How the cockpit manages anomalies: revisiting the dynamic fault management model for aviation

Abstract

More than 20 years ago, Woods proposed a model that accounts for the inherent complexity faced by operators when managing abnormal and emergency situations in highly complex sociotechnical systems. The model was reviewed a decade later and only a few studies have applied it to aviation. This paper proposes adjustments to the original model, based on recent theoretical developments and empirical evidence on the anomaly management activity in aviation. The model was divided into five components; three of which—activity, types of reasoning involved, and resources—were revisited and further developed. The two other components—fault behaviour and unit of analysis—were not updated and only discussed in the aviation context. As a result, the revisited model descriptively clarifies how the activity of anomaly management emerges from the use of a wide repertoire of strategies, involving a spectrum of types of reasoning and a set of resources for action, which are not limited to those anticipated by designers, such as checklists and the warning system. An instantiation of the revisited model highlights the implications of false alarms, which trigger a cascade of disturbances that, in turn, requires adaptive strategies based on heuristics and analogies and supported by pilot’s experience. The revisited model can support a more accurate analysis of anomalous situations and the redesign of work systems to achieve a better performance.