54TH ANNUAL CONFERENCE, Sofia, Bulgaria, 20-24 April 2015WP No. 162Distractions at WorkplacePresented by PLC |
Summary
Distractions of all types occur in everyday life, but when they take place in air traffic control environment, the results can be serious and undesirable. Inefficient management of distractions may compromise aviation safety. The objective of this working paper is to understand the effect of distractions on Air Traffic Control Officers and develop prevention strategies and lines of defense to minimise their effects.
Introduction
1.1 Distractions occur frequently in operation rooms or at the controllers working positions (CWPs). Air Traffic Control Officers (ATCOs) are facing these distractions day to day apart from performing their duties. The detrimental effect of distractions poses considerable threats to the safe operation of the air traffic management (ATM) system which may cause significant safety issues.
1.2 Distractions in the workplace could be self-induced or caused by third party, others might have environmental or equipment causes. Some distractions can be prevented through training, self-discipline or adoption of effective procedures. Others cannot be controlled and/or avoided and therefore ATCOs must cope with them.
1.3 In this paper, different distraction types and their contributing factors will be identified. The effects and consequences that distractions have on ATCOs as well as overall ATM system performance and safety will be discussed. Strategies to reduce and/or cope with distractions in order to enhance air traffic safety will be formulated.
Discussion
2.1 Definitions
2.1.1 Distraction is defined as the behaviour observed when there was diversion of attention during the execution of a primary task and/or a response, either verbal, visual, or emotional response, to a secondary task related or not to the primary activity performing. Distraction is what attracts the eye, the mind or attention to a different object or, it attracts the subject to a direction other than to the implementation of the proposed task (Bruno Monteiro Tavares Pereira, Alexandre Monteiro Tavares Pereira, Clarissa dos Santos Correia, Antonio Carlos Marttos Jr., Rossano Kepler Alvim Fiorelli, TCBC – RJ, Gustavo Pereira Fraga TCBC – SP. Interruptions and distractions in the trauma operating room: understanding the threat of human error. Journal of the Brazilian College of Surgeons. Vol. 38 No. 5 Rio de Janeiro Sep/Oct 2011).
2.1.2 Distraction is defined by the Federal Aviation Administration (FAA) as:
“one’s attention is drawn away; mental or emotional confusion or disturbance occurs. When working among many people, with frequent work interruptions, or when coping with stress, it is easy to become distracted”.
2.2 Background
2.2.1 On 1st July 2002, a Russian-operated TU-154 passenger flight collided with a cargo Boeing 757-200 at night over Überlingen, Germany. All 71 people on board the two aircraft were killed. The duty ATCO was handling two workstations at that time and was distracted by a malfunctioning phone system under maintenance. All these contributed to the failure to detect the confliction between the two aircraft in time.
2.2.2 In August 2009, distraction of an ATCO led to a tragic plane crash between a private plane and a tourist helicopter in New York City which took the lives of nine people. The investigation revealed as a major factor the ATCO being involved in a personal phone call whilst on duty.
2.2.3 In April 2011, an ATCO had himself distracted watching a movie while ignoring planes in Cleveland Air Route Traffic Control Center in Oberlin, Ohio. A pilot reported the case after the controller left the microphone open for three minutes and broadcasted the movie’s soundtrack to aircraft on the frequency.
2.2.4 In September 2011, a BAE Systems Avro RJ85 on take-off roll at Gothenburg, Sweden came close to collision with a vehicle on the runway. Subsequent investigation discovered that shortly after issuing the RJ85 with departure clearance, while engaged in a non-essential conversation, the controller gave permission for the vehicle to enter the runway. The distracted ATCO lost track of the vehicle’s position and believed that it was behind the aircraft, but it was instead near midpoint of the runway.
2.3 Distraction Types
2.3.1 Self-induced distractions
Sensitive emotional states like divorce, sick child at home, close friends or relatives passed away, family burden etc.; physical states like feeling cold/hot (body temperature), hunger, fatigue, sickness etc.; personal conduct and discipline like playing with personal electronic devices (PEDs) e.g. cell phones, notebook, notepad, portable DVD players, picking up personal phone calls or texting messages, reading magazines or newspaper, eating etc.
2.3.2 Third party distractions
Non-essential conversation from other colleagues or loud conversation between colleagues, messages or coordination from other ATCOs, queries or comments from supervisors.
2.3.3 Operating environment
Extraneous noise like from vacuum cleaner, closing/opening of the door when people enter or leave the control room, temperature of the control room, glare or reflection of light from displays or monitors.
2.3.4 Equipment
Uncomfortable or inconvenient working position like the design, positioning and height of the console, ATCOs’ chair and headset, equipment malfunction warnings and alerts.
2.3.5 These distractions may be subtle and momentary or intrusive, obvious and continuing, irrespective of their duration and intensity, all can be disruptive to ATCOs’ performance and make it difficult for ATCOs to concentrate on the task at hand.
2.4 Effects and Consequences of Distractions on ATCO performance
2.4.1 The primary effect of distractions is the break down of the normal flow of ongoing activities. It attracts the eye, the mind or attention of an ATCO to a different object, or in a direction other than to the implementation of the proposed task. Distractions decrease focus and increase stress. It often causes the ATCO to feel being rushed and faced with competing tasks of varying priority. This can result in a perception of increase in workload even when the actual task load is reasonable and steady. As a result, an ATCO faced with concurrent task demands will typically focus on one or a few tasks while ignoring all others. This response is typical of most people when dealing with excessive workload.
“Human brains do not perform two tasks at the same time. The brain handles tasks sequentially, switching attention between one, then another. The more you multitask, the worse you are at it. Multitasking leads to as much as a 40% drop in productivity, increased stress, and a 10% drop in IQ .”
(American Psychological Association, March 20, 2006. Multitasking: Switching Costs – Subtle “switching” costs cut efficiency, raise risk.)
2.4.2 Frequent distractions can also have negative effect on one’s emotions. They can prevent one from getting the task being done on time and ATCOs may feel being swamped and rushed with tasks, and consequently makes them feel more frustrated at work, which may lead to intensifying poor work practice and acerbate all of the issues that lead to poor performance. A negative spiral effect is created where poor performance leads to more stress which leads to more poor performance, and so on, and thus further compromising safety issues. Distractions are frequent threats facing ATCOs and have been shown to lead to significant safety problems.
2.4.3 When distractions and interruptions take up too much time, they may break the thread of complex and lengthy procedures. Interruption has a disruptive effect on one’s task performance and emotional state, and the degree of disruption depends on one’s mental ability to disregard, resolve or eliminate those distractions or interruptions. There is a risk that an ATCO will fail to complete certain task and/or compromise the performance of a task, and hence, a threat is generated. A threat is a condition in the operating environment that affects or complicates the performance of a task or compliance with applicable standards, which may lead to errors or omissions and/or undesirable consequences.
According to the Flight Safety Foundation, the omission of an action or inadequate action is the most common causal factor of accidents and incidents.
2.4.4 Psychologists say distraction is the number one cause of forgetting things (Skybrary. (2012) The Human Factors “Dirty Dozen”). ATCOs are always thinking ahead. Thus, there is a natural tendency, when one is being distracted and then returning to a job, to think that he/she is further ahead than actually is. Unless mitigated by effective compensatory techniques, a disruption leading to a lapse of attention may result in failure to monitor the flight profile, missing or misinterpreting pilots read-backs or requests, omitting an action, failing to detect and correct a mistake, failing to detect a confliction, lagging behind the traffic and feeling overloaded due to combination of unfinished tasks and diverted attention to distractions.
2.4.5 If distractions are not managed well, they can seriously erode one’s ability to focus on the task and may cause an ATCO fail to take an intended action which may lead to poor performance and judgment, and may consequently cause serious or fatal mistakes.
2.5 Strategies to Minimise and Mitigate Distractions
2.5.1 Distraction as a human factor cannot, under any circumstances, be completely eliminated from the operating environment. In order to reduce distractions to ATCOs, actions are required at both the strategic and personal levels. ANSPs should identify the sources of distractions and develop infrastructure and implement policies or operating instructions to minimise their effects and reduce safety risks.
2.5.2 The following aspects should be considered to develop prevention strategies and lines of defense to mitigate the effects of distractions:
(I) identify and recognise potential sources of distractions;
(II) understand their effects;
(III) reduce distractions and interruptions; and
(IV) develop mitigation strategies and lines of defense to minimise their risks.
2.5.3 From a strategic point of view, the software engineering like the design of airspace, ATS route and handling procedures and techniques should allow ATCOs to achieve a safe, orderly and efficient air traffic flow without much coordination needed with other ATCOs, sectors or ATC units. Keeping coordination to a minimum and sticking to standard handling procedures could greatly reduce distractions posed to ATCOs while at work.
2.5.4 The provision of reliable, well-organised and user-friendly infrastructure is also vital to eliminate distractions to ATCOs in utilising the hardware while performing their duties. The failure of an equipment may turn a routine procedure into a challenging event, thus ANSPs should ensure proper maintenance of the equipment and establish backup procedures in case of any unforeseen situation arise. Nuisance alerts and warnings could be extremely distractive to the primary task performance of ATCOs. They interrupt the current task flow and distract the ATCOs to determine whether the alerts/warnings are genuine and informative. There will be a time lag for an ATCO to resume the task at hand after the distractions. The delayed actions may cause an ATCO to feel lagged behind, rushed with task or even lapse of concentration. If nuisance alerts and false warnings occur too frequently, vice versa, this may lead to the problem of complacency and people start to ignore warnings and alerts even though they are genuine.
2.5.5 CWPs’ design and their positioning, operation room seating arrangement, ambient temperature, noise level and lighting could all affect the physical state of an ATCO and may induced distractions to them insidiously. Collaborative efforts and thorough communication between engineers and frontline air traffic controllers are needed to establish a distraction-free operating environment.
2.5.6 ANSPs should provide adequate training to ATCOs in raising the awareness of distractions, understanding their effects and the importance of eliminating distractions, building the line of defense as well as recovery from unavoidable distractions and restore situational awareness. Through the training, ATCOs should be able to (Skybrary. (2012) Managing Interruptions and Distractions):
(I) Recognise the disturbance, i.e. distractions;
(II) Identify what was the primary task;
(III) Remember where was the task being interrupted;
(IV) Decide what decisions or actions should be taken to return to the primary task;
(V) Act and Prioritise between tasks;
(VI) Plan the actions;
(VII) Review and verify.
2.5.7 It is a management challenge to promote distraction awareness among ATCOs and implement effective policies to eliminate distractions as far as practicable. In March 2013 in the United States, the National Air Traffic Controllers Association (NATCA) and the Federal Aviation Administration (FAA) started a joint communication campaign called “Turn Off, Tune In”, meaning “Turn Off” distractions and “Tune In” to safety. The goal of this campaign is to uphold the safety of the Nation Airspace System (NAS) through building continued awareness and education regarding the safety impact of distractions, with an emphasis on electronic distractions. No text message, email, website or distraction is worth the risk of endangering the lives of the flying public and/or compromising the safety of the NAS. FAA management supported the campaign by issuing guidance for its local managers. It is very encouraging that aviation organisations are dedicated to address the problem of distractions on ATM safety. ANSPs worldwide could organise similar educational campaign and give proper guidance to supervisors/managers to advocate the awareness of distractions and the importance of eliminate distractions, not necessarily restricted to electronic devices only. Supervisors/managers play an important role in building consensus among employees and reinforcing the proposed policies so as to reduce distractions and promote safety in the aviation industry.
2.5.8 Air traffic control safety and professionalism are of equal importance to the entire ATM system. ATCOs’ self-discipline and code of conduct within the control room are vital to maintain their professional behaviour and standards of performance. In fostering professionalism, many of the self-induced distractions, like emotions, stress, fatigue, reading magazines, playing with electronic devices, engaging in private phone calls or text messages, could be avoided. ATCOs should also avoid being a third-party distraction to others like talking loud or involving in non-essential conversations while at work, especially during critical timing of handover and takeover process where there is high risk of occurrences. Professionalism involves more than just what one does while on duty, it means everyone must report ready to work both physically and emotionally. That means all air traffic employees must manage their time off and personal matters appropriately and be rested and ready for duty. Air traffic control training programs should incorporate topics like how to deal with stress, fatigue, or manage emotions and emphasize good practices at work to make sure air traffic controllers learn the right disciplines apart from mastering the right skills and techniques.
Conclusions
3.1 Distraction draws one’s attention away from the task on which they are employed. Distractions decrease focus and increase stress. In ATC environment, ATCOs may fail to complete certain tasks or degrade in performance and the results could be serious which compromise aviation safety.
3.2 Some distractions are avoidable like self-induced distractions and could be managed through self-discipline and good practice at work. Some are unavoidable like third party distractions, operating environment and equipment. Effective management at both strategic and personal level are required to mitigate and minimise the effect of distractions on ATCOs’ performance.
Recommendations
4.1 It is recommended that this paper is accepted as information material.
4.2 It is recommended that the Executive Board be tasked to develop an Educational Initiative on Distractions at the Workplace.
References
American Psychological Association. Multitasking: Switching Costs – Subtle “switching” costs cut efficiency, raise risk. March 20, 2006.
AviationKnowledge. (2012) Distraction implications for Air Traffic Controllers (ATCO’s). https://aviationknowledge.wikidot.com/aviation:distraction-implications-for-air-traffic-control-at
Brian P Bailey, Joseph A Konstan, John V Carlis. The Effects of Interruptions on Task Performance, Annoyance, and Anxiety in the User Interface. University of Minnesota, Department of Computer Science and Engineering, Minneapolis, MN 55455.
Bruno Monteiro Tavares Pereira, Alexandre Monteiro Tavares Pereira, Clarissa dos Santos Correia, Antonio Carlos Marttos Jr., Rossano Kepler Alvim Fiorelli, TCBC – RJ, Gustavo Pereira Fraga TCBC – SP. Interruptions and distractions in the trauma operating room: understanding the threat of human error. Journal of the Brazilian College of Surgeons. Vol. 38 No. 5 Rio de Janeiro Sep/Oct 2011.
Cable News Network. (2011) Movie-watching the latest distraction in air traffic control saga. https://edition.cnn.com/2011/US/04/19/air.traffic.movie.watching/
Elizabeth Allan Flynn, Kenneth N Barker, JTyrone Gibson, Robert E Pearson, Bruce A Berger, Leo A Smith. Impact of Interruptions and Distractions on Dispensing Errors in an Ambulatory Care Pharmacy. Am J Health-Syst Pharm. 1999; 56:1319-25.
FlightGlobal Aviation Connected. (2012) Near-incursion prompts Swedes to float sterile-tower concept. https://www.flightglobal.com/news/articles/near-incursion-prompts-swedes-to-float-sterile-tower-376209/
LawyersandSettlements.com (2010) Pilot Error, Air Traffic Controller Distraction Resulted in Plane Crash. https://www.lawyersandsettlements.com/articles/plane_crashes/plane-crash-airplane-crashes-60-15058.html#.VLj8v0bXfCT
Skybrary. (2011) Interruption or Distraction. https://www.skybrary.aero/index.php/Interruption_or_Distraction
Skybrary. (2012) Managing Interruptions and Distractions. https://www.skybrary.aero/index.php/Managing_Interruptions_and_Distractions_(OGHFA_BN)
Skybrary. (2012) The Human Factors “Dirty Dozen”. https://www.skybrary.aero/index.php/The_Human_Factors_%22Dirty_Dozen%22
The Seattle Times. (2011) Distracted air traffic controllers a dangerous symptom of workplace problems. https://seattletimes.com/html/travel/2014836014_webairtrafficcontrollers21.html
Last Update: October 1, 2020