A Context for Error: Using Conversation Analysis to Represent and Analyse Recorded Voice Data

Abstract

Recorded voice data, such as from cockpit voice recorders (CVRs) or air traffic \ncontrol tapes, can be an important source of evidence for accident investigation, as \nwell as for human factors research. During accident investigations, the extent of \nanalysis of these recordings depends on the nature and severity of the accident. \nHowever, most of the analysis has been based on subjective interpretation rather \nthan the use of systematic methods, particularly when dealing with the analysis of \ncrew interactions. \nThis paper presents a methodology, called conversation analysis, which involves the \ndetailed examination of interaction as it develops moment-to-moment between the \nparticipants, in context. Conversation analysis uses highly detailed and revealing \ntranscriptions of recorded voice (or video) data that can allow deeper analyses of \nhow people interact. \nThe paper uses conversation analysis as a technique to examine CVR data from an \naccident flight. The focus accident was a controlled flight into terrain event \ninvolving an Israel Aircraft Industries Westwind 1124 jet aircraft, which impacted \nterrain near Alice Springs on 27 April 1995. \nThe conversation analysis methodology provided a structured means for analysing \nthe crew’s interaction. The error that contributed directly to the accident, an \nincorrectly set minimum descent altitude, can be seen as not the responsibility of \none pilot, but at least in part as the outcome of the way the two pilots communicated \nwith one another. The analysis considered the following aspects in particular: the \nsignificance of overlapping talk (when both pilots spoke at the same time); the \ncopilot’s silence after talk from the pilot in command; instances when the pilot in \ncommand corrected (repaired) the copilot’s talk or conduct; and lastly, a range of \naspects for how the two pilots communicated to perform routine tasks. In summary, \nthe conversation analysis methodology showed how specific processes of \ninteraction between crew members helped to create a working environment \nconducive to making, and not detecting, an error. By not interacting to work \ntogether as a team, pilots can create a context for error. \nWhen analysing recorded voice data, and especially for understanding instances of \nhuman error, often a great deal rests on investigators’ or analysts’ interpretations of \nwhat a pilot said, or what was meant by what was said, or how talk was understood, \nor how the mood in the cockpit or the pilots’ working relationship could best be \ndescribed. Conversation analysis can be a tool for making such interpretations.

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