Welcome to
TRACEr-lite
Technique for the Retrospective and Predictive Analysis of Cognitive Errors (v1.0)
Air Traffic Management Version
TRACEr-lite RETRO TRACEr-lite PREDICT
Retrospective Human Error Analysis Predictive Human Error Analysis
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Click here to see the TRACEr lite
Methodology Flowchart
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TRACEr-lite
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Method flowchart
RETRO Overview PREDICT Overview
TRACEr-lite RETRO
* Before you use TRACEr-lite, make sure you have identified the errors that occurred in the incident. Home
Then follow the four steps below for the first error, and repeat for each subsequent error.
Click here to learn more about Click here to see the TRACEr-lite
the background of TRACEr-lite Methodology Flowchart
Step R1/R5 - Context Statement and PSFs Click here
for Step
Repeat for each identified error
describe the contextual factors that may have affected performance
R1/R5
Step R2 - Task Error Click here
classify the error in terms of the task for Step R2
Step R3 - Internal Error (Modes and Mechanisms) Click here
classify the internal error mode and mechanism(s) for Step R3
Step R4 - Information Click here
classify the subject matter of the error for Step R4
Click here to see a TRACEr-lite
Worksheet
Aims of TRACEr-lite
Most incidents are associated with various 'human factors'. TRACEr-lite Retro is a tool to aid the process of
investigation and classification of human errors that occur in ATM incidents and the associated issues - related to
the controller, pilot and the working environment - which influenced events.
TRACEr-lite Retro is designed to be used by incident investigators, human factors specialists, or anyone else
iwith a responsibility for managing safety. The tool helps to classify the human factors aspects, such as the task
being performed, the 'mental' aspects of the error, and the general context of the error, including those factors
that 'aggravated' the situation, or made the situation more prone to error.
Classifying errors using TRACEr-lite Retro involves four steps, and takes little time. The result is a description of
the event in a way that can be recorded, searched, and tracked over time. This helps to identify human factors
'trends' and 'hotspots', for example, with regard to training, system design, procedures, or the working
environment. Ultimately, the aim to ensure that the best possible use is being made of incident data to try to put
in place measures to manage risk and improve safety.
TRACEr-lite Retro is available in a partner version for predictive use (TRACEr-lite Predict) in human error
analysis.
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.
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Step R1/R5 - Context Statement
* Please identify and describe any relevant factors, internal or external to the controller/pilot, that may have
affected overall task performance. Also record on the incident proforma those factors that were associated
with the occurrence of each specific error identifed.
RETRO Overview
Performance Shaping Factor (PSF) Relev Comments
ant?
1. Did Traffic and Airspace affect the controller's performance?
1.1 Traffic load (state expected
maximum, minimum and average)
1.2 Traffic mix/complexity
1.3 Weather
1.4 Time pressure
1.5 Administrative workload
1.6 Sector design
1.7 Temporary or irregular sector activities
1.8 Other traffic and airspace factors
2. Did Pilot-controller Communications affect the controller's performance?
2.1 RT workload
2.2 RT phraseology & standards
2.3 Language & accent
2.4 Information content
2.5 Communication method
2.6 Communication quality
2.7 Communication equipment
quality/reliability
2.8 Other pilot/controller factors
3. Did Procedures and Documentation affect the controller's performance?
3.1 Procedure type
3.2 Procedure availability
3.3 Procedure quantity
3.4 Procedure accuracy/correctness
3.5 Procedure comprehensiveness or
completeness
3.6 Procedure clarity
3.7 Procedure complexity
3.8 Procedure validity/version
3.9 Procedure structure
3.10 Procedure format (physical)
3.11 Procedure access/location
3.12 Procedure realism/feasibility/
suitability
3.13 Duration in use or stability
3.14 Compatibility with other procedures
3.15 Other procedural factors
4. Did Training and Experience affect the controller's performance?
4.1 Task familiarity
4.2 Level of experience
4.3 Time on sector
4.4 Availability of training
4.5 Recency of training
4.6 Training content quality
4.7 Training method quality
4.8 Compatibility/suitability of training
4.9 Competence testing
4.10 Mentoring quality
4.11 Other training/experience factors
5. Did Human-Machine Interaction affect the controller's performance?
5.1 Information availability
5.2 Information accuracy/correctness
5.3 Information type/format
5.4 Information availability/access
5.5 Information quantity
5.6 Information accuracy/correctness
5.7 Information comprehensiveness or
completeness
5.8 Information clarity
5.9 Information complexity
5.10 Information validity
5.11 Information structure
5.12 Information location/position
5.13 Equipment reliability
5.14 Trust in equipment
5.15 Task involvement
5.16 Allocation of function
5.17 Health risks
5.18 Console ergonomics
5.19 Input device quality
5.20 Visual display quality (general)
5.21 Traffic display quality (general)
5.22 Electronic tool quality (general)
5.23 Radio Telephone (R/T) quality
(general)
5.24 Land line quality (general)
5.25 Flight information/strip display quality
(general)
5.26 Supplementary information display
quality (general)
5.27 Alarms and warning devices quality
(general)
5.28 Workplace arrangement/
accommodation quality
5.29 Other workplace design factors
5.30 Other equipment or HMI factors
6. Did Ambient Environment affect the controller's performance?
6.1 Noise and distraction
6.2 Lighting
6.3 Temperature
6.4 Air quality
6.5 Other ambient environment factors
7. Did Personal factors affect the controller's performance?
7.1 Alertness/concentration/fatigue
7.2 Emotional or occupational stress
7.3 Anxiety/panic
7.4 Boredom
7.5 Confidence
7.6 Complacency
7.7 Job satisfaction/morale
7.8 Domestic issues
7.9 Fitness issues
7.10 Mental health issues
7.11 Physical health issues
7.12 Other personal factors
8. Did Social and Team factors affect the controller's performance?
8.1 Team co-ordination quality
8.2 Team communication quality
8.3 Handover/take-over
8.4 Team structures & dynamics
(formation)
8.5 Team relations and trust
8.6 Team maturity
8.7 Inter-team co-ordination
8.8 ATCO profile
8.9 Age
8.10 Shift organisation
8.11 Supervision
8.12 Assistance & support
8.13 Roistering
8.14 Working methods
8.15 Staff availability/sector manning
8.16 Allocation of function and
responsibility
8.17 Other team factors
9. Did Organisational factors affect the controller's performance?
9.1 Conditions of work
9.2 Job security
9.3 Commercial pressure
9.4 Relations with management
9.5 Organisational change
9.6 Other organisational factors
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Click here to go to Step R2
Step R2 - Task Error
* Please record the type of error that describes how the task was not performed satisfactorily. Home
Controller Task Errors Pilot Task Errors RETRO Overview
Task Error Task Error
Separation error Pilot-controller communications error
Controller-pilot communications error Aircraft handling error
Radar monitoring error Visual observation
Aircraft observation / recognition error Flight deck co-ordination/communications error
Co-ordination error Operational materials checking error
Control room communications error Training, supervision, or examining error
Aircraft transfer error HMI error
Hand-over / Take-over error Other task error
Aircraft landing or ground movement error
Flight progress strip use error
Operational materials checking error
HMI error
Training, supervision, or examining error
Other task error
Click here to go to Step R3
Step R3 - Internal Error (Modes and Mechanisms)
* Please answer the following Error Domain questions and record the Error Mode and Error Mechanism(s) Home
(where possible) for the error. Try to use just one Error Mode per error, and one (or up to two) associated
Error Mechanism.
RETRO Overview
a) Did the controller violate a procedure, rule or Yes Yes - Click here
instruction? for 'Violations'
No
b) Did the controller/pilot mis-see or mishear, or Yes Yes - Click here
fail to see or hear something? for 'Perception'
No
c) Did the controller/pilot forget or misrecall Yes Yes - Click here
information, or forget to do something? for 'Memory'
No
d) Did the controller/pilot make an error in Yes Yes - Click here
projecting required separation, or make an error for 'Decision'
of planning or decision making?
No
e) Did the controller/pilot do or say something Yes
Yes - Click here
unintended, or inadvertently incorrect / unclear?
for 'Action'
No Click here to go to Step R4
End
a) Did the controller violate a procedure, rule or instruction?
Violations
Routine violation
Behaviours in opposition to the rule, procedure or instruction that have become the normal or
automatic way of behaving within the controller's peer or workgroup.
Situational violation
Violations that occur as a result of factors dictated by the controller's immediate workspace or
environment (e.g. time pressure, weather).
Exceptional violation
Violations that are rare and occur only in exceptional circumstances, such as an emergency.
Optimising violation
Violations created by a motive to optimise a work situation.
Click here to go to Step R4
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b) Did the controller/pilot mis-see or mishear, or fail to see or hear something?
Internal Error Mode Internal Error Mechanism
Perception Easily detected > No diagnosis required or > Easily corrected, requiring no
> Immediate, clear, direct very reliable diagnosis changes to plan, and causing
feedback of actions/effects expected little or no additional workload
> Active involvement and > No ‘expectation > Plenty of time available for
High
constant monitoring bias’/’confirmation bias’ recovery
> Independent/third party
checks, automatic checks or
cues to check
Moderate-High
> Detectable > May require some > May necessitate changes to
> Feedback available interpretation or diagnosis plan or corrective action using
> Regular but intermittent > Incorrect diagnosis possible practised procedure causing
monitoring > May be some ‘expectation some additional workload
Moderate > Some cues to check or bias’/’confirmation bias’ > Controller prepared and able
occasional independent to intervene
checking by third party or > Some time pressure to
automation recover error
Low-Moderate
> Difficult to detect > Hard to diagnose, diagnosis > Plan modification or difficult
> No feedback, or poor, very likely to be incorrect or complex correction process
indirect or delayed feedback > Strong ‘expectation required, causing considerable
> No monitoring or passive bias’/’confirmation bias’ workload
monitoring > Controller unprepared or not
> High reliance on memory to familiar with procedures, with
Low
check or suspect error limited ability to intervene
> Strong time pressure, or
insufficient time available for
recovery
Click here to go to Step P5
Click here to repeat the steps for the next error
e next error
TRACEr-lite PREDICT
Home
Worksheet PREDICT Overview
* Below is an example of a worksheet that could be used to record the TRACEr-lite PREDICT analysis. The
columns can be adapted to suit the needs of the analysis.
Task Step External Error Internal Error Recovery/ RSL Recommendation/
Safeguards Comment
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Contact
Home
If you have any queries regarding TRACEr-lite or TRACEr, contact the developer Steve Shorrock:
steven.shorrock@tracer-lite.co.uk
The developer gratefully acknowledges the support of National Air Traffic Services in the development of TRACEr and
TRACEr-lite.
A website is available at:
http://www.tracer-lite.co.uk
Relevant Publications
Publication
TRACEr-lite
Application
Technique
TRACEr
Shorrock, S.T. Kirwan, B. and Smith, E. (2003). Individual and group approaches to human Y Y
error prediction - a tale of three systems. IBC Conference on Preventing Human Errors and
Violations , London, 27-28 February, 2003.
Shorrock, S.T. and Kirwan, B. (2002). The development and application of a human error Y Y
identification tool for air traffic control. Applied Ergonomics , 33, 319-336.
Shorrock, S.T. (2002). Error classification for safety management: Finding the right approach. Y Y
Proceedings of a Workshop on the Investigation and Reporting of Incidents and Accidents , 17th
to 20th July 2002, The Senate Room, University of Glasgow.
Shorrock, S.T. (2002). The two-fold path to human error analysis: TRACEr lite retrospection and Y Y
prediction. Safety Systems (Newsletter of the Safety-Critical Systems Club), 11 (3), September
2002.
Shorrock, S.T., Kirwan, B., MacKendrick, H. and Kennedy, R. (2001). Assessing human error in Y Y
Air Traffic Management systems design: Methodological issues. Le Travail Humain , 64 (3), 269-
289.
Shorrock, S.T., Kirwan, B., MacKendrick, H. , Scaife, R. and Foley, S. (2001). The practical Y Y
application of error analysis in UK ATM. Proceedings of People in Control: An International
Conference on Human Interfaces in Control Rooms, Cockpits and Command Centres , UMIST,
Manchester, UK: 18 - 21 June 2001.
Scaife, R., Smith, E. and Shorrock, S.T. (2001). The practical application of error analysis and Y Y Y
safety modelling in air traffic management. IBC Conference on Human Error . London, February
2001.
Shorrock, S.T., Kirwan, B., Scaife, R. and Fearnside, P. (2000). Reduced vertical separation Y Y
outside controlled airspace. IBC’s Third Annual Conference on Aviation Safety Management .
May 2000.
Shorrock, S.T. and Kirwan, B. (1999). TRACEr: A technique for the retrospective of cognitive Y Y
errors in ATM. In D. Harris (Ed.) Engineering Psychology and Cognitive Ergonomics: Volume
Three - Transportation Systems, Medical Ergonomics and Training . Aldershot, UK: Ashgate.
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