Output Number
Approval Date
Published Date Time
Recommendation type
Mode
Date released
Background Text

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 airline
operators:



1. Include in the ground training phases of pilot endorsement
courses;



(a) sufficient technical knowledge of aircraft systems; and



(b) knowledge of the design philosophies employed by aircraft
system manufacturers



to give pilots sufficient systems understanding to permit analysis
of system abnormalities and to determine appropriate responses in
situations for which checklists are not available.



2. Consider the safety lessons from discussions of incident and
accident scenarios during all initial, recurrent and CRM training
programs.

Organisation Response
Organisation
Airline Operators Asia-Pacific Region
ATSB Response

ATSB Note: As this recommendation was not issued to any specific
organisation, no response was expected.