circadian Rhythms in
General' in A. Scott (ed.) Occupational Medicine: State of the Art
Reviews, 5: 165-182. Philadelphia: Hanley & Belfus Inc.
348 Air Traffic Control: Human Performance Factors

Mitchell, J. (1983) 'When disaster strikes: the critical incident debriefing

process'. Journal of Emergency Medical Services. 8 (1): 36-39.
Mogford, R. (1994) 'Mental models and situation awareness in air traffic
control' in R.D. Gilson, D.J. Garland and J.M. Koonce (eds)
Situational Awareness in complex systems. Daytona Beach, FL:
Embry-Riddele Aeronautical University Press.
Monk, T. H. (1994) 'Shift work'. in M. H. Kryger, T. Roth, & W. C.
Dement (eds.) Principles and Practice of Sleep Medicine pp. 471-
476. Philadelphia: W. B. Saunders Company.
Monk.,T. H., and Folkard, S. (1992) Making Shiftwork Tolerable.
London: Taylor & Francis.
Moshansky, Mr Justice. (1992) 'Commission ofinquily into the Air
Ontario crash at Dryden, Ontario'. Ottawa: Ministry of Supply
and Services, Canada.
Muir, H. C. (1994) 'Passenger safety' in N.Johnston., N.McDonald.and
R.Fuller (eds) Aviation Psychology in Practice. Hants,England:
Avebury Technical.
Muir, H.C., Marrison, C. and Evans, A (1989) 'Aircraft Evacuation: The
Effect of Passengers Motivation and Cabin Configuration
Adjacent to the Exit', CAA Paper 89019, London, UK Civil
Aviation Authority.
Murrell, K.F.H. (1971) Ergonomics: Man in his working environment.
Chapman and Hall: London.
Nance, J.J. (1986) Blind Trust. Quill William Morrow: New York
Narborough-Hall, C.S. (1987) 'Automation- implications for retention as
a function of operator control responsibility' in D. Diaper and R.
Winder (eds) People and Computers III proceedings of the 3rd
Conference of British Computer Society Human Computer
Interaction Specialist Group. Cambridge University Press. 269-
282.
National Transportation Safety Board (1975) 'Aircraft Accident Report
regarding TWA Flight 514 near Dulles Airport, Virginia'.
NTSB/AAR-75116.
National Transportation Safety Board (1990) 'Aircraft Accident Report
regarding United Airlines accident at Sioux City Airport'.
NTSB/AAR-90/06.
National Transportation Safety Board ( 1991) 'Aircraft Accident Report
regarding Runway Collision at Los Angeles International Airport'.
NTSB/AAR-91/08.
 Bibliography 349

Nicholson, A.N. ( 1984) 'Adaptation to Irregularity of Rest and Activity',

Aviation, Space, and Environmental Medicine, 55(2): 102-112.
Noble, The Hon G.S. (1995) 'Commission of Inquiry into the collapse of
the viewing platform at Cave Creek, Punakaiki, West Coast'.
Wellington: Department of Internal Affairs, New Zealand.
Norman, D.A. (1988) The Psychology of Everyday Things. Basic Books:
New York.
O'Hare, D. and Roscoe, S.N. (1990) Flightdeck Performance : The
Human Factor. Iowa: State University Press.
Oliver, J. (1980) Response to Disaster. James Cook University of North
Queensland.
Orasanu, J.M. (1990) 'Shared mental models and crew decision making'.
CSL Report No. 46 Princeton University: Cognitive Science
Laboratory.
Orlady, H. (1989) 'The professional airline pilot of today: All the old
skills- and more'. Paper presented at the International Airline
Pilot training Seminar at VIASA Airlines and the Flight Safety
Foundation, Caracas, Venezuela.
Parasuraman, R. and Moulova, M.( 1996) (eds) Automation and Human
Performance: Theory and Applications. Lawrence Erlbaum
Associates Publishers: Mahwah, New Jersey.
Paries, J. (1996) 'Evolution of the aviation paradigm: Towards systemic
causality and proactive actions' in Hayward, B.J. and Lowe, A.R.
(eds) Applied Aviation Psychology: Achievement, Change and
Challenge. Aldershot: A vebury Aviation.
Paries, J. (1996) 'Human Factors aspects of the Mont Sainte-Odile
accident' in Hayward, B.J. and Lowe, A.R. (eds) Applied Aviation
Psychology: Achievement, Change and Challenge. Aldershot:
Avebury Aviation.
Paton, D. (1989) 'Disasters and helpers: psychological dynamics and
implications for counselling'. Counselling Psychology Quarterly.
2:303-321.
Paton, D. (1990) 'Assessing the impact of disasters on helpers'.
Counselling Psychology Quarterly. 3: 149-152.
Perrow, C. (1983) 'The Organizational Context of Human Factors
Engineering'. Administrative Science Quarterly 28: 521-541.
Perrow, C. (1984) Normal Accidents: Living with High-Risk Technologies.
USA: Basic Books.
350 Air Traffic Control: Human Performance Factors

Pritchett, A. R. and Hansman, R.J. (1995) 'Variations in ''party-line"

information importance between pilots of different
characteristics'. in R.S. Jensen and L.A. Rakovan. ( eds)
Proceedings of the Eighth International Symposium on Aviation
Psychology. The Ohio State University.
Quaintance, L. (1997) 'Plane Truths'. North and South.
Raphael, B. (1986) When disaster strikes. New York: Basic Books.
Rasmussen, J. (1980) 'What can be learned from human error reports?' in
K.D. Duncan, M. Gruneberg and D. Wallis (eds) Changes in
Working Life. Wiley. London.
Rasmussen, J. (1983) 'Skills, Rules and Knowledge: signals, signs and
symbols and other distinctions in human performance models'.
IEEE Transactions on Systems, Man & Cybernetics. 13: 257-266.
Rasmussen, J., Duncan. K.D. and Leplat. J. (1987) (eds) New Technology
and Human Error. Wiley: London.
Raymond, R. and Isaac, A.R. (1995) 'Simultaneous error: during altitude
deviations' in Fuller, R. Johnston, N., and McDonald, N. (eds.)
Human Factors in Aviation Operations. pp 149-154. Aldershot:
Avebury Aviation.
Reason, J.(1987) 'The Chenobyl errors'. Bulletin ofthe British
Psychological Society. 40: 201-206.
Reason, J. (1988) 'Modelling the basic error tendencies of human
operators'. Reliability Engineering and System Safety. 22: 13 7-15 3
Reason, J. (1990) Human Error. Cambridge: Cambridge University Press.
Reason, J. (1990) 'The contribution of latent human failures to the
breakdown of complex systems' in D.Broadbent, J.T.Reason and
A. Baddeley (eds) Human Factors in Hazardous Situations.
Oxford: Clarendon Press.
Reason, J. (1994) 'Comprehensive error management in aircraft
engineering'. In Human Factors in Maintenance. Proceedings of
the Aerotech 94 Congress. London: Institute of Mechanical
Engineers.
Reason, J. (1997) Managing the Risks of Organisational Accidents.
Aldershot:Ashgate.
Reason, J. and Mycielska, K (1982) Absent Minded? The psychology of
mental/apses and everyday errors. Prentice-Hall Inc: New Jersey,
USA.
 Bibliography 351

Redding, R.E., Cannon, J.R.and Lierman,B. (1991) 'Cognitive Task

Analysis of Air Traffic Control' in R.S. Jensen (ed) Proceedings of
the Sixth International Symposium on Aviation Psychology. 1:
491-496. Columbus, OH: Ohio State University.
Redding, S.G. and Ogilvie, J.G. (1984) 'Cultural effects on cockpit
communication in civilian aircraft'. Flight Safety Foundation
Conference, Zurich, Washington, DC: Flight Safety Foundation.
Report of the Royal Commission ( 1981) 'Inquiry into the crash on
Mount Erebus, Antarctica, of a DCJO aircraft operated by Air
New Zealand Limited': Wellington.
Rock, D.B., Dailey, J.T., Ozur, H., Boone, J.O. and Pickrel, E.W.
(1981) 'Selection ofApplicants for the Air Traffic Controller
Occupation,' Washington, D.C.: Federal Aviation Administration
Report No. DOT- FAA- AM- 82-11.
Roscoe, S.N. (1980) Aviation Psychology. Iowa: University State Press.
Rosen, J. and Fields, R. (1988) 'The long term effects of extraordinary
trauma: A look beyond PTSD'. Journal of Anxiety Disorders.
2:179-191.
Rotter, J.B. (1966) 'Generalised expectations for internal versus external
control of reinforcement'. Psychological Monographs. 80:609.
Rouse, W.B. and Rouse, S.H. (1983) 'Analysis and classification of
human error'. IEEE Transactions on Systems, Man and
Cybernetics. SMC- 13, 539-549.
Ruitenberg, B. (1995) 'Psychology and Air Traffic Control: who cares?'
in N. McDonald., N. Johnston., and R. Fuller, (eds.) Applications
of Psychology to the Aviation System. Aldershot: Avebury
Aviation.
Ruitenberg, B. (1996) 'Human Factors aspects in CNS/ATM systems' in
Hayward, B.J. and Lowe, A.R. (eds) Applied Aviation Psychology:
Achievement, Change and Challenge. Aldershot: A vebury
Aviation.
Saint-Exupery, A. de. (1939) Wind, Sand and Stars. London: Heinemann.
Saldivar, J. T., Hoffman, S.M. and Melton, C. E. (1977) 'Sleep in air
traffic controllers' Technical Report No. FAA-AM-77-5.
Washington, DC.: Federal Aviation Administration.
Sanders, M.S. and McCormick, E.J. (1987) Human Factors in
Engineering and Design. McGraw- Hill: New York.
Sarter, N.B. and Woods, D.D. (1991) 'Situation awareness: a critical but
ill-defined phenomenon'. International Journal of Aviation
Psychology 1: 45-57.
352 Air Traffic Control: Human Performance Factors

Sells, S.B., Dailey, J.T. and Pickrel, E.W.(1984) (eds) 'Selection ofAir
Traffic Controllers', Washington, DC: Federal Aviation
Administration Report No. FAA - AM - 84-2
Senders, J. W. and Morey, N.P. (1991) Human Error. London: Lawrence
Erlbaum.
Shanteau, J. (1987) 'Psychological Characteristics of Expert Decision
Makers' in J.L. Mumpower (ed) Expert Judgement and Expert
Systems. pp 289-304. Springer-Verlag
Shaw, L.S. and Sichel, H.S. (1971) Accident Proneness. Pergamon:
Oxford
Sheen, S. (1987) 'Herald ofFree Enterprise'. Report of Court No. 8074.
Department of Transport. London: HMSO.
Sheen, Mr. Justice (1987) 'MV Herald of Free Enterprise'. Report of
Court No. 8074. Formal Investigation. London: Department of
Transport.
Shouksmith, G. and Burrough, S. (1988) 'Job stress factors for New
Zealand and Canadian air traffic controllers'. Applied Psychology:
An International Review. 37: 263-270.
Shouksmith, G. and Taylor, J.E. (1997) 'The Interaction of Culture with
General Job Stressors in Air Traffic Controllers', International
Journal ofAviation Psychology. 7 (4): 343-352.
Signal, T.L.(1997) 'Stress and Coping in ATC Shift Work'. Unpublished
M.A. Dissertation. Massey University, New Zealand.
Singleton, W.T. and Hovden, J. (1987) (eds) Risk and Decisions.
Wiley: Chichester.
Sligo, F. ( 1988) 'Effective Communication in Business'. Palmerston
North:Software Technology.
Sloan, S.J. and Cooper, C.L. (1985) 'The impact oflife events on pilots: an
extension of Alkov's approach' Aviation, Space and
Environmental Medicine, 56: 1000-1003.
Smith, P., Billings, C., Woods, D., McCoy, E., Sarter, N., Denning, R. and
Dekker, S. (1997) 'Can Automation Enable a Cooperative Future
ATM System?' in R.S. Jensen and L.A. Rakovan. (eds)
Proceedings of the Ninth International Symposium on Aviation
Psychology. The Ohio State University.
Smith, R.C., Melton, C.E.and McKenzie, J.M. (1971) 'Affect Adjective
Checklist Assessment of Mood Variations in Air Traffic
Controllers' Technical Report No. FAA-AM-71-21. Washington,
DC: Federal Aviation Administration, Office of Aviation
Medicine.
 Bibliography 353

Sperandio, J. C. ( 1977) 'From the plane-space to the air mobile space:

experimental comparison between two displays of spatia-temporal
information'. Psychological Abstracts, 58, 884.
Stokes, A.F. ( 1991) 'Flight management training and research using a
micro-computer flight decision simulator' in R. Sadlowe (ed) PC
based instrument flight simulation - A first collection of papers. pp
47-52 New York: American Society of Mechanical Engineers.
Talbot, A., Manton, M. and Dunn, P.J. (1992) 'Debriefing the debriefers:
An intervention strategy to assist psychologists after a crisis'.
Journal of Traumatic Stress.5 (1): 45-62.
Taylor, R.M. (1990) 'Situational awareness rating technique (SART): the
development of a tool for aircrew systems design in AGARD'.
Neuilly sur Seine.
Taylor, A.J. and Frazer, A.G. (1981) 'Psychological sequelea of Operation
Overduefollowing the DC-10 aircrash in Antarctica.'
Wellington:University of Wellington Publications in Psychology.
No.27.
Tenner, E. (1996) Why Things Bite Back. London: Fourth Estate Limited.
Thierry, H.and Meijman, T. (1994). 'Time and behavior at work', in H. C.
Triandis, M.D. Dunnette and L. M. Hough (eds.) Handbook of
Industrial and Organisational Psychology Vol. 4, pp. 341-413.
Palo Alto, CA: Consulting Psychologists Press.
Trollip, S.R. and Jensen, R.S. (1991) Human Factors for general
aviation. Englewood: Jeppesen Sanderson. Inc.
Turner, B.A. (1978) Man-made Disasters. London: Wykeham.
Turnbull, G. (1995) 'Debriefing British POW's after the Gulf War and
released hostages from Lebanon: lessons learnt for use in a wide
variety of critical situations including aviation' in R. Fuller, N.
Johnston, and N. McDonald (eds) Human Factors in Aviation
Operations. Aldershot:Avebury.
Uttal, B. (1983) 'The Corporate Culture Vultures'. Fortune. 17.
Vaughan, D. (1990) 'Autonomy, interdependence and social control:
NASA and the Space Shuttle Challenger'. Administrative Science
Quarterly.35: 225-257.
Vaughan, D. (1996) The Challenger Launch Decision. University of
Chicago Press: USA
Vette, G. (1983) Impact Erebus. Auckland: Hodder and Stoughton.
354 Air Traffic Control: Human Performance Factors

Vidulich, M.A., Crabtree, M.S. and McCoy, A.L. (1993) 'Development

subjective and objective metrics ofpilot situational awareness ' in
R.Jensen, and D. Neumeister, (eds) Proceedings of the Seventh
International Symposium on Aviation Psychology, OSU.
Vortac, O.U., Edwards, M.B. and Manning, C.A. (1994) 'Sequences of
Actions for Individual and Teams of Air Traffic Controllers'.
Human-Computer Interaction. 9:319-343.
Wagenaar, W.A. and Groeneweg, J. (1987) 'Accidents at sea:multiple
causes and impossible consequences'. International Journal of
Man-Machine Studies, 27:587-598.
Walker, J (1985) 'Social problems of shiftwork'. inS. Folkard, and T. H.
Monk (eds.), Hours of Work-Temporal Factors in Work
Schedulingpp. 211-225. New York: John Wiley and Sons.
Waterhouse, J. M., Folkard, S., and Minors, D. S. (1992) 'Shiftwork,
Health and Safety: An Overview of the Scientific Literature 1978-
1990 '. London: HMSO.
Welford, A.T. (1960) 'The measurement of sensory-motor performance;
survey and reappraisal of twelve years progress'. Ergonomics 3:
189-230.
Weston, R. and Hurst, R. (1982) Zagreb One Four Cleared to Collide?
Ganada Publishing: UK..
Westrum, R. (1991) Technologies and Society. Belmont, California:
Wadsworth Publishing Company.
Westrum, R. (1993) 'Cultures with Requisite Imagination' in J. Wise, D.V.
Hopkin and P.Stager (eds) Verification and Validation of Complex
Systems: Humanfactors Issues. Springer-Verlag: Berlin.
Westrum, R. (1995) 'Organisational dynamics and safety' in N.
McDonald, N. Johnston and R. Fuller (eds) Applications of
Psychology to the Aviation System. Aldershot: Avebury Aviation
Whitfield, D. and Jackson, A. (1982) 'The air traffic controllers' picture as
an example of a mental model' in G. Johannsen and J.E. Rijnsdorp
(eds) Analysis, design and evaluation of man- machine systems.
New York: Pergamon.
Whorf, B.L. (1956) 'Science and Linguistics' in J.B. Carroll (ed)
Language, thought and reality: Selected writings of Benjamin Lee
Whorf Cambridge, MA:MIT Press.
Wickens, C. D. (1984) Engineering Psychology and Human Performance.
Merrill: Columbus Ohio.
Wickens, C. D. (1992) Engineering Psychology and Human Performance.
(2nd edition). New York: Harper Collins.
 Bibliography 355

Wickens, C. D.and Flack, J.M. (1988) 'Information Processing' in E.L.

Wiener and D.C Nagel (eds) Human Factors in Aviation San
Diego: Academic Press.
Wiener, E.L., Kanki, B.G. and Helmreich, B.L. (1993)(eds) Cockpit
Resource Management. New York: Academic Press.
Wiener, E.L., and Nagel, D.C. (1988) (eds) Human Factors in Aviation.
San Diego: Academic Press.
Wiener, L.R. (1993) Digital Woes: Why We Should Not Depend on
Software. Reading, Mass: Addison-Wesley.
Wilson, G. (1996) 'Readback/Hearback'. AIRLINER. Boeing.
Wing, H. (1991) 'Selecting for air traffic control: the state of the art' in
Wise. J.A., Hopkin. V.D. and Smith. M.L. (eds) Automation and
Systems Issues in air traffic control pp 409 - 427 Berlin: Springer -
Verlag. NATO ASI Series Vol F 73.
Wise, J.A., Hopkin, V.D. and Smith, M.L. (eds) 'Automation and Systems
Issues in air traffic control' Berlin: Springer - Verlag. NATO ASI
Series Vol F 73.
Wollman, D. (1993) 'Critical incident stress debriefing and crisis groups:
A review of the literature'. Group 17: 70-83.
Yerkes, R. M. and Dodson, J.D. ( 1908) 'The relation of strength of
stimulus to rapidity of habit-formation'. Journal of Comparative
Neurology and Psychology. 18: 459-482.
Yuille, A.L. and Ullman, S. (1990) 'Computational theories oflow-level
vision' in D.N. Osheron, S.M. Kosslyn and J.M. Hollerbach (eds)
Visual cognition and action pp. 5-39. Cambridge, M.A. MIT
Press.
Zakay, D. and Wooler, S. (1984) 'Time pressure, training and decision
effectiveness'. Ergonomics 27: 273-284.
Zsambok, C.E. and Klein, G. (1997) Naturalistic Decision Making. New
Jersey: Lawrence Erlbaum Associates.
Taylor & Francis
Taylor & Francis Group
http://taylorandfrancis.com