Advanced Technology Aircraft Safety Survey Report - Australian ...

ADVANCED TECHNOLOGY AIRCRAFT SAFETY SURVEY REPORT
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Conclusions
The results support the current industry concern of ensuring sufficient quality control and
pre-flight testing of automated products, especially automation software. The requirement for
pilots to engage in FMC/FMGS work-arounds is an indication of the continuing shortfall in
some aspects of software/hardware design. Although many of these deficiencies have been
rectified in subsequent software releases, ‘working around’ a known problem is a poor
solution, and represents a significant safety concern. Airline operators passively participate in
this process by failing to address the practice of system work-arounds through their policy and
procedure documents. It would appear that an undesirable subculture has developed amongst
aircrew which needs to be addressed by both aircraft manufacturers and airline management.
System work-arounds are most commonly performed to achieve a desired descent profile
which often reflects the incompatibility between advanced-technology aircraft and the current
ATC environment.
Similarly, the ability to enter incorrect data, which may or may not by identified, represents a
serious safety concern. Aircraft manufacturers should ensure that the ability of systems to
accept illogical data is reduced and preferably eliminated.
Further research is needed to determine the circumstances in which non-flying pilots make
flight-control inputs. This factor has been a contributing factor in at least one accident and
one serious incident within the Asia-Pacific region. Although aircraft manufacturers have
taken steps to address a shortfall in hardware design, the human factors aspect of this
phenomenon has not yet been fully explored.
Recommendations
The Bureau of Air Safety Investigation recommends that airline operators (R980037):
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 emphasise the consequences of multiple simultaneous
flight control inputs.
The Bureau of Air Safety Investigation recommends that aircraft design authorities consider
requirements for (R980038):
(a) a means of alerting the pilot when incorrect data has been entered into the FMUFMGS;
(b) all data entries being able to be corrected easily by flight crew;
(c) common industry terminology for automation hardware and software;
(d) FMS software and hardware to accommodate the various changes which are imposed by
ATC on an advanced technology aircraft during all phases of operation;
(e) quality control procedures for FMC software with the aim of eliminating the need for
system work-arounds; and
(f) the position, design and tactile differences of the frequently used mode selectors (such as
heading and speed), with the aim of eliminating any confusion regarding the use of these
controls.