SUBJECT
The Advanced Technology Aircraft Survey - Phase Two
OBJECTIVES
The objectives of the phase 2 study were to:
Determine specific types of human/system interface problems that
are occurring on advanced aircraft in service within the
Asia-Pacific region;
Collect information on flight-deck errors;
Assess the severity of errors;
Identify design-induced errors; and
Identify areas where pilots inappropriately manipulate automated
systems.
SCOPE
The report dealt with information supplied by respondents to the
Advanced Technology Aircraft Safety Survey and provided a detailed
analysis of the answers to both the 'open' and 'closed'
questions.
The accompanying analysis did not include the responses to closed
questions by Second Officers or McDonnell Douglas pilots due to
their disproportionately low representation within the sample.
However, all written comments made by all respondents have been
included and analysed.
The survey covers a range of technologies from the early 1980s to
the present. However, the survey sought pilots' perceptions of the
technology that they were using. Despite any differences in
technology, the Bureau believes that the survey results are
applicable to aviation in the Asia Pacific region.
SUMMARY OF RECOMMENDATIONS
Introduction
The following recommendations are organised according to their
corresponding chapter. Where applicable recommendations have been
address to:
Airservices Australia;
The Civil Aviation Safety Authority (Australia);
Aircraft design authorities; and
Airlines within the Asia-Pacific region.
However, this does not restrict the applicability of the
recommendation to the above mentioned agencies. BASI encourages
foreign agencies, both government and civil, to adopt all, or any,
of the following recommendations in the interests of improving
aviation safety throughout the international aviation
industry.
The objectives of this project are largely proactive. Our task has
been to determine specific errors and assess the severity of those
errors. Consequently some of the following recommendations are
phrased in a proactive sense. Regulatory authorities, aircraft
manufacturers and airline operators are now required to do the
same, basing their response on the evidence provided by 1268
pilots, many of whom are line pilots with considerable experience.
Our concern is that appropriate mechanisms and mindset are not yet
in place to assess proactive recommendations. This is the greatest
challenge currently before the aviation industry.
List of Relevant Recommendations by Report Chapter:
1. Air Traffic Control
R980024 to Airservices Australia
R980025 to the Civil Aviation Safety Authority
R980026 to airline operators within the Asia-Pacific Region
2. Automation
R980027 to airline operators within the Asia-Pacific Region
3. Crew Resource Management
R980028 to airline operators within the Asia-Pacific Region
4. Flying Skills
R980029 to the Civil Aviation Safety Authority
5. General
R980030 to The Civil Aviation Safety Authority
R980031 to airline operators within the Asia-Pacific Region
R980032 to design authorities and airline operators within the
Asia-Pacific Region
6. Modes
R980033 to aircraft design authorities
R980034 to airline operators within the Asia-Pacific Region
R980035 to the Civil Aviation Safety Authority
7. Situational Awareness
R980036 to airline operators within the Asia-Pacific Region
8. System design
R980037 to airline operators within the Asia-Pacific Region
R980038 to aircraft design authorities
9. Training
R980039 to the Civil Aviation Safety Authority
R980040 to airline operators within the Asia-Pacific Region
The Bureau of Air Safety Investigation recommends that the Civil
Aviation Safety Authority:
Ensure that all recurrent and rating renewal simulator exercises
are appropriate considering the level of automation fitted to the
aircraft type. Such exercises should reflect the level of
serviceability which the pilot may be expected to encounter during
line operations.
Before responding to specific recommendations, the following
general comments are offered.
As a result of the survey, BASI has made numerous
recommendations to airlines and aircraft design authorities as well
as CASA and Airservices. Some seem to be rather utopian, in that
they may be beyond current capabilities in automation.
Nevertheless, it is important that perceived deficiencies are
documented and that the various agencies concerned are alerted.
As far as the recommendations made to CASA are concerned, I am
having difficulty as to CASA's ability to come to terms with some
of the fundamental problems identified. One of the drawbacks of
CASA's move more towards an auditing function is a lessening of the
intimate knowledge that we previously had of particular operators.
Further, as the CASA legislative framework moves towards less
prescriptive legislation, it may be more difficult to manage to the
degree suggested in some of the BASI identified issues. The content
of simulator exercises along with the detailed qualifications and
recency of instructors are examples.
Recommendation R980029. "The Civil Aviation Safety Authority
ensure that all recurrent and rating renewal simulator exercises
are appropriate considering the level of automation fitted to the
aircraft type. Such exercises should reflect the level of
serviceability which the pilot may be expected to encounter during
line operations".
CASA Response
The requirements specified in Civil Aviation Regulations and
Civil Aviation Orders for flight reviews and ratings are normally
met by the airline CAR 217 check and training organisation being
approved by CASA to institute a cyclic training program. This is a
matrix of ground, flight and simulator training exercises which
covers all regulatory requirements. It includes the syllabus of
training and the standards to be achieved, and forms part of the
approved Training and Checking ManuaL
CASA has some reservations as to mandating that all simulator
exercises reflect the automation features available. Operators vary
in their approach to automation, with some requiring manual flight
and the use of raw data during certain manoeuvres. The CASA
assessment of simulator exercises is a quality check to ensure that
the overall program covers the syllabus and that the end product
achieves the regulatory requirement. Obviously, an exercise which
is manifestly inappropriate in the use of automation would not be
approved. As to exercises reflecting the serviceability expected
during line operations, the reality is that the simulator presents
the only means of practicing many abnormal procedures which may
arise from failures which occur infrequently. It would not be
productive to limit exercises to the everyday aircraft
serviceability rate.
Portion of letter dispatched to CASA on 19 November 1999:
"R980029 - The Bureau of Air Safety Investigation recommends
that the Civil Aviation Safety Authority:
Ensure that all recurrent and rating renewal simulator exercises
are appropriate considering the level of automation fitted to the
aircraft type. Such exercises should reflect the level of
serviceability which the pilot may be expected to encounter during
line operation
Response classification: OPEN
The Bureau does not consider that the CASA response adequately
addresses this recommendation. The response appears to ignore
proposed changes to the regulatory framework, specifically:
1. CASR 61 - Pilot Licences;
2. CASR 121 - Commercial Air Transportation (Aeroplanes);
3. CASR 133 - Commercial Air Transportation (Rotorcraft); and
4. CASR 135 - Air Transport Operations - <10 seats
CASA stated that "It would not be productive to limit
(simulator) exercises to the everyday aircraft serviceability
rate". The Bureau's recommendation does not propose to limit the
exercises as such, but proposes that they "should reflect the level
of serviceability which the pilot may be expected to encounter
during line operations".
CASA also stated that its assessment of simulator exercises is a
"quality check to ensure that the overall program covers the
syllabus and that the end product achieves the regulatory
requirement". However, the response did not:
1. make any reference to CRM training, as proposed in Subpart N of
CASR 121A;
2. address the considerations relating to advanced technology
aircraft in respect to Subpart E of CASR 121A - All Weather
Operations;
3. address how such syllabi shall be formulated under the proposed
CASR 61, 121, 133 or 135;
4. address the proposal to mandate (operators') Quality Systems
under CASR 121A.035, which refers to CASR 119.05; and
5. address how it intends to define objective training standards
under the proposed CASR's (61 and subpart N of 121A).
The Bureau therefore requests that CASA further review R19980029
in light of the above comments and provide the Bureau with a
further response as soon as practical.
Further responses, as indicated, to the above recommendations
are requested at your earliest convenience. In addition, for the
purpose submitting a clear indication of whether CASA accepts,
partially accepts or rejects recommendations made by the Bureau, it
would be appreciated if a clear statement to this effect could be
made on each recommendation before any further comment is offered.
Guidance on this protocol can be found in the current Memorandum of
Understanding between CASA and the Bureau."
