8
Systems Management

Over the next several years, the Federal Aviation Administration is planning major changes in the air traffic control system through the introduction of more highly automated equipment. In preparation, the agency will want to assess its existing management system in terms of its capacity to effectively support the change process. Our purpose in this chapter is to begin that assessment as a basis for providing managers with a framework for developing strategies, procedures, and organizational structures to help manage the anticipated changes. The discussion focuses on the internal structure and culture factors that form the context within which the air traffic control system operates and on the external factors that influence both the mission and the context. Of particular importance is the interaction between the structure and the culture as it relates to the acceptance of change.

The mission of the Federal Aviation Administration is to promote safety of flight and to foster the development of air commerce (Public Law 85-726). The manner and extent to which the FAA fulfills this dual mandate is scrutinized by constituent users, as well as by a variety of external groups. These groups exert pressures on FAA management to adjust its policies, priorities, procedures, and resources to maximize the efficiency of air travel while maintaining public confidence with respect to the safety of the air traffic control system (Broderick, 1995; Daschle, 1995; Hinson, 1995a). Congress establishes statutes (e.g., amendments to the Federal Aviation Act of 1958) and funding appropriations that constitute limiting conditions within which the FAA management must operate. Local governments also establish regulations—governing, for example, noise abatement and physical construction—that constrain FAA development and operations



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Flight to the Future: Human Factors in Air Traffic Control 8 Systems Management Over the next several years, the Federal Aviation Administration is planning major changes in the air traffic control system through the introduction of more highly automated equipment. In preparation, the agency will want to assess its existing management system in terms of its capacity to effectively support the change process. Our purpose in this chapter is to begin that assessment as a basis for providing managers with a framework for developing strategies, procedures, and organizational structures to help manage the anticipated changes. The discussion focuses on the internal structure and culture factors that form the context within which the air traffic control system operates and on the external factors that influence both the mission and the context. Of particular importance is the interaction between the structure and the culture as it relates to the acceptance of change. The mission of the Federal Aviation Administration is to promote safety of flight and to foster the development of air commerce (Public Law 85-726). The manner and extent to which the FAA fulfills this dual mandate is scrutinized by constituent users, as well as by a variety of external groups. These groups exert pressures on FAA management to adjust its policies, priorities, procedures, and resources to maximize the efficiency of air travel while maintaining public confidence with respect to the safety of the air traffic control system (Broderick, 1995; Daschle, 1995; Hinson, 1995a). Congress establishes statutes (e.g., amendments to the Federal Aviation Act of 1958) and funding appropriations that constitute limiting conditions within which the FAA management must operate. Local governments also establish regulations—governing, for example, noise abatement and physical construction—that constrain FAA development and operations

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Flight to the Future: Human Factors in Air Traffic Control in their areas. The representatives of air carriers, general aviation, and the military compete for limited resources. The National Transportation Safety Board, other agencies of the executive branch of government, aviation labor unions, representatives of litigants in aviation accidents, environmental groups, and the press also investigate FAA management and operations (Office of Technology Assessment, 1988; Daschle, 1995; Hinson, 1995a). Pressures are also created by other environmental factors. The projected growth in air traffic yields the prediction that both technological and procedural changes in air traffic control must be made to avert future overload of the system and its controllers—especially because there are practical limits to what can be achieved by adding more controllers. The development of new technologies also pressures FAA management, offering potential solutions to both safety and efficiency concerns while posing challenges regarding the optimal role of controllers and automation and the transition to new technology. The challenges posed by the predicted growth in air traffic, the aging of existing equipment, and the implementation of new technology are compounded by increasingly severe economic constraints, affecting both government budgets and the aviation industry (Office of Technology Assessment, 1988; Broderick, 1995; Daschle, 1995; Hinson, 1995a). In response to these pressures, the FAA has established formal statements of its vision, mission, and values (Federal Aviation Administration, 1995a, 1995f). These statements (paraphrased here) identify the following goals: make responsibility commensurate with authority; deliver, individually and institutionally, the highest-quality service (including maintenance of safety) on time at the lowest cost; adopt teamwork as the way of doing business and work collaboratively across organizations; empower employees to do their jobs, by providing the resources they require, involving them in decisions that affect their work, and allowing timely decisions to be made at the lowest organizational levels; foster trust, openness, dignity, integrity, and respect for the knowledge and expertise of the workforce; encourage employees to speak out, even when what they say is not popular; and encourage openness to new ideas and new ways of doing business. It is significant that these vision and values statements do not address the question of how trade-offs between conflicting goals are to be made or resolved. Such trade-offs bring management and organizational options into the purview of human factors, which can help resolve them. APPROACHES TO DESCRIBING THE CONTEXT OF AIR TRAFFIC CONTROL TASKS Several approaches have been taken to characterizing the organizational structure and culture in organizations concerned with maximizing safety. These approaches are presented in the work of Harss et al. (1990), International Civil Aviation Organization (1993), Moray and Huey (1988) and Reason (1987a,

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Flight to the Future: Human Factors in Air Traffic Control FIGURE 8.1 An air traffic control system management model. 1987b). One compelling approach suggests that air traffic controllers perform their tasks in the context of a "high-reliability organization" (HRO); this type of organization manages an extremely complex set of interacting technologies and is required to perform—and does perform—at an extraordinary level of safety and productive capacity in the face of catastrophic consequences of failure. Examples of other high-reliability organizations are nuclear power plants and aircraft carriers. The performance of operators and technicians in such organizations is affected by organizational context factors such as: operating rules, patterns of interdependency, decision-making and communication dynamics, and norms of behavior. Each of these factors can be defined both formally, for example, by written procedures, and informally, as part of the organizational culture (LaPorte, 1987, 1988, 1996a, 1996b; LaPorte and Consolini, 1991). The panel's approach is illustrated by Figure 8.1, which depicts the relationship between the various factors contributing to or influencing FAA management. As the figure illustrates, FAA management is influenced by its own stated goals and by the external pressures exerted by interest groups outside the agency. Taking into account these influences, as well as assessments of safety and efficiency, FAA management establishes and adjusts the formal organizational context and also influences the informal organizational context.

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Flight to the Future: Human Factors in Air Traffic Control LaPorte (1988) and LaPorte and Consolini (1991) reviewed large-scale, high-reliability organizations, including the FAA's air traffic control organization. They asked "How can a large, complex organization like the FAA manage to maintain virtually failure-free (high-reliability) performance despite equipment unreliability and the trial-and-error process characteristic of large organizations?" They found that such organizations, including the FAA, typically establish complex, detailed, hierarchical organizational structures bolstered by equally complex and standardized procedures that usually facilitate operations. These structures and procedures are often effectively bypassed at the field level, however, when planned or unplanned situations arise that require operations in response to a crisis or peak system loading. In these high-tempo situations, authority patterns shift to a basis of functional skill that is situation-dependent. In these modes, task-oriented leaders are spontaneously recognized by their coworkers—the individuals who possess the situational skill requirements become the de facto task leaders. LaPorte and Consolini suggest that this informal authority structure achieves the flexibility, teamwork, communication, and interdependent coordination that is required to maintain the high reliability of the system. These ad hoc adaptations allow what is normally a formal bureaucracy to function temporally in a highly flexible and inventive manner. The question is how to ensure that such adaptive flexibility is retained in an environment that is increasingly stressed and is increasingly dependent on very advanced technology. Before undertaking any major organizational restructuring, it may be worth-while to identify the organizational features that tend to ensure the capability to shift into a dynamic problem-solving state when it is needed. Such a study would benefit from a "bottom-up" observation of the informal leadership patterns of the organization (what works in practice), rather than from implementing only topdown reorganizations based on what may work in theory. In any case, both the formal and informal contexts influence the controller's performance. This performance yields safety and efficiency indicators that are monitored by both the FAA management and external constituents. In the sections that follow, we examine each of these interacting factors. ASSESSING SAFETY AND EFFICIENCY Safety and efficiency indicators are critical links between organizational context factors and FAA management and between the agency and external groups. Safety and efficiency indicators can both spur changes to the formal organizational context and help to validate its effects. Policies and procedures to manage the simultaneous achievement of these two organizational goals constitute a key feature of the air traffic organizational context. Accident rates, incident rates (aircraft incidents, near-midair collisions, deviations, runway incursions, operational errors), and hazards are major indicators of the level of safety. The relationship between the three may be described by a

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Flight to the Future: Human Factors in Air Traffic Control "tip of the iceberg" metaphor. Relatively few accidents, visible above the water line, suggest more numerous incidents, which are hidden and often unreported (submerged). However, such incidents may be symptomatic of latent situations that can lead to organizational accidents. Inadequacies at the organizational level can contribute directly to hazards, incidents, and accidents, for example, by failing to provide adequate resources to controllers, establishing inappropriate or conflicting rules for operations, incorrectly predicting the consequences of using the resources according to the rules, and neglecting to provide processes for reporting and analyzing safety issues and for correcting them. These direct links between antecedent formal organizational context variables and safety outcomes are critically important. The FAA has developed extensive experience with these links; in fact, the air traffic control system has been characterized as a network of resources (infrastructures and operational support equipment) and rules (procedures) that have evolved largely in response to practical lessons learned through accidents and incident (Planzer, 1995). The FAA regularly collects safety-related performance measures that include (1) for air traffic control: operational errors and operational deviations, runway incursions, air traffic delays, results of periodic on-site evaluations, and in-flight evaluation reviews and (2) for airway facilities: facility and service interruptions and outages, facility flight checks, and results of on-site inspections and evaluations (Federal Aviation Administration, 1989, 1994a). The FAA also maintains a number of databases in which safety-related data are recorded for analysis: The Air Traffic Activity Data System (ATADS) is a national system that records facility-specific monthly activities. The Air Traffic Operations Management System (ATOMS) is a personal computer network linking FAA headquarters, regions, and facilities; ATOMS contains data on operation levels and delays. The Operations Network (Ops Net) system records monthly data on out-ages, interruptions, and reduced services. The National Airspace Information Monitoring System (NAIMS) is an automated data system that tracks reported safety-related incidents such as operational errors, operational deviations, and near-midair collisions. The Aviation Safety Reporting System (ASRS) includes an FAA/NASA database that stores voluntary reports by pilots, controllers, passengers, and mechanics on safety-related events or conditions. ASRS reports preserve the confidentiality of the reporter. The Facility Flight Check database stores data from airborne computers and is used to periodically check the performance of NAVAID facilities. The evaluations of field operations performed periodically by the air traffic and airway facilities organizations are reported and stored for later review.

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Flight to the Future: Human Factors in Air Traffic Control In addition to these data collection efforts, each air traffic control facility records data sufficient to recreate both the state of the system and the operations (and voice communications) of controllers at the time of incidents that require investigation. The Office of Technology Assessment (1988) points out that the safety data collection system must produce data that are meaningful and can be manageably reviewed and analyzed. The FAA is in the process of developing an automated safety database that unifies the existing independent (and in some cases redundant) databases and provides a more user-friendly interface that supports efficient analysis. Beyond that, however, individuals must be motivated to report relevant incidents. The ASRS, for example, provides an opportunity for controllers, pilots, mechanics, and passengers to report observations and concerns pertinent to safety; its features of preserving confidentiality and permitting anonymity support the motivation to report information. In addition to espousing its stated goals of open communication, honesty, and trust, the FAA's safety office would benefit from advocating the perception that reporting safety (e.g., error) data represents an achievement—not a failure—and that such achievements are rewarded. The unique organizational position of the System Safety Office within the FAA provides it with the opportunity to consider the following recommendation, made by both the International Civil Aviation Organization Circular (1993) and Wood (1991): safety analysis should not be limited to consideration of the factors related to the situation, equipment, and personnel that are often emphasized subsequent to incidents and accidents. Rather, safety analysis should include careful attention to organizational context factors and extraorganizational factors that may contribute to safety issues—including factors contributing to "accident waiting to happen" situations. On this account, consideration should be given to enhancing such reporting mechanisms as the ASRS by including prompts that assist reporters in (1) considering concerns related to the formal organizational context and to organizational culture and (2) considering factors that predict future safety concerns. Indicators of organizational efficiency that are frequently addressed include capacity/demand ratio, delays, flexibility, predictability, access, and monetary cost. Although there is no universally accepted definition of efficiency for air traffic control, the primary definition applied by the FAA is the extent to which the capacity of system resources keeps up with demand, and the traditional measure of efficiency has been traffic delay (Federal Aviation Administration, 1996a). The FAA, however, is working with the aviation industry to develop and validate three additional measures of efficiency: (1) flexibility, the ability of the system to meet users' changing needs, (2) predictability, the variance in the system experienced by the user, and (3) access, the ability of users to enter the system and obtain service on demand (Federal Aviation Administration, 1996a). The measurement of the efficiency of the air traffic control system is complicated

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Flight to the Future: Human Factors in Air Traffic Control by the need to take into account the dynamic nature of both capacity and demand and the different contributions of various system resources (Federal Aviation Administration, 1993a). Demand, as indicated by the number of aircraft that wish to land at and take off from a given airport at a given time, can change as a function of many things, for example, aircraft fleet conditions and special events. Although ground space and the number of runways at a given airport are often taken as capacity limiters, this capacity can be dynamically altered by such factors as weather conditions, winds, and the mix of aircraft types. Measures of system capacity are insufficient to determine efficiency; the capacity of individual resources must also be considered. These resources, whose capacity can also change dynamically, include airspace subsystems (e.g., surveillance, navigation, communications, flight data processing) and air traffic controllers, whose capacity is often discussed in terms of workload. The FAA's consideration of efficiency increasingly attempts to take into account the monetary costs to the airline industry associated with the efficiency definitions mentioned above. For example, departure and landing delays translate to sizable monetary costs for the airlines (Planzer and Jenny, 1995). The FAA must also consider its own funding limitations; definitions of efficiency that stress maximizing capacity (Federal Aviation Administration, 1996a) may be inappropriate, because expending resources to achieve capacity that goes unused is not cost-effective. On that account, definitions of efficiency that emphasize balancing capacity and demand—enough but not too much—represent greater efficiency with respect to monetary costs. FORMAL ORGANIZATIONAL CONTEXT VARIABLES It is the responsibility of management to develop a formal organizational context for providing adequate resources (including reliable equipment and competent staff), appropriate rules for employing the resources to perform jobs effectively, and mechanisms for instituting changes as needed. The rules established by management constrain both who utilizes which resources and how the resources are to be utilized. Formal structural lines of authority, responsibility, and communication identify individuals and groups authorized to perform specified tasks and to make specified decisions. Policies and procedures (e.g., those governing safety and efficiency), sometimes constrained by legal liability considerations, establish the framework for decision making, priorities for the allocation and scheduling of resources, and approaches to the performance of tasks. The formal organizational context also includes procedures for determining the effectiveness of rules and the adequacy of resources. processes of change include procedures for assessing what changes to personnel, technology, and formal organizational context are necessary and feasible; for implementing the changes; and for evaluating the effects.

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Flight to the Future: Human Factors in Air Traffic Control The following discussion focuses on selected formal organizational context factors that may impact controller performance: Policies governing safety and efficiency, Authority and responsibility, Personnel policies and procedures including communication and teamwork, workload, work schedules, performance assessment, personnel development, and legal liability, and Labor-management relations. Policies and Procedures Governing Safety and Efficiency The FAA has clearly stated that, when the goals of safety and efficiency conflict, maintaining the safety of air travel is the agency's first priority (Broderick, 1995; Hinson, 1995a; Federal Aviation Administration, 1996a). In an effort to enhance human reliability and contain errors, the FAA prescribes detailed procedures that govern the operational activities of controllers. For example, FAA Order 7110.65J (1995b) prescribes air traffic control procedures, including the instruction to controllers to: ''Give first priority to separating aircraft and issuing safety alerts as required in this order. Good judgment shall be used in prioritizing all other provisions of this order based on the requirements of the situation at hand." The FAA also faces the challenge of improving safety and efficiency while finding new ways to cut costs (Daschle, 1995; Hinson, 1995a). This challenge is made more difficult by the fact that "aviation is so safe today that it takes major efforts to make even minor gains" (Hinson, 1995b). The FAA's strategic plan for 1995 emphasizes that, although resources are scarce (Volume 2, Section 1, "System Safety"): FAA will not sacrifice safety because of resources. Instead, FAA must find ways to maintain and even improve worldwide safety without requiring more resources. That means targeting FAA safety efforts where they will be most effective. It means risk assessment that compares the costs of FAA actions to both itself and the aviation community against the reduced risks of people being hurt and killed in aviation accidents and incidents. It means careful assessment of the most cost effective way to achieve an objective. The achievement of both safety and efficiency goals is complicated by (1) changing criteria of acceptability for both safety and efficiency, (2) possibly complex interactions between safety and efficiency, and (3) possible variance in controllers' interpretations of and responses to these objectives. To allocate resources effectively, to apply appropriate technologies and strategies for improvement, and to validate improvements, the establishment of clear indicators and definitions of acceptability for safety and for efficiency must be coupled with

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Flight to the Future: Human Factors in Air Traffic Control an understanding of the relationship between safety and efficiency and between individual indicators. Achieving multiple objectives (maintain and improve safety, maximize efficiency, and reduce costs) concurrently is likely to be complicated. A strategy to improve a given indicator may affect a different indicator, and an understanding of these interactions is also necessary if simultaneous objectives are to be achieved. For example, on one hand, introduction of an improved navigation system may improve both safety and efficiency indicators. On the other hand, the introduction of a procedure may improve safety but reduce efficiency by causing flight delays. These relationships also may change at different threshold points. For example, efficiency may be improved without affecting safety by reducing separation cushions to reduce delay (independent relationship) up to some threshold, at which further reduction in separation detracts from safety (negative correlation), particularly if unexpected crises develop in the airspace. Given the possibilities for complicated relationships, the unknowns associated with emerging indicators, and the importance of effective allocation of resources to improvement strategies, the FAA should strive to develop predictive models that establish the indicators, the levels of acceptability, and the relationships between indicators. Human reliability and good judgment are required to meet safety and efficiency goals. The strategies whereby controllers develop and apply judgments, especially in translating formal procedures to nonstandard situations, and when attempting to maximize efficiency while maintaining safety, are important areas for study. According to LaPorte and Consolini (1991), in high-tempo modes, what works in practice may differ from what works in theory. This supports the suggestion that the development of formal organizational structures and procedures should take into account the successful operations of informal structures and procedures. When formal structures and procedures are defined and promulgated "from the top" without due reference to the interpretations, perceptions, and practical experience of those required to implement them, the following potential problems can occur and can be difficult to resolve: (1) required actions may be inappropriate to specific circumstances; (2) they may be ambiguously specified; (3) their purpose may be unclear; (4) they may be unnecessarily laborious; and (5) they may conflict with other policies or procedures. This is not to say that FAA management does not take into account the experience and knowledge base of controllers when formulating organizational structures and procedures; it does. However, what we are suggesting is that additional study of controllers' informal organizations and procedures is needed to further elicit information from that experience and knowledge base. Moreover, decisions about automation need to take into account the critical importance of designing to enhance human reliability and good judgment. Other problems may also arise. Procedural failures diminish management's credibility in the eyes of the workers. Bad rules encourage more general contempt

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Flight to the Future: Human Factors in Air Traffic Control for rules. Research has shown that rules and procedures can have an adverse effect when applied to tasks that people are intrinsically motivated to perform (Deci et al., 1989). The more people are managed through external controls, the less likely they are to take personal responsibility for their tasks. This suggests that, to encourage controllers to develop and apply effective strategies to achieve both safety and efficiency objectives, rules and procedures should be kept to the minimum necessary to provide an adequate formal organizational context for safe and efficient working. Authority and Responsibility The key features of the FAA's major lines of authority and responsibility include: (1) a hierarchical chain of authority and responsibility organized along functional lines of business, (2) extension of direct chains of command from headquarters through regional and facility levels, and (3) a System Safety Office reporting directly to the FAA administrator. That authority structure reflects a recent reorganization spurred, in part, by external pressures. A 1988 report by the Office of Technology Assessment (OTA), Safe Skies for Tomorrow, summarized the major external pressures that suggested the need for change (p. 45): Although commercial aviation maintains an enviable safety record, dramatic growth in air travel, major changes in technology and industry operations and structure, the firing of air traffic controllers, and Federal budget constraints have left the FAA scrambling to catch up. Consequently, public attention has again focused sharply on whether the FAA has the institutional capability and resources to carry out its operation, standard setting, rulemaking, and technology development functions effectively and to guarantee compliance through its inspection programs. The OTA report concluded that a fundamental organizational problem within the FAA's air traffic control organization was the "splintering of authority" between headquarters management and the nine regional offices, which have broad and separate authority (p. 52). Such splintering of authority can result in confusion about responsibilities and in lack of accountability, which becomes especially salient with respect to safety responsibilities. In response to congressional concerns reflected in the OTA report, increasing industry demands that the efficiency mandate be more forcefully addressed, general federal budget constraints (including the requirement to downsize staff), and increasing public demands for higher standards of safety (fueled by reports of safety incidents and accidents and of the decreasing reliability of air traffic control equipment), the FAA announced in 1994 the restructuring of its organization (Federal Aviation Administration, 1994b, 1994c). In addition to the overall goal of making accountability commensurate with authority, the reorganization specifically addresses the OTA report's concern

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Flight to the Future: Human Factors in Air Traffic Control about the splintering of authority between FAA headquarters and regional management. Under the reorganization, the nine regional administrators remain responsible for carrying out the policies and regulations set by headquarters management. Each regional administrator reports to the associate administrator for administration, serving as the "eyes and ears" of the FAA administrator. However, regional administrators have no line authority over the operating services located within their regions. The regional operating services (including division managers for air traffic control, airports, flight standards regulation and certification, security, and airway facilities) have line authority over the field personnel and facilities within their respective regions, and they maintain the lines of accountability by reporting directly to their respective associate administrators at FAA headquarters. Another rationale for the reorganization is to achieve a combination of simplicity and flexibility that will allow the FAA to adapt quickly to the constantly changing demands of the aviation industry (Daschle, 1995). The reorganization undertaken in 1994 to address this problem can be characterized as centralized and hierarchical, a feature of high-reliability organizations. One advantage of this centralization may be the clarification of formal accountability. Another advantage may be the ability to standardize policies and policy interpretation; this would reduce confusion in the field and enhance employee morale. There remain, however, three essential questions concerning the practical utility of the reorganization with respect to meeting those goals: Are the leaders individually appropriate to their roles? Does the reorganization extend appropriately beyond headquarters to the field level? Are the formal structures compatible with the informal structures? The 1994 reorganization identifies stable offices and clear lines of authority, another feature of high reliability organizations. However, the FAA's frequent reorganizations have combined with a practice of moving managers through a variety of positions as a means of career progression, producing a continuing "musical chairs" among the leadership. Accountability holds more force when the accountable leader expects to remain accountable in the given office. Particularly when career progression involves competition, as it does at FAA headquarters, it is doubtful that either simple or complex reorganization of the formal authority and responsibility chart can produce the hoped-for teamwork, flexibility, and dynamic responsiveness. The 1994 reorganization primarily addresses headquarters functions. By implication, regional and facility offices participate in the reorganization, but they have not undergone fundamental internal reorganization. The question of possible gaps or discrepancies between the philosophies of headquarters and field management remains. The headquarters organization exhibits a hierarchical structure while espousing a "flat" teamwork philosophy. Which approach is actually

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Flight to the Future: Human Factors in Air Traffic Control defined in the collective bargaining agreement and the QTP process represent positive steps to ensure that controllers have a voice in how they work and what tools they use. INFORMAL ORGANIZATIONAL CONTEXT VARIABLES The culture of an organization characterizes both its informal workings and its climate and morale. It therefore characterizes workers' perceptions, attitudes, and behavioral norms, which may or may not agree with the formal organizational context. As Figure 8.1 illustrates, informal and formal contexts interact, both are affected by and influence management strategies, and both impact safety and efficiency. The FAA's strategic plan and vision statements acknowledge the importance of cultural factors and their likely interconnection with formal organizational context factors, as well as with safety and efficiency. Experience and research in the field of industrial and organizational psychology generally suggest that inadequate, inappropriate, or conflicting formal organizational rules, consequences, change processes, and resources contribute to negative organizational cultural climate, and, conversely, can result from them. It is also true that, when adequate and appropriate, formal organizational context factors can help to produce a positive culture, and vice versa. However, a robust set of quantitative and qualitative data is needed to define the extent to which and ways in which organizational culture factors can act as mediating variables, enhancing or detracting from both the formal features of organizational context and the performance of air traffic controllers. Reason (1987a, 1987b) and Stager (1990) provide detailed discussion of cognitive functions pertinent to such safety- and efficiency-related tasks as air traffic control; their unified conclusion suggests that the playing field on which mediating organizational culture variables exert their influence is the cognitive "environment" (Stager) of the controller. Four key factors that influence controllers' cognitive performance are: (1) the amount of correspondence and conflict between formal and informal norms and rules, (2) subculture differences, (3) job satisfaction, and (4) attitudes toward change. Informal Norms and Rules The cultural framework within which the formal organizational context is enacted is comprised of attitudes, perceptions, and behavioral norms that have evolved over a long period of time. A key element of this interaction between culture and formal context is the underlying dynamic of the communication among operators, technical professionals, and managers. Managers and technical professionals often enact formal structures, policies, and procedures to reinforce management control. If these procedures complement cultural norms, the resulting

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Flight to the Future: Human Factors in Air Traffic Control enhancement of job satisfaction, teamwork, and cooperative implementation of changes helps to explain how high-reliability organizations such as air traffic control manage to perform at an extraordinary level of safety and productive capacity in the face of very demanding circumstances. If management enacts formal context features that abrogate the cultural norms, then dissatisfaction and poor performance may result (LaPorte, 1996a). Westrum (1990) identifies as a link between informal and formal organizational contexts the receptivity of management to the communication of perceived problems. Westrum distinguishes three kinds of organizational culture: In pathological cultures, managers do not wish to know of safety problems, treat punitively those who report problems, avoid responsibility for problems, punish those associated with errors, and actively suppress new ideas. In bureaucratic cultures, managers may not be informed of problems (if the communication process does not involve them), passively receive information, accept responsibility for problems only if it is assigned to them, prefer to localize response strategies, and discourage new ideas. In generative cultures, managers actively seek out information (including reports of problems), train subordinates to seek out and to report information, share responsibility, respond to problems with far-reaching inquiries, and welcome new ideas—including those pertaining to organizational change. The FAA is attempting to promote a generative culture by endorsing goals of encouraging openness, communication, and uncensored reporting. LaPorte and Consolini point out that high-reliability, high-hazard organizations are especially driven to use a preventive decision-making strategy that encourages the discovery of potential problems and rewards reporting of them. Subcultures Although supporting data are anecdotal, subculture differences are known to exist between headquarters and the field, among geographic regions, and among facilities (Breenlove, 1993; panel visits). Mundra (1996) provides an example—the introduction of the ghosting display aid to the radar display—illustrating that subcultural differences in the willingness to adopt a new technology can reflect, in part, real differences between facilities with respect to operating procedures, constraints, and requirements. In addition, the very mission of the FAA may be interpreted differently at different levels of the organization, and these interpretations may receive different emphasis at different geographic regions or facilities. Controllers and local supervisors may focus on the practical aspects of moving aircraft safely and expeditiously in response to tactical conditions. Regional managers may focus on the installation and implementation of equipment and procedures. The focus of headquarters' managers may reflect a broad stance that

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Flight to the Future: Human Factors in Air Traffic Control permits acceptable responses to political questions. The following section describes the results of the FAA's employee attitude survey. In order to verify these plausible hypotheses, data need to be collected and analyzed regarding controller attitudes. If data could be sorted by facility, they could be examined to study the cultural differences between facilities. Such a study could contribute to the development of causal models of facility characteristics that may lead to better or worse cultural climates. Job Satisfaction Organizational culture includes the perceptions of the controllers and their managers about the adequacy of resources, rules, consequences, and change mechanisms for performing their jobs—as well as the extent to which job characteristics contribute to the satisfaction of individual needs—and their expectations as to whether these factors will maintain adequacy, improve, or deteriorate. Controllers compare their perceptions of things-as-they-are with their expectations of things-as-they-will-be, producing an overall sense of job satisfaction and morale. Since 1984, the FAA has conducted biennial surveys of employee job satisfaction. Initially, the survey took the form of the survey feedback action program (SFAP), focusing on employees' confidential reporting of their satisfaction with the styles and behaviors of their immediate supervisors, who discussed the results of survey analysis with their subordinates. The survey included items pertaining to job satisfaction. In 1991 the survey program was replaced by the currently administered employee attitude survey (EAS), which focuses on employees' perceptions of organizational culture factors. Administered biennially, the EAS addresses a core set of attitudinal variables, including: overall job satisfaction, employee empowerment, employee involvement, communication, recognition and rewards, teamwork, personnel development, and performance appraisal. Each administration of the EAS also addresses attitudes toward current issues of special interest; recent examples are telecommuting and alternative work schedules. EAS results are reported to upper management for each line of business within the FAA. Of course, many of the survey variables relate to the formal organizational context factors discussed in this chapter. The following discussion summarizes the results of the 1995 EAS for air traffic employees (including but not limited to controllers) and links these perceptions to the formal organizational context factors discussed above. The results for the 1995 EAS were presented in an FAA briefing. Annotated Summary of the 1995 EAS (Federal Aviation Administration, 1995c), in terms of the 5-point rating scale used in the survey's administration: 1 = very dissatisfied, 2 = somewhat dissatisfied, 3 = moderately satisfied, 4 = highly satisfied, and 5 = very highly satisfied. Considering overall job satisfaction, 71 percent of employees reported that

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Flight to the Future: Human Factors in Air Traffic Control they were either highly or very highly satisfied with their jobs. This category includes such factors as satisfaction with pay, benefits, working conditions, the nature of the job tasks, immediate work group and supervisor, and opportunities for development. The factors with which the highest percentage was satisfied are pay, benefits, and the nature of the work itself. In contrast, the factors with which the lowest percentage was satisfied included factors contributing to the environment in which the job is performed: working conditions, the supervisor, the organization, and opportunities to develop potential. The 1995 reported results were not significantly different from the previous (1992) survey. However, compared with the 1984 survey, the 1995 survey showed a 16 percent increase in the percentage of respondents reporting that they were either highly or very highly satisfied overall. Before concluding that these results demonstrate an improvement in the components that contribute to overall job satisfaction, this comparison should be qualified by three considerations: (1) although both surveys included items on overall job satisfaction, which is still considered a benchmark for agency morale, the surveys were different. The 1984 survey was an SFAP, the 1995 an EAS. (2) Overall job satisfaction is typically higher than facet-specific job satisfaction. (3) Job satisfaction measures are known to be positively skewed because those who are very dissatisfied leave the job, and those who experience dissatisfaction but stay on the job may convince themselves that they are more satisfied, in order to reduce cognitive dissonance. Any increase in reported job satisfaction since 1984 is tempered by a steady decline, since 1988, in the percentage of survey respondents agency-wide who expressed confidence that FAA management would use the EAS results to improve working conditions and morale. That percentage has declined from 36 percent in 1988 to 19 percent in 1995. Both the results for key overall job satisfaction factors and the response to the question of trust in management suggest that air traffic employees perceive a need for changes in management style and/or structure, particularly relating to specific formal organizational context variables. With respect to safety and efficiency goals, controllers are governed by formal procedures. They may also be influenced by informal procedures and pressures. In either case, controllers must understand the procedures and, ideally, should influence their development. EAS results indicate that air traffic employees are highly satisfied with their understanding of how their jobs ''contribute to the FAA mission." However, they are only moderately satisfied with the adequacy of management's communication of policies and with their opportunities to express concerns openly and with impunity. We therefore suggest that management should recognize, during the development of new policies or priorities with respect to safety and efficiency, that there may be a discrepancy between the intent of their policy communications and the interpretations drawn by controllers. We question whether the goals of openness and generativity are being met. One method of encouraging both

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Flight to the Future: Human Factors in Air Traffic Control understanding of and compliance with policy is involving the employees in its development; on this account, management should consider in particular employee perceptions pertaining to the open expression of concerns about policy changes. As noted above, the FAA has both established values statements and instituted reorganizations aimed at aligning responsibility with authority and at empowering employees to make decisions. The agency-wide results of the EAS, however, indicate that employees are only moderately satisfied with the extent to which decisions are made at appropriate levels, employees have authority to make day-to-day decisions, and employees are given the opportunity to contribute to decision making that affects their jobs. Data specific to air traffic functions were not available for these items. Although FAA management has formally expressed these cultural goals, the goals have apparently not been internalized in the culture. The results of the EAS also call into question the effectiveness of the quality through partnership (QTP) process, which was instituted by the union and FAA management to foster employee involvement in decision making. Communication issues also interact with other considerations. With respect to job satisfaction, we cannot overstress the importance of the extent to which employees feel free and encouraged to communicate their recommendations for change, as well as the extent to which they perceive communications from management to be clear and meaningful. The EAS results show that over 40 percent of surveyed air traffic employees believe that it is safer to agree with management than to disagree and that employees are not encouraged to speak openly. Only 60 percent reported that they feel free to discuss problems with their supervisor. Addressing this perception that communication is inhibited would be a useful means to develop improvements in other reported areas of dissatisfaction. With regard to the System Safety Office and associated reporting mechanisms, the panel's judgment is that employees should be encouraged to report not only observed incidents and deviations but also their perceptions of latent hazards that might contribute to future accidents or incidents. The substantial percentage of employees who do not feel free to report problems suggests that management should investigate the extent to which these inhibitions apply to the reporting of safety concerns. The FAA has established a sequenced program of training for controllers, with adjunct retraining when skill decrements are determined and when new technology is introduced. EAS results, however, indicate that employees are only moderately satisfied that they receive the training needed to perform effectively and that the training they receive is applied to their job. With respect to more general opportunities for growth, only about 30 percent of air traffic employees reported that they are satisfied with opportunities to develop their potential. With regard to the process of performance assessment for air traffic controllers, the EAS results indicate that air traffic employees experience generally low

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Flight to the Future: Human Factors in Air Traffic Control satisfaction with the extent to which recognition and rewards are given for exceptional performance, management responds positively to a job well done, recognition and rewards are administered promptly, and promotions are given on the basis of job qualifications. Assessing proposals for changes to the performance appraisal system, employees expressed high satisfaction with proposals aimed at increasing the timeliness of recognition and rewards, moderate satisfaction with proposals that separate pay from performance and include ratings by coworkers in the appraisal process, and low satisfaction with proposals that rely exclusively on ratings by coworkers. These results suggest that the ongoing process of revising the appraisal process for controllers should include careful consideration, with continued feedback from controllers, of both how performance should be appraised and how rewards and penalties should be tied to the results of appraisals. The EAS survey results also indicate that air traffic employees report low to moderate satisfaction with the impact of new technologies on their jobs. This topic included such issues as the extent to which new technology is appropriate, sufficient and timely information on the new technology is provided by management, and the organization is generally quick to adopt new work methods. Such results form part of the backdrop of organizational culture against which user involvement (or noninvolvement) occurs during the acquisition of new systems. There is a lack of research evidence establishing clear causal relationships between formal and informal organizational context factors, and between these factors and the performance of controllers. The EAS, however, does constitute a vehicle for the collection of data on culture, and these data could be applied to the study of these relationships. Attitudes Toward Change The general construct of trust is a key variable in the use of automated equipment. Controllers' actions are based not only on formal procedures, but also on the shared subcultural assessment of whether the equipment and the procedures merit trust. The declining reliability of air traffic control equipment, the projected increase in air traffic, pressures to contain staffing levels, and the long-term nature of acquisition processes for modernizing equipment combine to produce a tendency to rely on human controllers to compensate for the deficiencies of other resources and heighten the controllers' concerns about trust. Controllers' trust (or mistrust) of new equipment and procedures is a function of both the reliability or effectiveness of the changes and the controllers' trust in themselves (Lee and Moray, 1992). Recent press reports of controller reactions to increasing unreliability of air traffic control equipment suggest that, although controllers are becoming increasingly concerned that future equipment failures may exceed their abilities to compensate successfully, they publicly express confidence in their skills and abilities to maintain air traffic safety, However,

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Flight to the Future: Human Factors in Air Traffic Control trust in new equipment and procedures implies a willingness to take reasonable risks associated with adopting the changes; controllers' trust in their equipment, procedures, and one another is also affected by both formal and informal organizational rules pertaining to the taking of risks associated with introducing change. COORDINATING HUMAN FACTORS RESEARCH ACTIVITIES It is a central theme of this report that human factors considerations with respect to the development and implementation of automation for air traffic control are critical and broad. Human factors research activities should be applied across all phases of acquisition, from the definition of requirements through test and evaluation, and information about human performance, derived from human factors research, must be available to support all phases of acquisition and implementation. To do this, it is necessary that human factors research activities and the resources that support them be coordinated both within and across research, acquisition, and implementation activities. Such clear lines of responsibility and authority are not currently evident in the FAA. Human factors research activities are conducted at and/or managed through separate organizational entities. The Civil Aeromedical Institute (CAMI) conducts research internally and manages contracted research pertaining to air traffic control and to airway facilities in such areas as communication, selection, training, performance assessment, information display, workstation configuration, teamwork, fatigue and shift work, and organizational context factors (Federal Aviation Administration, 1996b; Collins and Wayda, 1994; Schroeder, 1996; briefings of panel by CAMI Human Resources Research Division, 1995). CAMI also conducts in-house and contracted research on general aviation, the flight deck, and bioastronautics that support such activities as regulation and certification. The FAA Technical Center (FAATC) applies its Research Development and Human Factors Laboratory, with extensive simulation capability, to the evaluation of advanced concepts and technologies for air traffic control and airway facilities (Stein and Buckley, 1994; Federal Aviation Administration, 1995g). Within the Research and Acquisition organization at FAA headquarters, the Human Factors Division, the Security Human Factors Branch, and separate integrated product teams sponsor human factors research in response to needs as they emerge. This research is conducted by CAMI; the FAATC; cooperating government facilities at NASA Ames, at the Volpe National Transportation Safety Center, and within the Department of Defense; and university and other contractors. The research entities within the FAA reside within different organizational entities. They do not report through a single chain of responsibility and authority, their resources (e.g., staff and budgets) are separately managed, and their activities are separately evaluated.

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Flight to the Future: Human Factors in Air Traffic Control Human factors application activities are similarly conducted by disparate organizational entities. The FAA's Human Factors Division occasionally provides support to acquisition programs. However, human factors activities in support of acquisition are performed largely by contract personnel, including human factors personnel working for the design contractor as well as human factors monitors working for FAA program management. Such efforts are currently managed by integrated product team leaders, who determine their own needs for human factors support. Separate human factors support activities, provided largely through contract personnel, are also managed on an as-needed basis within the Air Traffic Services organization (for Airway Facilities and advanced system planning areas) and within the Regulation and Certification organization (for standards and certification areas). In order to reinforce agency-wide appreciation for the importance of human factors, and in recognition of the need for coordination of human factors activities both across research and acquisition and across disparate organizational lines, in 1993 the FAA promulgated a human factors policy statement (Federal Aviation Administration, 1993b). This order prescribes that "Human factors shall be systematically integrated into the planning and execution of the functions of all FAA elements and activities associated with system acquisitions and system operations." The order also prescribes the composition and function of a Human Factors Coordinating Committee (HFCC). The HFCC is chaired by the FAA chief scientific and technical advisor for human factors, who is currently located within the Research and Acquisition organization. The HFCC is composed of representatives of several executive directors, associate administrators, assistant administrators, and center directors, all of whom retain authority to represent their organizations in human factors matters. The functions of the HFCC are to: (1) identify research requirements and coordinate research results; (2) foster the dissemination of human factors information across organizations; (3) facilitate the integration of human factors into rulemaking, systems acquisitions, and other activities within the agency; (4) identify the need for changes to existing policies, processes, research programs, regulations, or other human factors activities and programs; and (5) monitor the efficacy of human factors efforts and programs within the FAA. The HFCC, which meets infrequently, communicates largely through a newsletter. The HFCC represents, in effect, more of an information exchange vehicle than a management vehicle: its members manage (plan, direct, control, allocate resources for, and evaluate) separate human factors activities rather than a unified agency program. In addition, the National Plan For Civil Aviation Human Factors (Federal Aviation Administration, 1995d), recently approved by the FAA, outlines a general plan that provides conceptual direction for human factors research and applications, but the plan does not define how those activities will be managed. In sum, research activities are not adequately coordinated across research

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Flight to the Future: Human Factors in Air Traffic Control centers, research is not systematically performed to support practice needs, and research findings are not systematically applied. Application activities are not adequately coordinated and rely heavily on subcontractor efforts that are not managed by FAA human factors professionals. Given the importance of applying in a timely manner the appropriate skills and knowledge of the multidisciplinary staff that must comprise a human factors program, the importance of maintaining a synergy between research and acquisition activities across all phases of the development of new systems, and the practical constraints of limited budgets that demand effective use of resources, the fragmentation of human factors activities across the agency suggests the need for integrated management. To this end, overall management of human factors research and development activities for the FAA that relate to air traffic control and to airway facilities should be concentrated. Concentrated human factors management should be given authority over staff and budget commensurate with its responsibility and should be assured of the resources required to perform its functions. Furthermore, we urge that the relationship between the System Safety Office and the concentrated human factors management should be a strong one. It is beyond the scope of this report to consider the location, within the FAA's management structure (e.g., within which line of business or at what level of management), of this proposed concentration of human factors management, how human factors management itself should be organized, and the extent to which this management entity should assume responsibility and authority for human factors activities other than for air traffic control and airway facilities. A subcommittee of the FAA's Research, Engineering, and Development Advisory Council has recommended a plan for human factors within the FAA (Federal Aviation Administration, 1996c:iv): Establish an FAA human factors single point manager for all human factors research and application efforts within agency functions for acquisition, regulation and certification, security, and NAS operations, and across agency organizational elements (including the FAA William J. Hughes Technical Center and the Civil Aeromedical Institute): Assign authority and resources (people, dollars, and facilities) concomitant with the responsibility and accountability for an effective FAA Human Factors Program for research and applications. Designate the FAA Human Factors Division (AAR-100) as the agency's human factors single point manager, and hold that office accountable for the quality of the agency's human factors products and services. CONCLUSIONS New technologies are introduced into an existing organizational formal context and informal culture, whose characteristics interact with those of the new

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Flight to the Future: Human Factors in Air Traffic Control technologies to influence subsequent performance outcome indicators, like safety and efficiency. It is therefore critical in planning the introduction of new technologies in the air traffic control system to identify organizational feature that tend to ensure the capability for shifting to a dynamic problem-solving state when such is needed. Because it is responsible for instituting organizational change, air traffic control system management at all levels must regard itself as having a potentially strong influence on safety and efficiency, especially by virtue of how it reinforces the processes and values that underlie and support productive change. It is generally accepted that organizational culture exerts a pervasive influence on performance that is difficult to specify for two reasons: (a) there are distinct cultures and subcultures in different regions, options, and facilities and (b) the variables that comprise culture cannot be exhaustively enumerated. Cultural factors that deserve special attention because of their potential to influence the success of efforts to introduce new technologies into the air traffic control system include a positive change orientation, the perception that change can and will be accomplished effectively, and the belief that the new technologies will serve important performance needs or goals. Managing the technological change process well—from planning and procurement through implementation and full incorporation into the air traffic control organization and culture—is a significant way to promote positive performance effects. More research is needed on the multiplicity of conditions and variables that mediate the effects of formal organizational context and informal organizational context (culture) on technological change and performance (safety and efficiency) in the air traffic control system. When indicators and criteria of acceptability for safety and for efficiency are unclear or not accepted, proposals for technological or procedural improvements, including automation, may constitute solutions in search of a problem. To allocate resources effectively, to apply appropriate technologies and strategies for improvement, and to validate improvements, the establishment of clear indicators and definitions of acceptability for safety and for efficiency is necessary but not sufficient. An understanding of the relationship between safety and efficiency and between individual indicators is also required. To be effective, standard port facto analyses of the factors contributing to safety (accidents, incidents, and hazards) and to efficiency (e.g., delays) should be complemented by predictive risk assessments. Comprehensive predictive assessments should include the development and application of models that: (a) identify indicators, measures, and levels of acceptability for safety and for efficiency; (b) assess the interaction of safety and efficiency factors; and (c) assess the contributions of controller cognitive tasks, including decision making, to outcomes. Predictive assessments should precede the acquisition of technologies proposed as solutions to safety or efficiency concerns and should include assessment of the proposed technologies. The restructuring of the air traffic control organization, the development of policies and procedures governing operations that address safety and efficiency,

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Flight to the Future: Human Factors in Air Traffic Control and the development or acquisition of related technologies need to take into account both the formal and informal processes judged by controllers to work in practice. When necessary, it is important to study systematically the informal processes, especially those by which controllers respond to high-tempo contingencies. Personnel are critical resources that must be properly developed and maintained. The FAA is currently relying on the skills of its controllers to compensate for the deterioration of equipment resources. Examining the impact of staffing on opportunities for training would be useful. New or altered policies governing controllers' actions to maximize efficiency while maintaining safety need to be accompanied by requisite training. Existing safety databases and their proposed integration should be complemented by efforts to encourage the perception by controllers that reporting safety data represents an achievement, not a failure, that such reports will be rewarded, and that reports should include concerns relating to organizational factors. The FAA's biennial Employee Attitude Survey generally indicates that air traffic employees are dissatisfied or only moderately satisfied with management practices and the organizational context within which they perform their jobs, although the jobs themselves are reported as satisfying. Addressing their perception that communication is inhibited holds great promise as a means to develop improvements in other reported areas of dissatisfaction. If the existing EAS data can be sorted by facility, the data could be examined to study the cultural differences between facilities, which could contribute to the development of causal models of facility characteristics that may lead to better or worse cultural climates. Human factors activities within the FAA, including both research and practice activities, are fragmented. Research activities are not adequately coordinated across research centers, research is not systematically performed to support practice needs, and research findings are not systematically applied. Application activities are not adequately coordinated and rely heavily on subcontractor efforts that are not managed by FAA human factors professionals. Overall management of human factors research and development activities for the FAA that relate to air traffic control and to airway facilities should be concentrated. Concentrated management should be given authority over staff and budget commensurate with its responsibility, and it should be assured of the resources required to perform its functions. The relationship between the System Safety Office and the concentrated human factors management should be a strong one.