The Bureau of Air Safety Investigation recommends that aircraft
design authorities and airline operators:
Consider effective systems and procedures to ensure flight crew of
automated aircraft do not inadvertently fall asleep during
flight.
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 aircraft
design authorities and airline operators:
Consider effective systems and procedures to ensure flight crew of
automated aircraft do not inadvertently fall asleep during
flight.
ATSB Note: As this recommendation was not issued to any specific
organisation, no response was expected.