The team-based operation of safetycritical programmable systems in US commercial aviation and the UK maritime industries

Abstract

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 team-based 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. 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. © 2004 by International Federation for Information Processing. All rights reserved.