humanfactors

BY LOUKIA D. LOUKOPOULOS, R. KEY DISMUKES AND IMMANUEL BARSHI

As we started the taxi, I called for the taxi checklist but became confused about the route and queried the first officer
to help me clear up the discrepancy. We discussed the route and continued the taxi. ... We were cleared for takeoff from Run-
way 1, but the flight attendant call chime wasn’t working. I had called for the ‘Before Takeoff ’ checklist, but this was inter-
rupted by the communications glitch. After affirming the flight attendants were ready, we verbally confirmed the
‘Before Takeoff ’ checklist. On takeoff, rotation and liftoff were sluggish. At 100–150 ft, as I continued to rotate,
we got the stick shaker. The first officer noticed the no-flap condition and placed the flaps to 5. … We wrote up the
takeoff configuration warning horn but found the circuit breaker popped at the gate.1

I
s this an example of recklessness? from Birmingham (England) Interna- [stabilizer trim set for takeoff] to go
Complacency? Absent-mindedness? tional Airport at 155 kt after finding it unchecked.”2
Complex operating conditions? Com- impossible to rotate the aircraft. The Are these incidents exceptions to
plicated operating procedures? Insuf- investigation revealed that “a number usual practice or symptoms of wider-
ficient crew experience? Or something of distractions, combined with unusual spread vulnerability? What do they say
as subtle as multitasking? demands imposed by the poor weather, about the progress of an industry that
During another flight, in Febru- led to a breakdown of normal proce- has suffered at least three catastrophic
ary 2009, a crew rejected their takeoff dures and also allowed a missed action accidents when a takeoff configuration

The Perils of Multitasking

© Chris Sorensen Photogtaphy

Pilots overestimate their abilities, as well as the benefits of doing several things at once.

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 HUMANFactors

warning system failed to alert the crew (FAA) to characterize the nature and pieces of information from external
that they were attempting to take off demands of routine flight operations. sources. In the ideal world, everything
without having set the flaps?3,4,5 Preliminary findings13 raised red flags occurs at specific, predictable moments
In reviewing categories of accidents for an industry that, like many others, as the taxi phase of flight unfolds.
for 2008 — spurred in part by the fatal had unsuspectingly accepted multitask- This is the way activities are laid
Aug. 20 crash of a Spanair McDonnell ing as a normal state of affairs. out in the manuals, the way cockpit
Douglas MD-82 during an attempted We argued that commercial and tasks are taught in training, and the way
takeoff from Madrid, apparently with public pressures, organizational and pilots are expected to perform, on the
improperly set flaps, according to pre- social demands, and the increase in line. The activity-tracing exercise can
liminary reports6 — Flight Safety Foun- air traffic, mixed with a healthy dose be repeated for every phase of flight,
dation decried the “unwelcome return of pilots’ overestimation of their own and in each case, the ideal perspec-
of the no-flaps takeoff ” and concluded abilities, were creating situations that tive portrays crew activities as linear,
that “we are not making much progress were considered routine, although they or following a prescribed sequence;
in reducing the risk of these [types of concealed appreciable risk. predictable; and under the moment-to-
loss of control] high-fatality accidents” Our research at the Flight Cogni- moment control of the crew.
(ASW, 02/09, p. 18). tion Laboratory at NASA’s Ames Re- The real world is not as straight-
A quick search of the U.S. National search Center in California is based on forward. Observation of flight crews,
Aeronautics and Space Administra- a combination of methodologies that from the vantage point of the cockpit
tion (NASA) Aviation Safety Reporting through the years have included labora- jump seat, helps us understand the
System (ASRS) database reveals more tory experiments, structured interviews full ramifications of that. During our
than 50 reports of attempted no-flaps and surveys, in-depth analyses of flight observations, we recorded every event
takeoffs in the last decade, as well as manuals, participation and observation that caused some perturbation — or
reports of incorrectly set trim, airspeed of ground and flight training, incident disruption — of the ideal sequence of
and heading bugs; cockpit windows not and accident report analyses, and many activities of the two pilots. It did not
latched; and other omissions. In many hours of cockpit jump seat observations take long to realize that the real opera-
of these events, the crew was saved by during passenger-carrying operations. tional world is more complex and more
the proverbial bell — a takeoff configu- Taking advantage of these sources of dynamic than represented in writing
ration warning horn. That bell cannot data, we systematically analyzed and and in training.
be relied on to always work, however. contrasted cockpit operations in theory Let’s look at the taxi phase of flight
What leaves expert, conscientious and in reality.14 in more detail, as it often unfolds in the
pilots — and their passengers — hang- Take any carrier’s flight operations real operating environment. The base
ing by the thread of a last line of defense, manual (FOM) and draw out the flow layer (grayed-out and in the background
such as a warning horn or a checklist? of activities required of each pilot from of Figure 2, p. 21) is the ideal representa-
Articles abound in the daily news moment to moment while the aircraft tion depicted in Figure 1. Another layer
about a multitasking society and the is taxied from the gate to the run- has been added, formed by some of the
dangers inherent in our natural drive way for takeoff, and you will see the many disruptions that were observed
to have more than one thing going on theoretical, “ideal” taxi phase of flight from the jump seat during routine
at once.7,8,9,10 Most people know they (Figure 1, p. 20). flights. Ovals contain some of the pos-
should not talk on their cell phone while The crew’s activities can be traced sible, additional demands that are not
driving, although many do it anyway.11,12 from the moment the captain requests explicitly expressed in the FOMs.
But what does multitasking have to do that the first officer obtain taxi clear- The disruptions listed in each oval
with pilots on an airline flight deck? ance until the aircraft is lined up with carried additional task demands for
the runway centerline, ready for takeoff. attention and action. Ice or snow on
Complex Operations There are a number of procedures the ground meant that the captain
In 2000, we embarked on a research that pilots conduct individually, two deferred calling for flaps prior to taxi to
project sponsored by NASA and the checklists conducted by pilots together, avoid contaminating the wing surfaces
U.S. Federal Aviation Administration monitoring requirements and other with slush, continued with other taxi

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 humanfactors

activities, performed the taxi checklist is considerably more work than the Limitations
calling for verification of the flaps set- ideal perspective suggests. But it is People often feel they are perfectly
ting, and remembered to set the flaps not just a question of workload quan- capable of performing several tasks
right before takeoff. Encountering a tity. It is also a question of workload simultaneously. There seems to be a
busy frequency meant that the first of- management. Responding to the mul- popular myth that humans are good
ficer had to continue monitoring all ra- tiple, concurrent demands of flight multitaskers. In reality, however, human
dio calls in order to “jump in” when the operations requires interweaving ability to process more than one stream
frequency became available, all while new activities with old ones, defer- of information at a time and respond
monitoring the captain, maintaining ring or suspending some tasks while accordingly is severely limited. Truly
situational awareness and carrying out performing others, responding to un- simultaneous performance is possible
other pre-taxi preparations. expected interruptions and delays and only when tasks are highly practiced
Again, the exercise can be repeated unpredictable demands imposed by and rehearsed extensively together.
for each phase of flight. The resulting external agents — all while monitor- Performance in this situation becomes
“real” picture reveals activities that are ing everything that is going on. This largely automatic, making few demands
much more fluid, convoluted and vari- is multitasking in a pilot’s world. on the brain’s limited capacities for
able than in theory:
Activities are dynamic
‘Ideal’ Taxi Phase of Flight1
and not so linear, are
unpredictable, and are Monitor
not fully under the Monitor
ATC (ground)
ATC (ground),
Captain company First officer
control of the pilots. Request taxi clearance Obtain clearance
Taxi clearance
Pilots are routinely (taxi)
Taxi Procedure Taxi Procedure
forced to deviate Recall Check xxxx xxxxx xxxx x
from their linear, xxxx xxxxxx Flight controls Check
Flaps (green light) xxxx xxxx xxxx
well-practiced and xxxx xxxx xxxx Flaps (green light)
xxx xxxxx xxxx xx xxxx xx xxxx xxxxxxxxx
habitual execution of Cabin door Lock Monitor
procedures. Neither xxxx xx xxxx xxxxxxxx captain taxiing
Takeoff briefing Review
the nature nor the Ask for checklist Begin checklist
Taxi Checklist
timing of tasks and xxxx xxxxx xxxx x

events can be antici- Flight controls Checked

xxxx xxxxx
pated with certainty. Flaps Set, green light
Takeoff briefing Completed
Essential information xxxx xx xxxx xxxxxxxxxx
(at or near runway) Checklist complete
and/or the individuals Before Takeoff Procedure Before Takeoff Procedure
required to perform Engine start switches CONT
Takeoff clearance
xxx xxx xxxxxxx xx xx x
Landing lights and As FMC position update As desired
some activities are not strobe light switches desired
Transponder On
xxx xxxxxx xxxx xx
always available when Ask for checklist Begin checklist
Before Takeoff Checklist
expected. Tasks often xxxxx xxx xxx xx

must be initiated Packs Set

Transponder TA/RA
earlier or later than Master caution Checked
xxx xxxxxx xxxx xx
planned. Pilots must Line up with runway
Checklist complete

continually find ways

to fit more than the
“ideal” activities into ATC = air traffic control; CONT = continuous; FMC = flight management computer; TA/RA = traffic advisory/resolution advisory

the allotted time. 1. The ‘ideal’ phase represents that described in a flight operations manual.

One implica- Source: Loukopoulos, L.D.; Dismukes, R.K.; Barshi, I. The Multitasking Myth: Handling Complexity in Real-World Operations. Burlington, Vermont, U.S.: Ashgate
Publishing Co. 2009.
tion of the real
picture is that there Figure 1

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 HUMANFactors

attention and working memory. But human information processing attri- ad hoc, inventive ways. Too many of these
when an individual tries multitasking butes, and the experience, skill and goals seemingly benign situations bore a strik-
in a situation that involves novel tasks, of the individual — always within the ing resemblance to stories recounted by
complex decision making, monitoring, context of prevailing standard operating pilots in incident reports or that we read
or overriding habits, it all falls apart. procedures and operational restrictions. about in accident reports.15
In principle, pilots, like all people, However, the approach people take to For example, the crew cited in the
have limited choices when called to multitasking demands is not necessarily first paragraph of this article received a
multitask: They can interweave steps deliberate or well thought out. stick shaker warning after rotation and
of one task with steps of other tasks, During our observations, we spent realized they had inadvertently omitted
or defer one task until the other task is many hours watching pilots handle rou- setting the flaps to the takeoff posi-
completed, or even purposefully omit tine multitasking situations, apparently tion. This crew had been multitasking,
one task. The choice and the degree to without much effort or many errors — attempting to concurrently address a
which any of these proves successful but we became increasingly uneasy with discrepancy in their route and an inop-
depend on the interaction of the char- the risks they were unknowingly accept- erative call chime.
acteristics of the tasks being performed, ing each time they were called to react in The crew in the Birmingham event
rejected their takeoff,
after finding it impos-
‘Real’1 Taxi Phase of Flight
sible to rotate the air-
Monitor
craft, because they had
Monitor
Ask first officer to set flaps
ATC (ground)
ATC (ground),
Busy frequency inadvertently omitted
Captain company
Defer communication First officer
Request taxi clearance Obtain clearance setting the stabilizer
Verify ramp Taxi clearance Monitor frequency and
(taxi) contact when available trim for takeoff. This
clear area
Taxi Procedure Taxi Procedure
Recall Check Ice/snow Acknowledge
xxxx
clearance
xxxxx xxxx x crew was also multi-
Defer setting flaps Consider need for de-icing Flight Confirm captain’s
xxxx xxxxxx
Remember flaps(-,before takeoff De-icing checklist
controls Check
understanding tasking: They had to
Flaps green light) xxxx xxxx xxxx
xxxx xxxx xxxx
System configuration? (APU, packs) Unfamiliar with Flaps (green light) deice the aircraft, were
airport/taxi route
xxx xxxxxMonitor
xxxx xx Remember/identify xxxx xx xxxx xxxxxxxxx
airport
Cabin door
traffic
Lock turns/intersections
Review charts Monitor preoccupied by the
Monitor taxi progress
xxxx xx xxxx xxxxxxxx hold-short instruction
aircraft to follow
captain taxiing visual “clear” turns weather conditions,
Takeoff briefing Review
Ask for checklist Delay (traffic) Begin checklist were trying to meet a
Consider shuttingTaxi Checklist
down one engine New/additional
First officer busy xxxx
Restart engine xxxxx xxxx x
before takeoff taxi instruciton
takeoff time constraint,
Defer checklist After Flight controls Checked
start checklist and were focused on
Acknowledge instructions
Perform checklist as soon as possible xxxx xxxxx
Interruption
Flaps Set, green light Verify understanding remembering (which
RespondTakeoff
to interruption
briefing Completed Verify captain’s understanding
Resume xxxxchecklist
xx Switch
xxxx to tower frequency
xxxxxxxxxx
they did) to set the
(at or near runway)
Runway change Checklist complete
Before Takeofffeasibility
Procedure
Monitor
Before Takeoff Procedure
flaps, which they
Consider tower frequency
Engine start switches CONT
Consult charts/performance data Takeoff clearance
xxx xxx xxxxxxx xx
Just-in or revised load data xx x had deferred earlier
Landing lights and As
CalculateFMCnewposition update As desired
performance data
Brief
strobe light new runway
switches desired
Transponder
Reprogram new data On because of the slushy
xxx xxxxxx xxxx xx
Ask for checklist
Have captain verify new entries
Begin checklist conditions.
Before Takeoff Checklist Continue to monitor captain
xxxxx xxx xxx xx Inform company The Madrid ac-
Packs Set
cident apparently re-
Transponder TA/RA
Visually
Master “clear”Checked
caution runway sulted from the crew’s
xxx xxxxxx xxxx xx
Line up with runway
First officer’s turn to
Checklist fly
complete inadvertent omission
Take control of aircraft while finishing checklist
of setting the flaps
for takeoff, coupled
APU = auxiliary power unit with the failure of the
1. The ‘real’ phase represents the findings of jump seat observers. takeoff configura-
Source: Loukopoulos, L.D.; Dismukes, R.K.; Barshi, I. The Multitasking Myth: Handling Complexity in Real-World Operations. Burlington, Vermont, U.S.: Ashgate
Publishing Co. 2009.
tion warning system.
Was this crew also
Figure 2 multitasking? There

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 humanfactors

are indications that the crew was distracted by often so busy that it is extremely difficult for pilots
an overheating probe, and had to return to the to pause long enough to review whether they have
gate for maintenance, receive additional fuel, completed deferred or interrupted tasks.
and start the engines anew. Pilots also are highly vulnerable to errors of
Our research has focused on key aspects of omission when they must attempt to interweave
human cognition that lie at the heart of multitask- two or more tasks — performing a few steps of a
ing, namely remembering to perform tasks that task such as flight management system (FMS) data
must be deferred (prospective memory), auto- entry, switching attention to another task such as
matic processing and switching attention between monitoring taxi progress, back and forth. Much
tasks. There is considerable scientific evidence of the time pilots can interweave tasks without
that pilots, like all people, are highly vulnerable to problems, but if one task becomes demanding—
inadvertent but potentially deadly omissions when the FMS does not accept the input, for example
a situation leads them to defer a task that nor- — their attention is absorbed by these demands,
mally is performed at a particular time and place. and they forget to switch attention to other tasks.
Deferring a task breaks up the normal sequence of Monitoring, a crucial defense against threats and
habitual actions and removes environmental cues errors, often falls by the wayside when pilots must
that help pilots remember what to do next. interweave it with demanding tasks. In fact, moni-
Interruptions create especially dangerous toring is far more difficult to maintain consistently
prospective memory situations — by requiring than most pilots realize, as evidenced by studies of
pilots to remember to resume the deferred, inter- automation monitoring.16,17
rupted task — but are so commonplace that pilots
may not recognize the threat. Interruptions typi- Dispelling the Myth
cally disrupt the chain of procedure execution so There is no single best technique to manage the
A crane lifts the abruptly that pilots turn immediately to the source challenges posed by multitasking in flight opera-
wreckage of a of interruption without noting the point where tions, but we have suggested various things that
Spanair McDonnell the procedure was suspended, without forming an pilots and organizations can do.18 First, we must
Douglas MD-82 that explicit intention to resume the suspended pro- dispel the myth that multitasking comes easily to
crashed in August cedure, or without creating salient cues to remind humans, especially to pilots with “the right stuff.”
2008 during takeoff themselves to resume the interrupted task. Certain We must help pilots recognize typical multitask-
from Madrid. phases of flight such as taxi-out and approach are ing situations that create vulnerability to error
even in the most routine aspects of operations.
Organizations must take a close look at the dif-
ference between the ideal perspective and the real
nature of actual flight operations and adjust pro-
cedures, training and expectations accordingly.
Fortunately, both individual pilots and or-
ganizations can reduce the peril of multitasking.
Pilots can treat interruptions, suspending tasks,
deferring tasks or performing tasks out of normal
sequence as red flags. When interrupted, they can
reduce vulnerability by pausing momentarily to
mentally note the point at which the procedure is
interrupted and by reminding themselves to return
to that place later, before addressing the interrup-
tion. When suspending or deferring tasks, they can
identify when and where they intend to perform
© Associated Press
the task; create salient reminder cues, such as

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 HUMANFactors

putting an empty coffee cup over Immanuel Barshi is a research psychologist 9. Wallis, C. (2006, March 19). “The
the throttles when they have deferred at the Human-System Integration Division at Multitasking Generation.” Time, March
NASA Ames Research Center. 19, 2006. <www.time.com/time/magazine/
setting the flaps to their takeoff position;
article/0,9171,1174696-9,00.html>.
and ask the other pilot to help remember. Their book, The Multitasking Myth, was re-
viewed in ASW in April 2009, on p. 53. 10. “Help! I’ve Lost My Focus.” Time. Jan. 10,
When forced to interweave tasks, such
2006. <http://time.com/time/magazine/
as monitoring and data entry, pilots can Notes article/0,9171,1147199,00.html>.
bolster their implicit intention to not stay 1. NASA ASRS. Report no. 658970. May 11. Strayer, D.L.; Drews, F.A.; Johnston,
head-down too long by explicitly noting 2005. W.A. (2003). “Cell Phone-Induced
to themselves the need to perform only a 2. U.K. Air Accidents Investigation Branch Failures of Visual Attention During
few steps of the one task before checking (AAIB). AAIB Bulletin 7/2009. <www. Simulated Driving.” Journal of
the status of the other task. aaib.gov.uk/sites/aaib/publications/bul- Experimental Psychology: Applied
letins/july_2009/boeing_737_3l9__g_ Volume 9(1): 23–32.
At the organizational level, we were
ogbe.cfm>. 12. Redelmeier, D.A.; Tibshirani, R.J. (1997).
greatly encouraged when one of the air
3. U.S. National Transportation Safety “Association Between Cellular-Telephone
carriers participating in our research, Calls and Motor Vehicle Collisions.” The
Board (NTSB). Northwest Airlines, Inc.,
inspired by our preliminary findings, McDonnell Douglas DC-9-82, N312RC, New England Journal of Medicine Volume
undertook a comprehensive review of Detroit Metropolitan Wayne County 336 (Feb. 13, 1997): 453–458.
all normal cockpit procedures. After Airport, Romulus, Michigan, August 16, 13. Loukopoulos, L.D.; Dismukes,
months of analysis, that carrier’s review 1987. Report no. PB88-910406, NTSB/ R.K.; Barshi, I. “Concurrent Task
committee devised procedural modifi- AAR-88-05. Demands in the Cockpit: Challenges
4. NTSB. Delta Airlines, Inc., Boeing 727-232, and Vulnerabilities in Routine Flight
cations to reduce multitasking demands
N473DA, Dallas-Fort Worth International Operations.” In R. Jensen (editor),
in daily operations and to help crew Proceedings of the 12th International
Airport, Texas, August 31, 1988. Report no.
performance become resilient in the PB89-910406, NTSB/AAR-89-04. Symposium on Aviation Psychology (pp.
face of inevitable disruptions of the 5. Comisión de Investigación de Accidentes 737–742). Dayton, Ohio, U.S. The Wright
ideal flow of procedure execution. The e Incidentes de Aviación Civil (CIAIAC). State University. 2003.
revised procedures demonstrated sub- Preliminary Report A-32/2008. <www. 14. Loukopoulos; Dismukes; Barshi. The
stantial decrease in error rates. fomento.es/NR/rdonlyres/C58972BC- Multitasking Myth: Handling Complexity
B96C-4E14-B047-71B89DD0173E/43303/ in Real-World Operations. Burlington,
Although the risks of multitasking
PreliminaryReportA_032_2008.pdf>. Vermont, U.S.: Ashgate Publishing Co.
have been widely underestimated by both 2009.
6. Some 154 people were killed and 18
individual pilots and flight organizations, 15. Dismukes, R.K.; Berman, B.; Loukopoulos,
were seriously injured in the crash,
we are confident that by taking decisive which destroyed the airplane. As a result L.D. The Limits of Expertise: Rethinking
action, the industry can make substantial of preliminary findings, the European Pilot Error and the Causes of Airline
progress in protecting pilots from these Aviation Safety Agency issued an Accidents. Burlington, Vermont, U.S.:
risks and reducing the types of accidents airworthiness directive calling for flight Ashgate Publishing Co. 2007.

that have been associated with them.  crews on DC-9/MD-80 series airplanes 16. Sarter, Nadine B.; Mumaw, Randall J.;
to check the takeoff warning system Wickens, Christopher D. (2007). “Pilots’
For more information and to download relevant before starting engines for every flight. Monitoring Strategies and Performance
presentations and publications, visit <human- The system warns crews if flaps and slats on Automated Flight Decks: An Empirical
factors.arc.nasa.gov/flightcognition>. are not correctly set. Study Combining Behavioral and
Loukia D. Loukopoulos is a senior research asso- 7. Javid, F.; Varney, A. (2007). “The Grand Eye-Tracking Data.” Human Factors:
ciate at the U.S. National Aeronautics and Space Seduction of Multitasking.” ABC News, The Journal of the Human Factors and
Administration (NASA) Ames Research Center/ 20/20, Aug. 14, 2007. <http://abcnews. Ergonomics Society, Volume 49 (3):
San Jose State University Research Foundation, go.com/2020/story?id=3474058&page=1>. 347–357.
and is involved in research and teaching activities 8. Lohr, S. “Slow Down, Brave Multitasker, 17. NTSB. A Review of Flightcrew-Involved
through the Hellenic Air Accident and Aviation and Don’t Read This in Traffic.” The New Major Accidents of U.S. Air Carriers, 1978
Safety Board, the Hellenic Air Force and the York Times, Business Section, March 25, Through 1990. Report no. PB94-917001,
Hellenic Institute of Transport. 2007. <www.nytimes.com/2007/03/25/ NTSB/SS-94/01. 1994. <http://libraryon-
R. Key Dismukes is the chief scientist for aerospace business/25multi.html?ex=1332475200&en= line.erau.edu/online-full-text/ntsb/safety-
human factors at the Human-System Integration f295711cb4a65d9b&ei=5088&partner=rssny studies/SS94-01.pdf>.
Division at NASA Ames Research Center. t&emc=rss>. 18. Loukopoulos; Dismukes; Barshi. 2009.

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