THE ROLE OF

HUMAN FACTORS
IN IMPROVING

AVIATION SAFETY
Human error has been documented as a primary contributor
to more than 70 percent of commercial airplane hull-loss
accidents. While typically associated with flight operations,
human error has also recently become a major concern in
maintenance practices and air traffic management. Boeing
human factors professionals work with engineers, pilots,
and mechanics to apply the latest knowledge about the
interface between human performance and commercial
airplanes to help operators improve safety and efficiency
in their daily operations.

SAFETY
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CURT GRAEBER

HUMAN FACTORS ENGINEERING

CHIEF ENGINEER

BOEING COMMERCIAL AIRPLANES GROUP

he term human factors

Because technology continues to
physiology, visual perception,
has grown increasingly
evolve faster than the ability to
ergonomics, and human-computer
popular as the commerpredict how humans will interact
interface design. Applied colleccial aviation industry has realized with it, the industry can no longer tively, their knowledge contributes
that human error, rather than
depend as much on experience
to the design of Boeing airplanes
mechanical failure, underlies most
and intuition to guide decisions
and support products that help
aviation accidents and incidents.
related to human performance.
humans perform to the best of
If interpreted narrowly,
their capability while
human factors is often
compensating for their
Biomechanics - structure, posture
Performance - strength,
considered synonymous
natural limitations.
endurance, speed, reaction
Operating environment
temperature, vibration, noise, jet lag
Sensory input - vision,
with crew resource
Because improving
smell, touch
management (CRM) or
human performance can
maintenance resource
help the industry reduce
management (MRM).
the commercial aviation
However, it is much
accident rate, much of
Physical
Cognitive
Human
broader in both its
the
focus is on designhuman
human
performance
knowledge base and
ing
human-airplane
factors
factors
Userscope. Human factors
interfaces and developcentered
involves gathering
ing procedures for both
design
information about
flight
crews and mainHuman
Human
dimensions
behavior
human abilities, limitenance technicians.
tations, and other
Boeing also continues
characteristics and
to examine human
Industrial
design
applying it to tools,
performance throughout
machines, systems,
the airplane to improve
tasks, jobs, and enviusability, maintainability,
Population type - sex, race,
Behavioral - habits, stress,
ronments to produce
reliability, and comfort.
profession
danger, emotion, group dynamics
safe, comfortable, and
In addition, human
Protective equipment -gloves,
Cognitive - decisionmaking,
learning ability, perception, knowledge,
effective human use.
factors specialists
clothing
interpretation, reasoning, memory
Range in population - percentiles
In aviation, human
participate
in analyzing
Cultural - expectations,
Work envelope - reach, vision,
language,
education,
customs
factors is dedicated to
operational safety and
access capabilities/limits
Environmental - space, shape,
better understanding
developing methods and
lighting, texture, color, hazards, noise
how humans can most
tools to help operators
safely and efficiently
better manage human
be integrated with the technology. Instead, a sound scientific basis
error. These responsibilities require
That understanding is then trans- is necessary for assessing human
the specialists to work closely with
lated into design, training, policies, performance implications in design, engineers, safety experts, test and
training, and procedures, just as
or procedures to help humans
training pilots, mechanics, and
developing a new wing requires
perform better.
cabin crews to properly integrate
sound
aerodynamic
engineering.
human factors into the design of
Despite rapid gains in technology,
all Boeing airplanes. Their areas
Boeing has addressed this issue
humans are ultimately responsible
of responsibility include addressfor ensuring the success and safety by employing human factors
of the aviation industry. They must specialists, many of whom are also ing human factors in
continue to be knowledgeable,
flexible, dedicated, and efficient
while exercising good judgment.
Meanwhile, the industry continues
to make major investments in
training, equipment, and systems
that have long-term implications.

pilots or mechanics, since the

1960s. Initially focused on flight
deck design, this group of about
30 experts now considers a much
broader range of elements (see
graphic), such as cognitive
psychology, human performance,

FLIGHT DECK DESIGN

Over the past several decades, safer

and more reliable designs have been
responsible for much of the progress
made in reducing the accident rate and
increasing efficiency. Improvements in
engines, systems, and structures have
all contributed to this achievement.
Additionally, design has always been
recognized as a factor in preventing
and mitigating human error. When
Boeing initiates a new design activity,
past operational experience, operational
objectives, and scientific knowledge
define human factors design requirements. Analytical methods such as
mockup or simulator evaluations are
used to assess how well various design
solutions meet these requirements.
Underlying this effort is a humancentered design philosophy that has
been validated by millions of flights
and decades of experience. This
approach produces a design that applies
technology in the best way to satisfy
validated requirements:

Customer input.

Appropriate degree of automation.

Crew interaction capability.

Communication, Navigation
and Surveillance/Air
Traffic Management
improvements.

Customer input.
Boeing involves
potential customers in defining
top-level design requirements for new
designs or major derivatives and in
applying human factors principles. A
good example is the high level of airline involvement in designing the 777.
From the beginning, operators flight
crews and mechanics worked side by
side with Boeing design teams on all
airplane systems. Eleven of the initial
operators also participated in dedicated
flight deck design reviews early in the
design process. An independent external
team of senior human factors scientists
also participated in a parallel set of
reviews. In the final review, flight crews
and other representatives from each
operator spent time in the 777 engineering flight simulator to evaluate
the design in a variety of normal and
nonnormal situations. These activities
ensured that operator requirements
were considered from the beginning,
and validated that the implementation
included a sound pilotflight deck
interface.

Appropriate degree of automation.

Boeing flight decks are designed to
provide automation to assist, but not
replace, the flight crew member
responsible for safe operation of the
airplane. Flight crew errors typically
occur when the crew does not perceive
a problem and fails to

1. Flight deck design.

2. Design for maintainability
and in-service support.
3. Error management.
4. Passenger cabin design.

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correct the error in time to prevent

the situation from deteriorating.
Consequently, Boeing flight decks
incorporate intuitive, easy-to-use
systems. These systems support instrument displays with visual and tactile
motion cues to minimize potential
confusion about what functions are
automated. In the fly-by-wire 777,
visual and tactile motion cues are
provided by backdriven controls. These
controls reinforce situational awareness
and help keep the flight crew fully
aware of changes occurring to the
airplanes status and flight path
during all phases of automated and
manual flight.

Crew interaction capability.

Flight crew communication relies on
the use of audio, visual, and tactile
methods. All these methods must be
used appropriately in the communication that takes place during flight.
This includes crewmember-to-airplane,
crewmember-to-crewmember, and
airplane-to-crewmember communication.
Consequently, the duplicated flight
controls of all Boeing airplanes are
also interconnected. Both
control wheels turn
together

UPLINK MESSAGE FORMAT

FIGURE

when either is moved so that the control inputs of each flight crew member
are immediately obvious to the other.
The same is true for column movements. The tactile and visual feedback
provided by interlinkage is much more
immediate than verbal coordination
and better enables pilots to help each
other in time-critical emergencies.

Communication, Navigation
and Surveillance/Air Traffic
Management interface.
In the future, flight crews will be
expected to assume much larger roles
in route planning and metering for
approaches. Cognitive engineering has
already assumed an important role as
the industry considers the effects of
new technology on the skills, workload, and coordination with other
airplanes required of both flight
crews and air traffic
controllers. For example,
cooperation among human
factors specialists, data link
communications
engineers, and
end users has
resulted in significant changes in
the design of the
interfaces that flight
crews and controllers
have with the computers
that support their tasks
and in the operational
use of data link messages.
The changes enhance user
comprehension, reduce error
rates, and result in decreased
training requirements.

DESIGN FOR MAINTAINABILITY

AND IN-SERVICE SUPPORT

Over the past several years, airplane

maintenance has benefited from an
increased focus on how human factors
can contribute to safety and operational efficiency. In maintenance, as in
flight deck design, Boeing employs a
variety of sources to address human
factors issues, including

Perhaps the simplest example is the

progression from an aircraft communication addressing and reporting system
interface to a future air navigation
system (FANS) interface for data link.
Boeing initially studied the effects
of uplink message formats on pilot
comprehension in 747-400 operational
trials (fig. 1). Lessons learned were
used when designing the data link
interface in the Pegasus flight management system incorporated into
current-production 757 and 767 airplanes. These same changes are being
applied retroactively to the 747-400.
Another example is the 777 communications management interface,
which uses multifunction displays and
cursor controls to simplify management
of data-linked communications and
can be customized by operators.

Chief mechanic participation.

Computer-based maintainability
design tools.

Fault information team.

Customer support processes.

Chief mechanic participation.

Modeled on the role of chief pilot, a
chief mechanic was appointed to the
777 program and to all subsequent
airplane programs (717, 737-600/-700/
-800/-900, 757-300, and 767-400
Extended Range [ER]). As with the
chief pilot, the mechanic acts as an
advocate for operator or repair station
counterparts. The appointment of a
chief mechanic grew out of the
recognition that the maintenance
community contributes significantly
to the success of airline operations in
both safety and on-time performance.
Drawing on the experience of airline
and production mechanics, reliability
and maintainability engineers, and

2
FIGURE

CATIA HUMAN MODELING

human factors specialists, the chief

mechanic oversees the implementation
of all maintenance-related features.

Computer-based maintainability
design tools.
Beginning with the 777 program, Boeing
stopped building full-scale airplane
mockups, which in the past helped
determine whether a mechanic could
reach an airplane part for removal and
reinstallation. Now, using a computeraided three-dimensional interactive
application (CATIA), Boeing makes this
type of determination using a human
model. During design of the 737-600/
-700/-800/-900, Boeing used human
modeling analysis to determine that
the electrical/electronic bay needed to
be redesigned to allow a mechanic to
access all wire bundles for the expanded
set of avionics associated with the
updated flight deck concept (fig. 2).
In addition to ensuring access and
visibility, human factors specialists
conduct ergonomic analyses to assess
the human capability to perform maintenance procedures under different
circumstances. For example, when a
mechanic needs to turn a valve from
an awkward position, it is important
that the force required to turn the
valve must be within the mechanic's
capability in that posture. For another
example, when a maintenance operation
must be accomplished in poor weather
at night, secure footing and appropriate
handling forces are necessary to protect the mechanic from a fall or from
dropping a piece of equipment.

Fault information team (FIT).

Human factors considerations in maintenance also led to the formation of
the FIT. During development of the
737-600/-700/-800/-900, Boeing
chartered the FIT to promote effective
presentation of maintenance-related
information, including built-in test
equipment (BITE) and maintenance
documentation. The FIT charter has
since expanded to promote consistency
in maintenance processes and design
across all systems and models. The
goal is to enable mechanics to maintain all Boeing commercial airplanes
as efficiently and accurately as possible. This cross-functional team has

representatives from maintenance, engineering, human factors, and operators.

One of the teams primary functions
is to administer and update standards
that promote uniformity among Boeing
airplane maintenance displays. For
the text of these displays, Boeing has
created templates that provide for
common fault menus for all systems.
The interface should look the same to
the mechanic regardless of the vendor
or engineering organization that
designs the component. Engineers
responsible for airplane system design
coordinate their BITE and maintenance
design efforts with the FIT. The FIT
reviews all information used by the
mechanic, including placards, manuals,
training, and size, location, and layout
of controls and indicators, and works
with the engineers to develop effective,
consistent displays. The team also
provides input and updates to Boeing
design standards and requirements.

Customer support processes.

In the early 1990s, Boeing formed a
maintenance human factors group.
One of the groups major objectives
was to help operators implement the
Maintenance Error Decision Aid
(MEDA) process.
The group also helps maintenance
engineers improve their maintenance
products, including Aircraft Maintenance
Manuals, fault isolation manuals, and
service bulletins. As maintenance
support becomes more electronically
based, human factors considerations
have become an integral part of the
Boeing design process for tools such
as the Portable Maintenance Aid. In
addition, the group is developing a
human factors awareness training program for Boeing maintenance engineers
to help them benefit from human
factors principles and applications in
their customer support work.

ERROR MANAGEMENT

Failure to follow procedures is not

uncommon in incidents and accidents
related to both flight operations and
maintenance procedures. However, the
industry lacks insight into why such
errors occur. To date, the industry has

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not had a systematic and consistent

tool for investigating such incidents.
To improve this situation, Boeing has
developed human factors tools to help
understand why the errors occur and
develop suggestions for systematic
improvements.

Two of the tools operate on the philosophy that when airline personnel
(either flight crews or mechanics) make
errors, contributing factors in the work
environment are part of the causal
chain. To prevent such errors in the
future, those contributing factors must
be identified and, where possible,
eliminated or mitigated. The tools are

Procedural Event Analysis Tool.

Maintenance Error Decision Aid.

Procedural Event Analysis Tool (PEAT).

This tool, for which training began in
mid-1999, is an analytic tool created
to help the airline industry effectively
manage the risks associated with
flight crew procedural deviations. PEAT
assumes that there are reasons why
the flight crew member failed to follow
a procedure or made an error and that
the error was not intentional. Based
on this assumption, a trained investigator interviews the flight crew to
collect detailed information about the
procedural deviation and the contributing factors associated with it.
This detailed information is then
entered into a database for further
analysis. PEAT is the first industry
tool to focus on procedurally related
incident investigations in a consistent

and structured manner so that effective

remedies can be developed (see p. 31).

Maintenance Error Decision Aid (MEDA).

This tool began as an effort to collect
more information about maintenance
errors. It developed into a project to
provide maintenance organizations with
a standardized process for analyzing
contributing factors to errors and
developing possible corrective actions
(see Boeing Introduces MEDA in
Airliner magazine, AprilJune 1996, and
Human Factors Process for Reducing
Maintenance Errors in Aero no. 3,
October 1998). MEDA is intended to
help airlines shift from blaming maintenance personnel for making errors
to systematically investigating and
understanding contributing causes.
As with PEAT, MEDA is based on the
philosophy that errors result from a
series of related factors. In maintenance
practices, those factors typically include
misleading or incorrect information,
design issues, inadequate communication, and time pressure. Boeing maintenance human factors experts worked
with industry maintenance personnel
to develop the MEDA process. Once
developed, the process was tested with
eight operators under a contract with
the U.S. Federal Aviation Administration.

crews acquire, interpret, and integrate

data into information upon which to
base their actions. CIRA helps Boeing
understand how the crew arrived or
failed to arrive at an understanding of
events. Since it was developed in the
mid-1990s, CIRA has been applied
internally in safety analyses supporting
airplane design, accident and incident
analyses, and research.

Training aids.
Boeing has applied its human factors
expertise to help develop training aids
to improve flight safety. An example is
the companys participation with the
aviation industry on a takeoff safety
training aid to address rejected takeoff
runway accidents and incidents.
Boeing proposed and led a training

3
FIGURE

Human factors specialists use an

eyetracker to study pilot mode awareness in the 747-400 flight deck.

Three other tools that assist in

managing error are
Crew information requirements
analysis.

Training aids.

Improved use of automation.

4
FIGURE

Crew information requirements

analysis (CIRA).

Improved use of automation.

Both human factors scientists and
flight crews have reported that flight
crews can become confused about the
state of advanced automation, such as
the autopilot, autothrottle, and flight
management computer. This condition

is often referred to as decreased mode

awareness. It is a fact not only in aviation but also in todays computerized
offices, where personal computers
sometimes respond to a human input
in an unexpected manner. The Boeing
Human Factors organization is involved
in a number of activities to further
reduce or eliminate automation surprises and to ensure more complete
mode awareness by flight crews. The
primary approach is to better communicate the automated system principles,
better understand flight crew use of
automated systems, and systematically
document skilled flight crew strategies
for using automation. Boeing is conducting these activities in cooperation
with scientists from the U.S. National
Aeronautics and Space Administration
(fig. 3). When complete, Boeing will
use the results to improve future
designs of the crewmember-automation
interface and to make flight crew
training more effective and efficient.

Boeing developed the CIRA process to

better understand how flight crews
use the data and cues they are given.
It provides a way to analyze how

737-600/-700/-800/-900
OVERWING EMERGENCY EXIT

The overwing exit and the exit placard

were redesigned using human factors
methodology.

FLIGHT CREW HUMAN

FACTORS STUDY

Since the inception of MEDA in

1996, the Boeing maintenance human
factors group has provided on-site
implementation support to more than
100 organizations around the world.
A variety of operators have witnessed
substantial safety improvements, and
some have also experienced significant
economic benefits because of reduced
maintenance errors.

tool effort with participation from line

pilots in the industry. The team
designed and conducted scientifically
based simulator studies to determine
whether the proposed training aid
would be effective in helping crews
cope with this safety issue. Similarly,
the controlled flight into terrain
training aid resulted from a joint
effort by flight crew training instructor
pilots, human factors engineering,
and aerodynamics engineering.

PASSENGER CABIN DESIGN

The passenger cabin represents a significant human factors challenge related

to both passengers and cabin crews.
Human factors principles usually

associated with the flight deck are

now being applied to examine human
performance functions and ensure that
cabin crews and passengers are able to
do what they need or want to do.
Some recent examples illustrate how
the passenger cabin can benefit from
human factors expertise applied during
design. These include

Automatic overwing exit.

Other cabin applications.

Automatic overwing exit.

The 737-600/-700/-800/-900 is
equipped with an improved version of
the overwing emergency exit (fig. 4),
which opens automatically when activated by a passenger or cabin or flight
crew member. Human performance and
ergonomics methods played important
roles in both its design and testing.
Computer analyses using human models
ensured that both large and small
people would be able to operate the
exit door without injury. The handle
was redesigned and tested to ensure
that anyone could operate the door
using either single or double handgrips.
Then, approximately 200 people who
were unfamiliar with the design and
who had never operated an overwing
exit participated in tests to verify

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that the average adult can operate the

exit in an emergency. The exit tests
revealed a significantly improved capability to evacuate the airplane. This
major benefit was found to be unique
to the 737 configuration. The human
factors methodology applied during test
design and data analysis contributed
significantly to refining the door mechanism design for optimal performance.

Other cabin applications.

Working with payloads designers, human
factors specialists also evaluate cabin
crew and passenger reach capability,
placard comprehension, emergency
lighting adequacy, and other human
performance issues. Because of the focus
on human capabilities and limitations,
the analyses and design recommendations are effective in reducing potential
errors and in increasing usability and
satisfaction with Boeing products.
More general issues of human usability
have also been addressed. For instance,
human factors specialists collaborated
with engineers in various studies during 767-400ER program design. The
reach and visibility of the passenger
service units components were
reviewed so cabin crews could use
them more easily and effectively. The
glare ratio on the sidewalls was analyzed and improved for increased passenger comfort. In addition, the cabin
crew panel for controlling the in-flight
entertainment system was modified for
easier operation and maintainability.

PROCEDURAL EVENT ANALYSIS TOOL

In mid-1999 Boeing began distributing the Procedural Event
Analysis Tool (PEAT) to its operators. The company is offering
this safety tool to help operators understand the reasons
underlying incidents caused by flight crew deviation from
established procedures.
PEAT is a structured analytic tool (fig. 1) that operators can
use to investigate incidents and develop measures to prevent
similar events in the future. It is available to operators free
of charge and is the result of a cooperative development
effort among airlines, pilot union representatives, and Boeing
human factors specialists.

1
goal of the Boeing design philosophy
S U M M A R Y Ais chief
to build airplanes that can be flown
safely while offering operational efficiency. An essential part
of this philosophy is continuous improvement in designs and
flight crew training and procedures. Integral to this effort is
an ongoing attempt to better address human performance concerns as they relate to design, usability, maintainability, and
reliability. By continuously studying the interface between
human performance and commercial airplanes, Boeing continues
to help operators apply the latest human factors knowledge for
increased flight safety.

BOEING POSITION ON NONPUNITIVE REPORTING

Improving the safety of flight operations depends on
understanding the lessons learned from operational
events. Success depends on having sufficient data to
do so. Today the industrys data scope is limited
because the only data guaranteed to be collected is
that related to accidents and major incidents. A
more proactive approach is needed if we are to
move forward.

after any incident. We must be careful not to limit

data collection to any one segment of the safety
chain. Boeing believes that if we, the aviation community, hope to further reduce the overall accident
rate, we must continue to promote and implement
proactive, nonpunitive safety reporting programs
designed to collect and analyze aviation safety
information.

Unfortunately, it is difficult to obtain insightful

data in an aviation system that focuses on accountability. Flight and maintenance crews are often
unduly exposed to blame because they are the last
line of defense when unsafe conditions arise. We
must overcome this "blame" culture and encourage
all members of our operations to be forthcoming

CHARLES R. HIGGINS

J. KENNETH HIGGINS

VICE PRESIDENT, AVIATION

SAFETY AND AIRWORTHINESS
BOEING COMMERCIAL
AIRPLANES GROUP

VICE PRESIDENT, AIRPLANE

VALIDATION AND FLIGHT OPERATIONS
BOEING COMMERCIAL
AIRPLANES GROUP

THE PEAT PROCESS

FIGURE

Operations report (FOQA)

Crew report
(BASIS/ASIS, ASAP)

PEAT?

Yes
Explain PEAT
purpose and
philosophy
Collect
general
information

Collect
event
description

Airline
implements
enhancements

Identify
procedural
errors

Enter into
PEAT database

Analyze
contributing
factors

Analyze data
and trends

Develop
recommendations/share
with crew

Share data:
Internal
External

(voluntary)

very rarely fail to intentionally comply with a procedure.

In addition, operators must adopt an investigative
approach that fosters cooperation between the flight
crew and the safety officer conducting the investigation.
PEAT contains more than 200 analysis elements that
enable the safety officer to conduct an in-depth
investigation, summarize the findings, and integrate
them across various events. PEAT also enables operators
to track their progress in addressing the issues revealed
by the analyses.
Operators can realize several benefits by
using PEAT:
A structured, systematic approach
to investigations.
Monitor

Consistent application and results.

safety
performance
Visibility of incident trends and
risk areas.
Reduction or elimination of
procedural-related events.
Improved operational safety.
Improved economic efficiencies.
A means for communicating and
sharing relevant information between
organizations, both internal and
external to the airline.
Compatibility with existing industry
safety tools.
Operators must acquire hands-on training
to effectively adopt and apply the PEAT process and
software. Requests for training should be addressed
to Mike Moodi in Boeing Flight Technical Services
(fax 206-662-7812). More information is available on the
Boeing PEAT web site:

PEAT originated from an extensive effort to identify the

key underlying cognitive factors that contributed to procedural noncompliance in past accidents. In 1991 Boeing
concluded a 10-year study that showed that flight crew
deviation from established procedures contributed to nearly
50 percent of all hull-loss accidents. The aviation industry
http://www.boeing.com/news/techissues/peat/
still lacks sufficient knowledge about the reasons for these
deviations, however, and had
no formal investigation tool to
TAKING A COGNITIVE APPROACH
Crew
help identify them.
attention

In addition to helping operators find these reasons, PEAT

was designed to significantly
change how incident investigations are conducted. When
followed correctly, the PEAT
process focuses on a cognitive
approach (fig. 2) to understand
how and why the event
occurred, not who was responsible. Using PEAT successfully
depends on acknowledging the
philosophy that flight crews

FIGURE

resources

Contributing factors:
Procedural
Environmental/
Stimuli
facilities
Equipment
Situation awareness
Crew performance
shaping

Crew coordination
and communication

Technical knowledge,
skills, and experience
Others

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Crew
short-term
sensory
store

Crew
perception

Crew decision
and response
selection

Working
memory
Long-term
memory

Memory
Feedback

Crew
Crew actions
response
execution