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Cognitive Engineering and
Safety Organization in Air
Traffic Management
Cognitive Engineering and
Safety Organization in Air
Traffic Management

By
Tom Kontogiannis and Stathis Malakis
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2018 by Taylor & Francis Group, LLC

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Library of Congress Cataloging-in-Publication Data

Names: Kontogiannis, Tom, author. | Malakis, Stathis, author.

Title: Cognitive engineering and safety organization in air traffic
management / Tom Kontogiannis, Stathis Malakis.
Description: Boca Raton : CRC Press, Taylor & FrancisGroup, 2017.
Identifiers: LCCN 2017018537| ISBN 9781138049727 (hardbook : acid-free paper)
| ISBN 9781315168814 (ebook)
Subjects: LCSH: Air traffic control–Decision making–Case studies. |
Aeronautics–Safety measures. | Air traffic controllers–Psychology.
Classification: LCC TL725.3.T7 K66 2017 | DDC 387.7/404260684–dc23
LC record available at https://lccn.loc.gov/2017018537

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To all air traffic controllers, who keep our skies safe
although working hard behind the scenes
and away from the media spotlights
Contents

LIST OF A B B R E V I AT I O N S xv
LIST OF FI G U R E S xxi
LIST OF TA B L E S xxv
P R E FA C E xxix
ABOUT THE AUTHORS xxxv
COGNITIVE ENGINEERING IN A C H A N G I N G WO R L D xxxvii

PA R T I A N O V E R V I E W O F M A N AG E M E N T OF
O P E R AT I O N S A N D S A F E T Y 1
CHAPTER 1 TH E A I R TR A F F I C M A N A G E M E N T S Y S T E M 3
1.1 Introduction 3
1.2 The ATM System 4
1.2.1 Procedures and Regulations 7
1.2.2 Air Traffic Controllers (ATCOs) 9
1.2.3 Automation Systems 9
1.2.4 Communication Systems 13
1.2.5 Navigation Systems 14
1.2.6 Surveillance Systems 15
1.3 ATC Units 16
1.4 Airport Control Tower (TWR) Operations 18
1.4.1 Airport Controller Duties 20
1.4.2 Pilot Duties during Taxiing, Start up, or
Landing 21

VII
VIII C O N T EN T S

1.5 Approach Control (APP) Operations 22

1.5.1 Approach Controller Duties 23
1.5.2 Pilot Duties during Take-off, Climb,
Descent, and Approach for Landing 25
1.6 Area Control Center (ACC) Operations 27
1.6.1 Area Controller Duties 27
1.6.2 Pilot Duties at the Cruising Phase 28
1.7 Air Traffic Flow and Capacity Management
(ATFCM) Operations 29
1.8 Safety Regulatory Framework 31
1.9 Incidents and Accidents 33
1.10 Concluding Remarks 35

CHAPTER 2 FA C T O R S A F F E C T I N G ATM P E R F O R M A N C E 39
2.1 Introduction 39
2.2 Challenges in Coping with Abnormal Situations 40
2.3 Work Demands and Stress in the Operating
Environment 43
2.4 Classical Performance Models in Aviation 48
2.4.1 Aviate 48
2.4.2 Navigate 49
2.4.3 Communicate 50
2.5 Classical Performance Models in ATC 52
2.5.1 Management of Occurrences 52
2.5.2 Mental Pictures of Traffic 53
2.6 Aspects of Complexity and Coupling in the ATM
Environment 55
2.7 Aspects of Uncertainty in Making Sense of Information 58
2.7.1 Missing Information 59
2.7.2 Unreliable Information 60
2.7.3 Inconsistent Information 61
2.7.4 Information Noise 61
2.7.5 Hard to Interpret Information 62
2.8 Concluding Remarks 63

CHAPTER 3 S A F E T Y O R G A N I Z AT I O N AND RIS K MA N AG E M E NT 65

3.1 Introduction 65
3.2 Basic Safety Concepts 67
3.3 The Safety Envelope of Aviation Systems 69
3.4 The Four Quadrants or Pillars of Safety Management 72
3.4.1 Safety Policy 72
3.4.2 Hazards and Risks 73
3.4.3 Safety Assurance 75
3.4.4 Safety Promotion 77
3.5 A Control Framework Linking the Four SMS Pillars 77
3.6 Challenges to Safety Management 80
3.6.1 Safety Policy 80
3.6.2 Risk Management 83
3.6.3 Safety Assurance 84
3.6.4 Safety Promotion 85
 C O N T EN T S IX

3.7 Revisiting the Safety Envelope and Applying

Resilience Engineering 87
3.8 Risk Assessment Approaches 88
3.8.1 Systemic Risk Assessment 89
3.8.2 Operational Risk Management 95
3.9 EASA Requirements of Risk Assessment Methods 97
3.10 Concluding Remarks: Toward Resilient Risk
Assessment Methods 102

PA R T II COGNITIVE ENGINEERING 10 5
CHAPTER 4 DECISION-MAKING 107
4.1 Introduction 107
4.2 Theoretical Foundations 109
4.3 Rational or Analytical Decision-Making 110
4.4 Naturalistic Decision-Making 114
4.5 Toward a Decision-Making Model in ATC 120
4.6 Taskwork Functions and Strategies 121
4.6.1 Recognition 122
4.6.2 Modeling and Critiquing 126
4.6.3 Anticipation 127
4.6.4 Planning 128
4.6.5 Workload Management 130
4.6.6 The Taskwork Model 131
4.7 Teamwork Functions and Strategies 134
4.7.1 Team Orientation and Shared Understanding 137
4.7.2 Team Coordination 138
4.7.3 Information Exchange—Communication 139
4.7.4 Error Management 140
4.7.5 Task Distribution or Change Management 141
4.7.6 The Teamwork Model 143
4.8 Applications of T2EAM in Training, Debriefing,
and Investigation of Mishaps 143

CHAPTER 5 SENSEMAKING 145

5.1 Introduction 145
5.2 Frames and Cognitive Functions of Sensemaking 145
5.3 The Challenges of Low Level Wind Shear Phenomena 149
5.4 Explanatory Frames and Sensemaking Strategies 151
5.4.1 Identifying a Frame 153
5.4.2 Questioning a Frame 154
5.4.3 Reframing: Comparing Multiple Frames 154
5.4.4 Reframing: Creating a New Frame 155
5.4.5 Preserving the Frame 156
5.4.6 Elaborating a Frame 156
5.4.7 Behavioral Markers for Team Sensemaking
Strategies 156
5.5 Requirements for Team Sensemaking 158
5.5.1 Data Synthesis 158
X C O N T EN T S

5.5.2 Seeking Data 158

5.5.3 Monitoring Data Quality 159
5.5.4 Resolving Disputes 159
5.5.5 Dissemination 160
5.6 Concluding Remarks 160

CHAPTER 6 HUMAN ERROR DETECTION AND REC OVE RY 163

6.1 The Concept of Human Error 163
6.2 Error Management Processes 166
6.3 Classification of Human Error 169
6.3.1 A Model of Unsafe Acts 169
6.3.2 The TRACEr Classification 173
6.4 A Framework for Understanding Error Detection
and Recovery 175
6.5 Cognitive Strategies in Error Detection and
Identification 178
6.5.1 Strategies in Awareness-Based Detection 182
6.5.2 Strategies in Planning-Based Detection 184
6.5.3 Strategies in Action-Based Detection 185
6.5.4 Strategies in Outcome-Based Detection 186
6.6 Cognitive Strategies in Error Recovery 188
6.6.1 Planning and Replanning in Error Recovery 188
6.6.2 Coordination Tactics in Error Recovery 191
6.7 Concluding Remarks 192

CHAPTER 7 A DA P TIVE P R ACTI C E S IN A I R TR A F F I C C O N T R O L 197

7.1 Introduction 197
7.2 Conditions Creating Performance Variability in
Work Practices 199
7.2.1 Variability of Task Characteristics 200
7.2.2 Organizational Changes and Transitions 201
7.2.3 Goal Conflicts That Cannot be Reconciled 202
7.2.4 Unruly Technology 203
7.2.5 Professional Norms and Social Context 204
7.3 A System Dynamics View of Work Practices 205
7.4 Reflection-in-Action: Mindful Work Practices and
Improvisation 209
7.5 Reflection-on-Action: Organizational Learning and
Practice Communities 212
7.6 Concluding Remarks 218

PA R T III REDUCING COMPLE XIT Y BY DESIGN

A N D TR A I N I N G 2 21
CHAPTER 8 TR A I N I N G FOR A B N O R M A L S I T UAT I O N S 223
8.1 Introduction 223
8.2 Handling Abnormal Situations in the ATM Domain 224
 C O N T EN T S XI

8.3 Anomaly Response and Cognitive Strategies 225

8.4 EAS Scenarios in Simulator Training 228
8.5 Patterns of Resilience, Coordination, and Affordances 231
8.5.1 Patterns of Resilient Taskwork 231
8.5.2 Patterns of Adaptive Teamwork 232
8.5.3 Patterns of Affordances 233
8.6 Cognitive Tasks Analysis (CTA) 234
8.6.1 The Airspace Clearing Scenario 235
8.6.2 The Airport Diversion Scenario 238
8.7 The ABCDE Method of Cognitive Task Analysis 240
8.8 Concluding Remarks 246

CHAPTER 9 WO R K L OA D AND COMPLE XITY 249

9.1 Introduction 249
9.2 Complexity in the ATM System 249
9.3 Complexity Mitigation Strategies 252
9.3.1 Adjustments in Monitoring and Anticipation 252
9.3.2 Replanning and Managing Uncertainty 254
9.3.3 Managing Workload and Change 255
9.3.4 Restructuring Tasks across Sectors 256
9.3.5 Changes in Communication and Coordination 256
9.4 Selection of Strategies for Different Levels of
Complexity 257
9.5 Concluding Remarks 259

C H A P T E R 10 NEW CHALLENGES IN ATM 261

10.1 Introduction 261
10.2 Taskwork Performance 263
10.2.1 Recognition and Monitoring 263
10.2.2 Planning and Conflict Resolution 266
10.2.3 Anticipating 266
10.2.4 Critiquing and Adapting to Workload 267
10.3 Collaborative Decision-Making 269
10.3.1 Sharing Understanding, Orientation, and
Trust 269
10.3.2 Managing Task Allocation 271
10.3.3 Team Coordination 272
10.3.4 Multi-Modal Information Transfer and
Communication 273
10.4 Concluding Remarks 274

PA R T IV S YS T E M S AND O R G A N I Z AT I O N A L
MODELS 277
C H A P T E R 11 O R G A N I Z AT I O N A L M O D E L S OF SAFE T Y 279
11.1 Introduction 279
11.2 Defenses-in-Depth and Organizational Safety 281
X II C O N T EN T S

11.2.1 Concepts and Applications of Defenses in

Depth 281
11.2.2 Organizational Resistance and Safety Culture 285
11.3 Systems Thinking Models 289
11.3.1 Proponents of Systems Thinking 289
11.3.2 Socio-Technical Approaches 291
11.3.3 Control Theoretic Approaches to System
Safety 294
11.4 Resilience Engineering 297
11.4.1 The Proponents of Resilience Engineering 297
11.4.2 The Four Qualities of Resilience 299
11.4.3 Making Trade-offs in the Four Qualities of
Resilience 302
11.5 Complex Adaptive Systems 302
11.6 Functional Resonance as a Model of System Accidents 305
11.7 Concluding Remarks 307

C H A P T E R 12 SYS TE M M O D E LIN G AND ACCIDENT

I N V E S T I G AT I O N 311
12.1 Introduction 311
12.2 A Control Theoretic Approach to System Safety 313
12.2.1 Control Flaws and Underlying
Organizational Breakdowns
in Accidents 313
12.3 Application of STAMP to a System Failure 317
12.3.1 Description of a System-Wide ATM Failure 317
12.3.2 STAMP Analysis of NATS System Failure 322
12.4 The Viable System Model (VSM) 327
12.5 Mapping the STAMP Technique onto the VSM
Organizational Model 332
12.6 Concluding Remarks 337

C H A P T E R 13 I N T E G R AT I N G H U M A N A N D O R G A N I Z AT I O N A L
MODELS OF PERFORMANCE 341
13.1 Introduction 341
13.2 A Human Performance Model of Taskwork and
Teamwork 344
13.3 A Performance Model of Organizational Work 348
13.4 Toward a Joint Model of Human and
Organizational Performance 352
13.4.1 A Classification Scheme of Operational and
Organizational Functions 352
13.4.2 Human and Organizational Performance in
Time 355
13.5 Modeling Patterns of Breakdown Resulting in
“Loss of Control” Events 357
13.5.1 Patterns of Steering Failures 359
 C O N T EN T S X III

13.5.2 Patterns of Planning Failures 360

13.5.3 Patterns of Monitoring and Modeling Failures 361
13.5.4 Patterns of Adaptation Failures 364
13.5.5 Patterns of Poor Coordination 365
13.6 Concluding Remarks 366

C H A P T E R 14 O R G A N I Z AT I O N A L D E C I S I O N M A K I N G I N
M A N A G I N G W O R K TR A D E - O F F S : A R E S I L I E N C E
A PPROACH 369
14.1 Introduction 369
14.2 Human and Organizational Performance in
Balancing Work Trade-offs 370
14.3 Balancing Trade-offs at the Organizational Level 376
14.3.1 Steering 376
14.3.2 Modeling 377
14.3.3 Adapting to Change 377
14.3.4 Planning 378
14.3.5 Monitoring 378
14.3.6 Cooperating 379
14.3.7 Operating 379
14.4 Balancing Trade-offs at the Operational Level 380
14.4.1 Steering 380
14.4.2 Modeling 381
14.4.3 Adapting to Change 381
14.4.4 Planning 382
14.4.5 Monitoring 382
14.4.6 Coordination 383
14.4.7 Operating 384
14.5 Challenges in Managing Performance Trade-offs 384
14.5.1 Developing Competence to Operate at Both
Sides of the Spectrum to Choose the
Right Option 385
14.5.2 Switching between Modes and Evaluating
the Cost of Change 385
14.5.3 Blending Alternative Options or Operating
Modes 386
14.5.4 Developing a Mindset for Adaptation and
Change 386
14.6 Concluding Remarks 387
C H A P T E R 15 E FFECTIVE SAFE T Y RIS K MA N AG E M E NT 391
15.1 Introduction 391
15.2 An Overview of Safety Risk Management 392
15.3 System Models for Risk Management 393
15.4 Risk Models 399
15.4.1 Fault Tree Analysis 399
15.4.2 Event Tree Analysis 403
15.5 Influence Models 410
XIV C O N T EN T S

15.6 Risk Mitigation Measures 413

15.6.1 Aspects of System Design 413
15.6.2 Aspects of Controller Training 414
15.6.3 Communities of Practice and Safety
Knowledge 416
15.7 Concluding Remarks 417

REFERENCES 421
INDEX 445
List of Abbreviations

A
ACC Area control center
ACS Area control surveillance
ADS Automatic dependent surveillance
AFTN Aeronautical Fixed Telecommunications Network
AIP Aeronautical information publication
AMAN Arrival manager
ANSP Air navigation service provider
AoR Area of responsibility
APP Approach control unit
APW Area proximity warning
ASM Airspace management
ATC Air traffic control
ATCO Air traffic controller
ATFCM Air traffic flow and capacity management
ATFM Air traffic flow management
ATM Air traffic management
ATS Air traffic service
ATZ Airport traffic zone

C
CAA Civil Aviation Authority
CAM Conflict alert message
XV
XVI LIS T O F A B B RE V I AT I O NS

CC Coordinating controller
CDO Continuous descend operations
CFIT Controlled flight into terrain
CLAM Cleared level adherence monitoring
CNS Communication, navigation, and surveillance
CSE Cognitive systems engineering
CTA Cognitive tasks analysis
CWP Controller’s working position

D
DMAN Departure manager
DME Distance measuring equipment
DSS Decision support systems

E
EASA European safety aviation agency
EAT Expected approach time
EATMP European air traffic management program
EC Executive controller
EEC Experimental center
ELT Emergency locator transmitter
ESARR EUROCONTROL Safety Regulatory Requirement
ETTO Efficiency–thoroughness trade-off
EUROCONTROL European Organization for the Safety of Air
Navigation
F
FAA Federal Aviation Administration
FAB Functional airspace block
FCOM Flight crew operating manual
FDPS Flight data processing system
FIS Flight information service
FL Flight level
FMS Flight management system
FOM Flight operations manual
FPS Flight progress strip
FRAM Functional resonance accident model
Ft Feet
FTA Fault tree analysis
FUA Flexible use of airspace
 LIS T O F A B B RE V I AT I O NS X VII

G
GA General aviation
GAT General air traffic
GPS Global positioning system
GRD Ground controller
GS Glide slope

H
HERA Human error in ATM
HF High frequency
HFCAS Human factors analysis and classification system
HFE Human factors engineering
HMI Human machine interaction
HRO High reliability organization
HTA Hierarchical task analysis

I
I/O Input/Output
IANS Institute of Air Navigation Services
IAP Instrument approach procedure
ICAO International Civil Aviation Organization
IFR Instrument flight rules
ILS Instrument landing system
IM Inner marker
IRP Integrated risk picture

J
JCS Joint cognitive systems

L
LLWS Low level wind shear
LoA Letter of agreement
LOC Local controller

M
MDI Minimum departure interval
MEL Minimum equipment list
METAR Meteorological terminal air report
MM Middle marker
X VIII LIS T O F A B B RE V I AT I O NS

MONA Monitoring aids

MSAW Minimum safe altitude warning
MSL Mean sea level
MTCD Medium term conflict detection

N
NATS National Aviation Traffic Services
NDM Naturalistic decision making
NextGen Next generation air transportation system
Nm Nautical mile

O
OAT Operational air traffic
ODS Operator input and display system
OJT On-the-job training
OJTI On-the-job training instructor
OM Outer marker
ORM Operational risk management

P
P/A Public announcement
PANS Procedures of air navigation services
PPL Private pilot license
PSR Primary surveillance radar

Q
QNH Code for altimeter setting indicating altitude above Mean
Sea Level
QRH Quick reference handbook

R
RA Resolution advisory
RADAR Radio detection and ranging
RAM Route adherence monitoring
RAT Risk analysis tool
RCF Radio communication failure
RDP Radar data processor
 LIS T O F A B B RE V I AT I O NS XIX

RIMCAS Runway incursion monitoring and conflict alert

system
RTF Radio telephony
RVA Radar vectoring area
RVSM Reduced vertical separation minima
RX Reception

S
SA Situation awareness
SADT Structured analysis and design technique
SAR Search and rescue
SARPs Standards and recommended practices
SES Single European skies
SESAR Single European sky ATM research program
SID Standard instrument departure
SME Subject matter expert
SMR Surface movement radar
SNET Safety net
SOPs Standard operating procedures
SSR Secondary surveillance radar
STAMP Systems-theoretic accident model and processes
STAM Short-term ATFCM measures
STAR Standard arrival route
STCA Short term conflict alert
Std Standard

T
T 2EAM Taskwork/teamwork for effective and adaptive
management
TA Traffic advisory
TCAS Traffic alert and collision avoidance system
TEM Threat and error management
TMA Terminal maneuvering area
TRACEr Technique for the retrospective and predictive analysis
of cognitive error
TRM Team resource management
TWR Tower
TX Transmission
XX LIS T O F A B B RE V I AT I O NS

U
UAC Upper area control
UACC Upper area control centre
UCS Unit competency scheme
UHF Ultra high frequency
UNL Unlimited
UTP Unit training plan

V
VFR Visual flight rules
VHF Very high frequency
VSM Viable system model
VMC Visual meteorological conditions
VOR Very high frequency omni directional radio range
List of Figures

Figure 1.1 A high-level functional representation of the air traffic

management system. 6

Figure 1.2 Vertical profile of flight phases and Air Traffic Control Services. 6

Figure 1.3 Safety nets loop in the ATM system. 12

Figure 1.4 Flight crew–controller communications loop. 14

Figure 1.5 A correlated track of an aircraft shown on the radar screen of

controllers. 17

Figure 1.6 Classes of airspaces in the ATM system. 18

Figure 1.7 Typical operations in airports. 19

Figure 1.8 A schematic of two arriving flows merged for landing

in a runway. 23

Figure 1.9 A protected airspace created in the case of 3 Nm horizontal

and 1000 ft vertical separation. 24

Figure 1.10 An example of imbalance between demand and capacity in flow

management. 32

Figure 1.11 An example of horizontal separation minima infringement. 36

Figure 2.1 A transactional model of stress. 43

Figure 3.1 A safety envelope created by the boundaries of financial

failure, high workload and safety failure. (From Rasmussen, J.,
Safety Science, 27, 183–213, 1997.) 69

XXI
X X II LIS T O F FI GURE S

Figure 3.2 Mapping high and low reliability organizations into the safety
envelope. (From Cook, R.I. and Rasmussen, J., Quality and Safety in
Health Care, 14, 2, 130–134, 2005.) 71

Figure 3.3 Flowchart of a typical occurrence investigation procedure. 74

Figure 3.4 Flowchart of a safety assessment procedure following a system

change. 76

Figure 3.5 System safety as a control process between organizational levels. 78

Figure 3.6 Barrier failures create precursors in increasing severity

from conflicts to accidents. 91

Figure 3.7 Left hand part of a bow-tie analysis. 97

Figure 3.8 Right hand part of a bow-tie analysis. 98

Figure 4.1 Matching decision models to different situations in a cognitive

continuum. 110

Figure 4.2 A decision tree for comparing teams of three or four controllers. 112

Figure 4.3 An adaptation of the Skill-Rule-Knowledge model. 116

Figure 4.4 The Recognition Primed Decision (RPD) model showing the
functions of pattern-matching, situation diagnosis, and course
evaluation. (From Klein, G.A., The Power of Intuition, Currency
Books, New York, NY, 2004.) 118

Figure 4.5 The Recognition/Metacognition Model. (From Cohen et al.,

Human Factors, 38, 206–219, 1996.) 120

Figure 4.6 2
A flow of cognitive functions in taskwork (T EAM). 132

Figure 4.7 Regulation of cognitive functions in teamwork (T2EAM). 143

Figure 5.1 Cognitive processes of the data-frame model. (From

Klein, G.A. et al., IEEE Intelligent Systems, 21, 5, 88–92, 2006.) 147

Figure 5.2 Effects of LLWS phenomena on aircraft performance. 150

Figure 5.3 Explanatory structure of controller’s perception of LLWS

phenomena. 152

Figure 6.1 The threat and error management (TEM) model. (Adapted from
Helmreich, R.L. et al., Proceedings of the Tenth International
Symposium on Aviation Psychology, The Ohio State University,
Columbus, OH, 677–682, 1999.) 167

Figure 6.2 Slips, lapses, mistakes, and violations. (Adapted from Reason, J.T.,
Human Error, Cambridge University Press, Cambridge, 1990.) 170

Figure 6.3 A nonlinear process of error detection, explanation, and recovery.

(From Kontogiannis, T., Journal of Safety Science, 42, 73–85, 2011.) 177
 LIS T O F FI GURE S X X III

Figure 6.4 A four process model of performance in air traffic control. (From
Kontogiannis, T. and Malakis, S., Safety Science, 47, 693–706,
2009.) 180

Figure 7.1 “Reflection-in-action” attenuated by reflexive responses as

familiarity with exceptions and threats increases with experience.
(From Kontogiannis, T. and Malakis, S., Theoretical Issues in
Ergonomics Science, 14, 6, 565–591, 2013a.) 206

Figure 7.2 Mindful practices that amplify “reflection-in-action.” (From

Kontogiannis, T. and Malakis, S., Theoretical Issues in Ergonomics
Science, 14, 6, 565–591, 2013a.) 210

Figure 7.3 Initial traffic flow for the arriving aircraft from ALPHA point. 215

Figure 7.4 A “bumpy” integration of ALPHA and BRAVO traffic flows. 216

Figure 7.5 A smooth integration of ALPHA and BRAVO traffic flows. 217

Figure 8.1 Flow control of taskwork and teamwork functions in the

T2EAM model. (From Malakis, S. and Kontogiannis, T.,
International Journal of Aviation Psychology, 22, 1, 59–77, 2012.) 227

Figure 8.2 A schematic diagram of the airspace clearing scenario. 235

Figure 9.1 A cognitive model of controller activities. (From Kontogiannis,

T. and Malakis, S., Safety Science, 57, 27–34, 2013.) 251

Figure 9.2 Mapping complexity-mitigation strategies to increasing

levels of complexity. 259

Figure 10.1 The concept of dynamic resectorization. 265

Figure 11.1 Organizational forces of resistance and vulnerability in the

safety space. (Adapted from Reason, J., Managing the Risks of
Organizational Accidents, Ashgate, Aldershot, 1997.) 285

Figure 11.2 Hierarchical model of socio-technical systems on a cause-

consequence chart. (Adapted from Rasmussen, J. and
Svedung, I., Proactive Risk Management in a Dynamic Society,
Swedish Rescue Service Agency, Karlstad, 2000.) 293

Figure 11.3 Resilience qualities and their interactions. (Adapted

from Hollnagel, E., Remaining Sensitive to the Possibility of Failure,
Ashgate, Aldershot, 2008.) 299

Figure 12.1 Four interacting elements in the safety control structure.

(Adapted from Stringfellow, M., Accident Analysis and
Hazard Analysis for Human and Organizational Factors, PhD
Dissertation, Massachusetts Institute of Technology, Boston,
2010.) 314

Figure 12.2 Control flaws leading to accidents according to STAMP. 316

X XIV LIS T O F FI GURE S

Figure 12.3 A simplified architecture of the hardware systems with two sector
suites in the National Aviation Traffic Services (NATS, UK). 319

Figure 12.4 A hierarchical representation of the wider organization of

NATS operations (STAMP perspective). 323

Figure 12.5 A generic recursive template for the analysis of interactions

between management, operations, and environment
(VSM perspective). 329

Figure 13.1 Revision of taskwork and teamwork functions (T2EAM). 345

Figure 13.2 A variant of VSM for organizational processes in system safety. 349

Figure 13.3 Amplifying own capability and attenuating complexity in the

environment. 351

Figure 15.1 A SADT description of the functions of en-route conflict

management. (Adapted from Eurocontrol, ATM Process Model
SADT Diagrams, Eurocontrol, Bretiny, 2005.) 394

Figure 15.2 A system description of the safety organization in terms

of control loops. (STAMP analysis.) 395

Figure 15.3 An extract of HTA analysis of the tactical separation

function of the executive controller. 397

Figure 15.4 A cognitive task analysis of the tactical separation function. 398

Figure 15.5 A conventional fault tree of a “loss of separation” event. 400

Figure 15.6 An expanded fault tree of a “loss of separation” event

represented in gray boxes. 402

Figure 15.7 A conventional event tree of the response of controllers

to an initial disturbance. 403

Figure 15.8 An expanded event tree of the response of controllers

to an initial disturbance. 405

Figure 15.9 A conventional event tree of a response to a severe and

deteriorating LLWS phenomenon. 407

Figure 15.10 An expanded event tree of a response to a severe and

deteriorating LLWS phenomenon. 408
List of Tables

Table 1.1 Fundamental Characteristics of the ATC Units 8

Table 1.2 The Four Phases of Controller Training 10

Table 1.3 Characteristics of Mainstream Ground-Based Navaids 15

Table 2.1 Work Stressors at Different Levels in the ATM System 44

Table 2.2 The ASSIST Model for Handling Abnormal ATM Situations 52

Table 2.3 Criteria Used to Frame and Reframe Mental Pictures in Air
Traffic Control 54

Table 3.1 Challenges to Safety Management Addressed in the Book Chapters 81

Table 3.2 Scenarios Making “Unplanned” Conflicts Difficult to Detect by

Controllers 93

Table 3.3 A Generic Data Structure for Conducting Risk Assessment 99

Table 4.1 Expected Values for Two Shift Options 112

Table 4.2 Taskwork Functions and Strategies (T2EAM) 123

Table 4.3 Teamwork Functions and Strategies (T2EAM) 136

Table 5.1 Team Sensemaking Strategies and Behavioral Markers in Coping

with LLWS Phenomena 157

Table 6.1 Psychological Error Mechanisms in TRACEr 174

Table 6.2 Cognitive Strategies in Error Detection and Identification 182

XXV
X XVI LIS T O F TA B L E S

Table 8.1 EAS Scenarios in Refresher Training 229

Table 8.2 Typical Operational Problems Recorded in Real Incidents 230

Table 8.3 Patterns of Resilient Taskwork 232

Table 8.4 Patterns of Adaptive Teamwork 233

Table 8.5 Patterns of Affordances 234

Table 8.6 Decision Requirements in the “Airspace Clearing” Scenario 236

Table 8.7 Resilience, Coordination and Affordance Patterns in the

Airspace Clearing Scenario 237

Table 8.8 Cognitive Task Analysis of Controller Strategies across Time in

the Airport Diversion Scenario 239

Table 8.9 Assessment of Situation in Approach Control 241

Table 8.10 Balance of Constraints and Resources in Approach Control 242

Table 8.11 Communicating Information, Actions, and Intentions in

Approach Control 243

Table 8.12 Decisions and Plans in Approach Control 243

Table 8.13 Error Detection and Recovery in Approach Control 244

Table 9.1 Prototype Taxonomy of Complexity Mitigation Strategies 253

Table 11.1 CAIR Indicators for Assessing Organizational Resistance 287

Table 11.2 Control Loops Required for Managing Safety in Organizations 296

Table 11.3 A Comparison of the Three Organizational Safety Approaches 307

Table 12.1 A Chronology of Major Events That Took Place in the NATS
Incident 321

Table 12.2 Flaws in the Control Loops at the Operational Level of NATS
Activities 325

Table 12.3 Flaws in the Control Loops at the Regulation Level of NATS
Activities 326

Table 12.4 Balancing the Varieties of Organization and Environment in

NATS Activities 331

Table 12.5 Seven Control Functions Common to STAMP and VSM 333

Table 12.6 Ten VSM Principles that Help Diagnose Organizational

Breakdowns 335

Table 13.1 Revision of Taskwork and Teamwork Functions (T2EAM) 346

Table 13.2 Control Functions at the Organizational and Operational Levels 353
 LIS T O F TA B L E S X X VII

Table 13.3 Patterns of Performance Breakdown Leading to “Loss of

Control” Events 358

Table 14.1 Controller Performance as Balancing Trade-offs at Multiple Levels 375

Another random document with
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Milk, cocoa-nut flavoured, for sweet dishes, 456
lemonade, delicious, 583
remarks on, 450
Mild eschalot sauce, 127
mustard, 130
ragout of garlic, or l’ail à la Bordelaise, 126
Minced collops, 201
fowl, 276
veal, 230
veal, with oysters, 231
Mincemeat (author’s receipt), 368
superlative, 369
fritters, 383
Mince pies (entremets), 369
royal, 370
Miniature round of beef, 199
Mint julep, 582
sauce, 132
Mock, brawn, 260
turtle soup, 23
turtle soup, good old-fashioned, 26
Modern blanc-mange-mould, 476
cake-mould, 540
chicken pie, 353
jelly-mould, 470
potato pasty, 350
varieties of calf’s feet jelly, 463
Monitor’s tart, or tourte à la Judd, 370
Moor game, to roast and hash, 291, 292
Mould for French pies, or casseroles of rice, 344
Mull, to, wine, an excellent receipt (French), 581
Mullagatawny soup, 35
vegetable, 37
Mullet, grey, to boil, 76
red, to bake, broil, or roast, 76
Mushroom catsup, 146
catsup, another receipt for, 148
catsup, double, 148
forcemeat, 159
powder, 154
sauce, brown, 123
sauce, another, 123
sauce, white, 122
Mushrooms, au beurre, 329
dried, 153
partridges with, 289
in pigeon pie, 354
pickled, in brine for winter use, 536
to pickle, 535
potted (delicious), 330
toast, or croûte aux champignons, 330
Mussel-plums, preserves of, 516
Mustard, to make, 130
mild, 130
Tartar, 155
another Tartar, 155
horseradish vinegar for ditto, 153
Mutton, broth, 44
to choose, 233
cutlets broiled, and Soubise sauce, 243
cutlets, to broil, 241
cutlets of, cold, 243
cutlets, stewed in their own gravy, 240
fillet of, roast or stewed, 238
haunch of, to roast, 234
 kidneys à la Française (entrée), 243
kidneys, broiled, 244
kidneys, Oxford receipt for, 244
leg of, to boil (an excellent receipt), 237
leg of, boned and forced, 236
leg of, braised, 236
leg of, roast, 235
loin of, roast, 238
loin of, stewed like venison, 239
neck of, roast, 239
pie, common, 355
pie, good, 355
pudding, 401
saddle of, to roast, 235
shoulder of, broiled, 240
shoulder of, to roast, 239
shoulder of, forced, 240
a good family stew of, 242
stock for soup, 16
Nasturtiums, to pickle, 539
Nesselrôde cream, 471
pudding, 491
Norfolk biffins, dried, 572
sauce, 99
Norman harricot, 224
Normandy pippins, 572
Nougat, 564
Nouilles, to make, 5
Œufs au plat, 450
pochés au jus, 449
Old-fashioned boiled custard, 481
Oil, to fry salmon and other fish in (Jewish), 607
Olive sauce, 128
Omlette aux fines herbes, 380
soufflée, 381
Omlets, observations on, 380
Omlet, common, 380
King of Oude’s, 612
Onion sauce, brown, 125
sauce, brown, another receipt for, 125
sauce, white, 125
Onion and sage stuffing for ducks and geese, No. 9, 160
rich white sauce of, or Soubise, 126
Onions, to pickle, 537
stewed, 342
Orange, baskets for jelly, 466
calf’s feet jelly, 464
conserve for cheese-cakes, or pudding, 501
fritters, 384
gravy, 102
isinglass jelly, 465
marmalade, 527, 529
plums, preserve of, 514
salad, 571
snow-balls, 420
wine, 585
Orange-flower, candy, 565, 566
Seville, paste, 568
filled with jelly in stripes, 466
Tangerine, 571
Oven, American, 178
management of, 595
objection to iron ones, 595
Oxford receipt for Bishop, 580
for mutton kidneys, 244
 punch, 580
Ox-cheek, stuffed and baked, 208
Ox-tail, broiled (entrée), 195
stewed, 195
soup, 42
Ox tongue, to pickle, 202
potted, 305
Oyster forcemeat, No. 5, 159;
No. 6, 159
patties, 359
sauce, common, 114
sauce, good, 114
sausages, 87
soup, white, or à la Reine, 30
Oysters, curried, 302
to feed, 85
to fry, 80
scalloped, à la Reine, 86
to scallop, 86
to stew, 86
to stew, another receipt, 87
Pain de pore frais, or sausage-meat cake, 261
Pain de veau, or veal cake, 222
Pain de veau (Bordyke receipt), 222
Palace-bonbons, 567
Palates, beef, to dress, 194, 195
Panada, 165
Pancakes, 382
to crisp, 130
fried, 130
Parsley green for colouring sauces, 129
Parsneps, to boil, 337
fried, 337
Partridge, broiled (breakfast dish), 290
broiled (French receipt), 290
French, or red-legged, to dress, 290
potted, 305
pudding, 401
soup, 35
Partridges, boiled, 289
with mushrooms, 289
to roast, 288
salmi, or rich hash of, 292
salmi of (French), 292
Paste, almond, 367
brioche, 349
cherry (French), 504
currant, 510
gooseberry, 501
very good light, 346
English puff, 316
fine puff, or feuilletage, 345
quince, 525
Pastry, to colour almonds or sugar-grains for, 542
to glaize or ice, 345
icing for, 345
sugar-icing for, 543
her Majesty’s, 366
general remarks on, 344
sandwiches, 374
Pasty, potato, 350
varieties of, 351
mould for, 351
Pâte Brisée, or French crust for hot or cold pies, 347
Patties à la Pontife (entrées), 360
 good chicken, 359
common lobster, 559
superlative lobster, author’s receipt, 359
oyster (entrée), 359
sweet boiled, 422
tartlets, or small vols-au-vents, to make, 361
Peach, fritters, 384
jam, or marmalade, 518
mangoes, 534
Peaches, compote of, 459
to dry, an easy and excellent receipt, 518
to pickle, 534
preserved in brandy (Rotterdam receipt), 571
stewed, 459
Suédoise of, 488
vol-au-vent of, 358
Pears, baked, 573
stewed, 573
meringue of, 486
Pearled fruit, 570
Peas, green, to boil, 320
green, with cream, 321
green, soup of, 39, 40
green, stewed, à la Française, 320
pudding, 401
soup, common, 41
soup without meat, 42
soup, rich, 41
Perch, to boil, 82
to fry, 83
Pheasant, boudin of, 288
cutlets, 275
to roast, 287
salmi of, 292
 soup, 33, 34
Pickle, for beef, tongue, and hams, 197
Hamburgh, for pork, &c., 197
to, beet-root, 537
cherries, 532
eschalots, 532
gherkins, 537
gherkins (French receipt), 533
limes, 538
lemons, 538
lemon mangoes, 538
melon, sweet (foreign receipt), 534
mushrooms in brine, 536
mushrooms (an excellent receipt), 535
nasturtiums, 539
onions, 537
peaches, and peach mangoes, 534
red cabbage, 539
walnuts, 536
Pickles, where to be procured good, 532
general remarks on, 531
Pie, beef-steak, 354
a common chicken, 353
a modern chicken, 353
a good common English game, 352
mutton, common, 355
a good mutton, 355
pigeon, 354
Pies, excellent, cream crust for, 347
French crust for, 347
suet-crust for, 348
meat jelly for, 92
mince, 369
mince royal, 370
pudding (entremets), 371
 raised, 356
Pigeons, to boil, 280
to roast, 280
served with cresses, for second course, 280
Pig, divisions of, 247
Kentish mode of cutting up and curing, 254
to bake a sucking, 250
sucking, en blanquette (entrée), 250
to roast a sucking, 249
à la Tartare (entrée), 250
Pig’s cheeks, to pickle, 254
feet and ears, in brawn, 260
Pike to bake, 81
to bake (superior receipt), 81
to boil, 80
Pilaw, a simple Syrian, 613
Pine-apple marmalade, superior, 513
pudding-sauce, 405
pudding-sauce, very fine, 405
Pintail, or Sea Pheasant, to roast, 294
Pippins, Normandy, to stew, 572
Piquante sauce, 118
Plaice, to boil, 75
to fry, 75
Plate, hot, for cooking, 174
Plum-puddings, 416, 417, 441, &c.
Plums, compote of, 458
Imperatrice, to dry, 521
Imperatrice, marmalade of, 521
Poêlée, 169
Poet’s, the, receipt for salad, 135
Polenta à l’Italienne, 393
Pontac catsup, 150
Poor author’s pudding, 442
Pork, to choose, 247
cutlets of, to boil or fry, 251
Italian cheese of, 260
different joints of, 247
observations on, 247
to pickle, 254
to roast, 251
to roast a saddle of, 251
sausages of, 261, 263
Portable lemonade, 583
Potage à la Reine, 29
Pot-au-Feu, or stock pot, 8
fowls, &c., boiled in, 9
Potato-balls (English), or croquettes, 314
boulettes (good), 314
bread, 600
fritters, 384
flour, or fecule de pommes de terre, 154
pasty (modern), 350
puddings, 436
ribbons, to serve with cheese, 313
rissoles, French, 315
soup, 21
Potatoes, à la crême, 315
à la Maître d’Hôtel, 315
to boil, as in Ireland, 310
to boil (Lancashire receipt), 311
boulettes (entremets), 314
to boil (Captain Kater’s receipt), 312
crisped, or potato-ribbons (entremets), 313
fried (entremets), 313
 mashed and moulded in various ways 313
new, in butter, 312
new, to boil, 311
remarks on their properties and importance, 309
to roast or bake, 312
scooped (entremets), 312
Potted anchovies, 306
chicken, partridge, or pheasant, 305
ham, 304
hare, 307
meats (various), 303
meat for the second course, moulded, 306
mushrooms, 330
ox-tongue, 305
shrimps, or prawns, 306
Poultry, to bone, 265
to bone, another mode, 265
to bone, for fricassees, &c., 266
to choose, 264
to lard, 181
Powder, mushroom, 154
of savoury herbs, 155
Prawns, to boil, 93
to dish cold, 93
to pot (see shrimps:306)
to shell easily, 93
Prepared apple or quince juice, 456
calf’s head (the cook’s receipt), 211
Preserved fruit, general remarks on the use and value of, 493
Preserve, a fine, of red currants, 509
delicious, of white currants, 510
good common, 512
an excellent, of the green orange, or Stonewood plum, 514
groseillée, a mixed, 513
 another good mélange, or mixed, 513
nursery, 512
Preserve, to, the colour and flavour of fruit-jams and jellies, 497
Preserving-pan, 495
Preserves, French furnace and stewpan convenient for making, 494,
495
general rules and directions for, 496
Pruneaux de Tours, or compote of dried plums, 573
Prince Albert’s pudding, 411
Pudding (baked), à la Paysanne (cheap and good), 442
almond, 425
almond, Jewish, 608
apple or custard, 437
apple (the lady’s or invalid’s new), 608
Bakewell, 427
barberry and rice, 406
light batter, 443
good bread, 429, 430
common bread and butter, 429
rich bread and butter, 428
cake and custard, and various inexpensive, 437
curate’s, 442
the good daughter’s mincemeat, 426
Dutch custard, or raspberry, 438
the elegant economist’s, 428
Gabrielle’s, or sweet casserole of rice, 438
green gooseberry, 435
good ground rice, 437
a common ground rice, 435
Mrs. Howitt’s (author’s receipt), 426
an excellent lemon, 426
lemon-suet, 427
Normandy, 441
plum, en moule, or moulded, 424
 poor author’s, 442
(baked) potato, 436
a richer potato, 436
the printers’, 424
the publishers’, 410
Queen Mab’s, 470
a common raisin, 441
a richer raisin, 442
raspberry, or Dutch custard, 438
ratafia, 427
cheap rice, 434
a common rice, 433
a French rice, or Gâteaux de riz, 433
rice, meringué, 434
richer rice, 434
rice, à la Vathek, 440
Saxe-Gotha, or tourte, 431
a good semoulina, or soujee, 430
a French semoulina (or Gâteau de semoule), 430
soujee and semola, 439
sponge cake, 436
vermicelli, 439
welcome guest’s own, 412
common Yorkshire, 440
good Yorkshire, 440
young wife’s (author’s receipt), 425
Pudding (boiled) à la Scoones, 416
apple, cherry, currant, or any other fresh fruit, 408
a common apple, 409
the author’s Christmas, 417
common batter, 406
another batter, 406
batter and fruit, 407
beef-steak, or John Bull’s, 399
beef-steak, epicurean receipt for, 400
small beef-steak, 400
a black-cap, 407
 Ruth Pinch’s, or beef-steak à la Dickens, 401
bread, 418
brown bread, 419
cabinet, 413
a very fine cabinet, 414
common custard, 411
the elegant economist’s, 415
German pudding and sauce, 412
Herodotus’ (a genuine classical receipt), 409
Ingoldsby Christmas, 416
Her Majesty’s, 410
mutton, 401
partridge, 401
peas, 401
small light plum, 416
Prince Albert’s, 411
the publishers’, 410
vegetable plum, 417
a very good raisin, 415
a superior raisin 415
a cheap rice, 420
a good rice, 419
rice and gooseberry, 420
rolled, 418
savoury, 399
Snowdon, 414
Kentish suet, 407
another suet, 408
the welcome guest’s own (author’s receipt), 412
a Kentish well, 417
Baden-Baden, 431
Puddings, general directions for baked, 423
to mix batter for, 397
general directions for boiled, 395
butter crust for, 398
cloths for, to wash, 366
suet-crust for, 398
 to clean currants for, 397
Madeleine, to serve cold, 432
sauces for sweet, 402, 406
to steam in common stewpan, 397
Sutherland, or castle, 432
Pudding-pies, 371
a common receipt for, 371
Pudding sauces, sweet, 402-406
Puff-paste, canellons of, 417
English, 346
finest, or feuilletage, 345
very good light, 346
Puffs, German, 484
raspberry, or other fruit, 375
Punch, Cambridge milk, 581
Oxford, 580
Punch, Regent’s, or George IV.’s (a genuine receipt), 582
sauce for sweet puddings, 402
Purée, fine, of onions, or Soubise sauce, 126
of tomatas, 328
of turnips, 127
of vegetable marrow, 127
Quenelles, or French forcemeat, 163
Queen cakes, 556
Queen’s custard, 481
Queen Mab’s pudding, 470
Quince blamange, 478
blamange, with almond cream, 478
custards, 482
jelly, 524
juice, prepared, 456
marmalade, 524
 and apple marmalade, 525
paste, 525
Rabbits, to boil, 286
Rabbit, to fry, 287
to roast, 286
soup, à la Reine, 31
soup, brown, 31
Radishes, turnip, to boil, 318
Ragout, mild, of garlic, 126
Raisin puddings, 441, 442
wine, which resembles foreign, 583
Ramakins à l’Ude, 375
Raspberries, to preserve for creams or ices, without boiling, 506
Raspberry jam, 506
jam, red or white, 506
jelly, for flavouring creams, 507
jelly, another good, 508
vinegar, very fine, 578
Red cabbage, to stew, 340
Regent’s, or George IV.’s punch (genuine), 582
Remoulade, 137
Rhubarb, or spring fruit, compote of, 457
Rice, to boil for curries, or mullagatawny soup, 36
boiled, to serve with stewed fruit, &c., 422
cake, 546
casserole of, savoury, 351
casserole of, sweet, 438
croquettes of, 385, 386
savoury croquettes of, 386
puddings, 419, 420, 433-435
soup, 14
 soup, white, 15
sweet, à la Portugaise, or arocē docē, 489
Rice flour, to make, 154
soup, 15
to thicken soups with, 4
Risotto à la Milanaise, 615
Rissoles, 387
very savoury, English (entrée), 387
Roasting, general directions for, 169
slow method of, 171
Roast beef (see Chapter X.)
chestnuts, 574
game (see Chapter XV.)
lamb (see Chapter XII.)
mutton (see Chapter XII.)
potatoes, 312
pork (see Chapter XIII.)
poultry (see Chapter XIV.)
veal (see Chapter XI.)
Rolled shoulder of mutton, 240
ribs of beef, 198
sirloin of beef, 198
Roll, beef, or canellon de bœuf, 201
Rolls, breakfast or dinner, 600
Geneva, 601
excellent meat, 360
Roux, or French thickening brown (for sauces), 106
white, 106
Rusks, sweet, 554
Rusks, 602
Sago soup, 14
Salad, to dress (English), 140
forced eggs for garnishing, 137
French, 140
of mixed summer fruits, 570
excellent herring (Swedish receipt), 143
lobster, 142
very elegant lobster, 584
orange, 571
peach, 570
the Poet’s receipt for, 135
Suffolk, 141
walnut, or des cerneaux, 141
Yorkshire ploughman’s, 141
dressings and sauces, 140
sorrel, 142
of young vegetables, 141
Salamander to brown with, 183
Salmi of moor fowl, pheasants or partridges, 292
French, or hash of game, 292
of wild fowl, 294
Salmon à la Genevese, 59
à la St. Marcel, 60
baked over mashed potatoes, 60
to boil, 59
crimped, 60
to fry in oil, 607
pudding (Scotch receipt), 60
Salsify, to boil, 341
to fry in batter, 341
Salt fish, to boil, 62
à la Maître d’Hôtel, 63
Salt, to, beef, in various ways, 196
Sandwiches, lemon, 374
pastry, 374
Sand-launce, or Sand-eel, mode of dressing, 77
Salzburger Nockerl, 620
Sauce (American), cold, for salads, salt fish, &c., 133
anchovy, 115
baked apple, 124
boiled apple, 124
brown apple, 125
arrow-root, clear, 403
asparagus, for lamb cutlets, 120
béchamel, 107
béchamel maigre, 108
another common béchamel, 108
bread, 112
bread, with onion, 113
caper, 121
brown caper, 121
caper for fish, 121
celery, 128
brown chestnut, 129
white chestnut, 129
Chatney, capsicum, 144
Chatney, sausage, 609
Chatney, shrimp (Mauritian receipt), 144
Chatney, tomato, 609
Chatney (Bengal receipt), 146
Christopher North’s own (for many meats), 119
crab, 114
cream, for fish, 115
common cucumber, 121
another common cucumber, 122
white cucumber, 122
currants, 404
Dutch, 111
cold, Dutch, 133
common egg, 110
egg, for calf’s head, 111
very good egg, 110
English, for salad, cold meat, &c., 134
epicurean, 151
mild eschalot, 127
Espagnole, 100
Espagnole, with wine, 100
fricassee, 112
fruit, superior, 404
mild garlic, 126
Genevese, or sauce Genevoise, 117
German, for fricassees, 107
German cherry, 406
German custard pudding, 403
gooseberry, for mackerel, 120
horseradish, excellent, to serve hot or cold, with roast beef, 118-
133
hot horseradish, 119
the lady’s, for fish, 117
common lobster, 113
Maître d’Hôtel, or steward’s sauce, 116
cold Maître d’Hôtel, 133
Maître d’Hôtel sauce maigre, 117
sharp Maître d’Hôtel, 116
Imperial mayonnaise, 136
mayonnaise, red or green, 136
mayonnaise (very fine), to serve with cold meat, fish, or
vegetables, 135
mint, common, 132
mint (superior), for roast lamb, 133
strained, 132
brown mushroom, 123
another mushroom, 123
white mushroom, 122
Norfolk, 109
olive, 128
brown onion, 125
another brown onion, 125