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:
Review their standard operating procedures (SOP) and airline
policy to require only one crew member to make control inputs at
any one time unless stated to the contrary in an emergency/abnormal
procedure, and to emphasise the consequences of multiple
simultaneous flight control inputs.
CASA has reviewed the Operational Standard "Simultaneous
Opposite Direction Operations" as you have recommended.
Following Occurrence 9700052 on 5 January 1997 the instructions
in AIP OPS paragraph 19.4 were changed by NOTAM to require pilots
to remain on Tower frequency until instructed to change, thus
enabling Tower to correct the kind of confusion evident during the
occurrence. The amendment will be correctly inserted into the AIP
OPS text by AIP Amendment List 20, effective 4 December 1997.
Given the change to procedures our conclusion is that the
standard expressed in the CASA Manual of Operational Standards
(MOS) Part 3 Chapter 5.9 is adequate.
The MOS standard will be further reviewed in the light of any
study which may be undertaken by Airservices in response to your
recommendation R970150.
After dispatching a copy of the [name supplied] report to CASA
the following response was received on 28 Aug 1998:
The letter requests a formal CASA response to the
recommendations in a report attributed to [name supplied]. It cites
the CASA/BASI MOU as the basis for advice of actions CASA intends
to take in response to those recommendations.
It is our belief that this request is not consistent with the
MOU between our two organisations. That MOU lays out a basis for
CASA to respond to safety deficiencies identified by BASI and
recommendations made by BASI to rectify those deficiencies. It does
not require CASA to address recommendations made by a third
party.
It was our understanding that BASI would be forwarding a draft
investigation report to CASA for comment. That report would be
along the lines of the outline we had informally discussed early in
July, and would at your discretion incorporate such findings of the
Gleave report as you saw fit. We would of course be pleased to
provide comment on such a report and indicate actions taken or
planned to address any recommendations the Bureau may choose to
make. We are, as you know, already addressing a number of the
issues discussed at our meeting in July. If you have any questions
on this issue please don't hesitate to call.
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