Advanced Technology Aircraft Safety Survey Report - Australian ...

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SUMMARY OF RECOMMENDATIONS SUMMARY OF RECOMMENDATIONS Introduction The following recommendations are organised according to their corresponding chapter. Where applicable, recommendations have been addressed to: Airservices Australia; the Civil Aviation Safety Authority (Australia); aircraft design authorities; airlines within the Asia-Pacific region; and airlines around the world. However, this does not restrict the applicability of the recommendations to the abovementioned agencies. BAS1 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. Traditionally, recommendations flowed from ‘reactive’ investigations where active or latent failures were found to have directly contributed to an accident or incident. In response, government authorities, aircraft manufacturers and airline operators made changes to various aspects of their operation with the aim of limiting further occurrences. Unlike reactive investigations, much of modern research is framed in a proactive sense. Researchers are given the difficult task of finding potential problems before they arise. Fortunately, safety professionals within the aviation industry are embracing proactive remedies, although ever so slowly. TCAS is a good example of a proactive safety tool that some airline operators were reluctant to implement. Safety professionals now often quote the accidents which have been avoided by responding to a TCAS message. 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 1,268 pilots, many of whom are line pilots with considerable experience. Our concern is that appropriate mechanisms and an appropriate mindset are not yet in place to assess proactive recommendations. This is the greatest challenge currently before the aviation industry. 1. ATC The Bureau of Air Safety Investigation recommends that Airservices Australia (R980024) and the Civil Aviation Safety Authority (R980025): Review their airways and procedures design philosophies to: (a) ensure that STAR, SID and airways design is compatible with aircraft FMS programs; (b) allow a fl0-kts range with respect to descent speed below 10,000 ft to allow for the tolerances of FMS-equipped aircraft, with the aim of reducing the requirement for system work-arounds; (c) provide ATC personnel with information on the aerodynamic characteristics of advanced technology aircraft; and (d) seek the co-operation of airline operators for a program of advanced technology flight deck observation for all ATC personnel during both their initial and recurrent training. 97
ADVANCED TECHNOLOGY AIRCRAFT SAFETY SURVEY REPORT 98 The Bureau of Air Safety Investigation recommends that airline operators within the Asia- Pacific region (R980026): Consider a program of flight crew observation of ATC operations during both initial and recurrent training. Such a program should be incorporated into the syllabus of training and include subjective elements requiring observation and assessment. 2. AUTOMATION The Bureau of Air Safety Investigation recommends that airline operators (R980027): 1. Ensure that flight crew of advanced technology aircraft are educated in the concept , and safety implications, of passive command syndrome. 2. Include a comprehensive statement of automation policy in their general operations manual and/or airline policy documents. 3. CREW RESOURCE MANAGEMENT The Bureau of Air Safety Investigation recommends that airline operators (R980028): Employ appropriate methods and examples during initial and refresher CRM training to enhance the transmission of safety information between flight crew members during flight. Such training should stress the consequences of not communicating essential flight safety information. 4. FLYING SKILLS The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority (R980029): 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. 5. GENERAL The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority (R980030): Review the minimum standards for the quality of information provided in FMC databases with the aim of eliminating FMC database errors. The Bureau of Air Safety Investigation recommends that airline operators (R980031): 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. The Bureau of Air Safety Investigation recommends that aircraft design authorities and airline operators (R980032): Consider effective systems and procedures to ensure that flight crew of automated aircraft do not inadvertently fall asleep during flight.
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Department of Transport and Regiona
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CONTENTS CONTENTS ACKNOWLEDGMENTS A
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ATC and situational awareness Terra
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ACKNOWLEDGMENTS The Bureau of Air S
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asic automate ations, navigation, s
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ADVANCED TECHNOLOGY AIRCRAFT SAFETY
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AIR TRAFFIC CONTROL AIR TRAFFIC CON
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70% - 60% - AIR TRAFFIC CONTROL FIG
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AIR TRAFFIC CONTROL FIGURE B2.4 The
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AIR TRAFFIC CONTROL the responses t
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AIR TRAFFIC CONTROL Given direct tr
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AIR TRAFFIC CONTROL By nominating s
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9 ADVANCED TECHNOLOGY AIRCRAFT SAFE
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GENERAL Introduction This chapter a
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FIGURE B9.2 Have you detected any F
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accident near Cali, Colombia (12 De
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GENERAL It appears that much of the
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Page 50 and 51: ADVANCED TECHNOLOGY AIRCRAFT SAFETY
Page 58 and 59: SITUATIONAL AWARENESS SITUATIONAL A
Page 60 and 61: SITUATIONAL AWARENESS FIGURE B4.1 I
Page 62 and 63: SITUATIONAL. AWARENESS FIGURE B4.4
Page 64 and 65: SYSTEM DESIGN Introduction Research
Page 66 and 67: FIGURE B1.2 It is easy to detect wh
Page 68 and 69: SYSTEMS DESIGN Some reported accide
Page 70 and 71: Table B5.3 'I am sometimes forced t
Page 72 and 73: TRAINING Introduction The introduct
Page 74 and 75: TRAINING The majority of respondent
Page 76 and 77: FIGURE B8.5 My training has prepare
Page 78 and 79: Provision of a FMGS for hands-on tr
Page 80 and 81: TRAINING Im roved tech manuals, e l
Page 82 and 83: TRAINING The depth of training, the
Page 84 and 85: WORKLOAD WORKLOAD Introduction The
Page 86 and 87: FIGURE 86.2 In an emergency, automa
Page 88 and 89: Normal ops automation is very benef
Page 90 and 91: A COMPARISON WITH PREVIOUS STUDIES
Page 96 and 97: Conclusion Although this comparison
Page 102 and 103: SUMMARY OF RECOMMENDATIONS 6. MODES
Page 104 and 105: REFERENCES Aeronautica Civil of the
Page 106 and 107: SURVEY QUESTIONNAIRE DETAILS e SURV
Page 108 and 109: AIR TRAFFIC CONTROL Questions 2.1 t
Page 110 and 111: CREW RESOURCE MANAGEMENT AND SAFETY
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