Lessons learned from the introduction of cockpit automation in advanced technology aircraft

The commercial aviation industry has many years of experience in the application of computer based human support systems, for example the flight management systems installed in today`s advanced technology (``glass cockpit``) aircraft. This experience can be very helpful in the design and implementation of similar systems for nuclear power plants. The National Aeronautics and Space Administration (NASA) sponsored a study at the Idaho National Engineering Laboratory (INEL) to investigate pilot errors that occur during interaction with automated systems in advanced technology aircraft. In particular, we investigated the causes and potential corrective measures for pilot errors that resulted in altitude deviation incidents (i.e. failure to capture or maintain the altitude assigned by air traffic control). To do this, we analyzed altitude deviation events that have been reported in the Aviation Safety Reporting System (ASRS), NASA`s data base of incidents self-reported by pilots and air traffic controllers. We developed models of the pilot tasks that are performed to capture and maintain altitude. Incidents from the ASRS data base were mapped onto the models, to highlight and categorize the potential causes of the errors. This paper reviews some of the problems that have resulted from the introduction of glass cockpit aircraft, the methodology used to analyze pilot errors, the lessons learned from the study of altitude deviation events, and the application of the results to the introduction of computer-based human support systems in nuclear power plants. In addition, a framework for using reliability engineering tools to incorporate lessons learned from operational experience into the design, construction, and operation of complex systems is briefly described