The Team-Based Operation of Safety-Critical Programmable Systems in US Commercial Aviation and the UK Maritime Industries

This paper analyzes a range of incidents involving team-based interaction with safety-critical programmable systems. The incidents were submitted to NASA’s Aviation Safety Reporting System (ASRS) and to the UK Marine Accident Investigation Branch (MAIB) between December 2001 and February 2003. Our results show that incidents, which complicated the teambased operation of safety-critical, computer systems in commercial aviation, are now being reported within the UK maritime industry. This reflects the increasing use of programmable navigation and collision avoidance devices both in ferry operations and in commercial fishing. For example, many incidents in both industries now stem from operators making inappropriate assumptions about the likely behavior of co-workers and their programmable systems even though part of their task is to actively monitor those activities. In the aftermath of adverse events, operators often argue that monitoring was unnecessary because of their previous reliability record. This seems to indicate that greater training is required in order for operators to understand the likely limitations both of their co-workers and the programmable systems that they operate. Our results also show that a growing number of incidents are triggered when teams must rapidly reprogram complex, safety-critical systems in response to unpredictable changes in their operational requirements.