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Accident Analysis
Overview

Introduction

From the literature, comments from the experts we surveyed, news media, and other sources, we identified 34 aircraft accident reports that we thought might contain evidence related to the flight deck automation issues. We were able to obtain 20 of these reports from the US National Transportation Safety Board and other national and international agencies that conduct accident investigations. We reviewed these reports, looking for statements by the investigating board identifying one or more of the flight deck automation issues as contributing to the accident. We have since identified and reviewed 11 additional accident reports for a total of 31 reports reviewed.

The strength we assigned to the statements we identified as evidence in the reports was based on how close the investigating board's findings were to one of our issues and on the extent to which the problem they described contributed to the accident or incident (or at least how confident the board was that it contributed to it). We used the following table for assigning strengths to accident/incident evidence.

Strength Contribution to Accident Similarity of Board's Statement to Issue Statement

+5

probable

equivalent to issue statement

+4

possible

equivalent to issue statement

+3

probable

similar to issue statement

+2

possible

similar to issue statement

+1

probable/possible

analyst unsure

+1

analyst unsure

any of the above

In the table, the phrase "equivalent to issue statement" means that the board's description of the problem they discovered in their investigation was approximately the same as the problem suggested by the issue statement of one of the flight deck automation issues. The phrase "similar to issue statement" means that their description did not quite match the issue statement but that their essential meaning seemed to be the same, or that it seemed to the analyst that the investigating board described a problem very similar to that suggested by the issue statement. The phrase "analyst unsure" means that the analyst thought that the board had implied one of the issues in the accident but the way the board worded its findings was ambiguous.

The investigating board's statement that a problem's contribution to the accident/incident was "probable" means that the board determined that it was a major contributing factor in the accident, while "possible" means that it was merely a contributing factor or possibly just one of the board's hypotheses. In the same column, "analyst unsure" means that the analyst could not determine from the description how significant the board found the problem to be, but that the board at least seemed to imply that it could have played a role.

For example, if we read that a board investigating an accident concluded that the flightcrew's lack of understanding of the flight level change mode of the aircraft's autoflight system contributed to the accident -- but was not its probable cause -- we would record evidence for issue105 with strength +4.

We did not look for or find contradictory evidence in accident reports. An accident or incident investigation is not an experiment and the fact that an investigating board finds that, for example, the pilots of an accident aircraft were thoroughly knowledgeable in the use of autoflight system and that lack of knowledge did not contribute to the accident is not evidence that all (or even most) pilots thoroughly understand the automation they use.

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Accident Report Results

The following is a list of the aircraft accidents in which we found evidence related to the flight deck automation issues. The accidents are listed alphabetically by air carrier and include links to the bibliographic information and evidence found in the reports:

Investigator(s) Aircraft Accident
National Transportation and Safety Board Aeromexico DC10-30 accident, Luxembourg Europe, 11 Nov 79 EVIDENCE
Investigation Commission of Ministry of Transport - France Air France A320 accident, Mulhouse-Habsheim France, 26 Jun 88 EVIDENCE
Investigation Commission of Ministry of Transport - France Air Inter A320 accident, near Strasbourg France, 20 Jan 92 EVIDENCE
Council of State Appointed Investigation Commission - Finland Air Liberte Tunisie DC9-83 (MD83) accident, Kajaani, Finland, 3 Nov 93 EVIDENCE
Aeronautica Civil of the Republic of Colombia American Airlines Flight 965, B757-223 accident, near Cali, Colombia, 20 Dec 95 EVIDENCE
National Transportation and Safety Board Atlantic Coast Airlines Jetstream 4101 accident, Columbus, OH USA, 7 Jan 94 EVIDENCE
Air Accident Investigation Branch, Department of Transport - England British Midland B737-400 accident, Leicestershire England, 8 Jan 89 EVIDENCE
Aircraft Accident Investigation Commission - Ministry of Transport Japan China Airlines A300B4-622R accident, Nagoya, Japan, 26 Apr 94 EVIDENCE
National Transportation and Safety Board China Airlines B747-SP-09 accident, near San Francisco, CA USA,19 Feb 85 EVIDENCE
National Transportation and Safety Board Eastern L1011 accident, near Miami, FL USA, 29 Dec 72 EVIDENCE
Ministry of Civil Aviation - India Indian Airlines A320 accident, Bangalore, India, 14 Feb 90 EVIDENCE
Main Commission Aircraft Accident Investigation - Poland Lufthansa A320-211 accident, Warsaw Poland, 14 Sep 93 EVIDENCE
National Transportation and Safety Board Scandinavian Airlines DC10-30 accident, New York City, NY USA, 28 Feb 84 EVIDENCE
Aircraft Accident Investigation Committee - Nepal Thai Airways International A310 accident, Kathmandu, Nepal, 31 Jul 92 EVIDENCE
National Transportation and Safety Board Trans World B707-331C accident, Jamaica, NY USA, 12 Dec 72 EVIDENCE
National Transportation and Safety Board World Airways DC10-30 accident, Boston, MA USA, 23 Jan 82 EVIDENCE
National Transportation and Safety Board Controlled Flight Into Terrain, Korean Air Flight 801, Boeing 747-300, HL7468, Nimitz Hill, Guam, August 6, 1997 EVIDENCE
National Transportation and Safety Board In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997 EVIDENCE
National Transportation and Safety Board Wheels-Up Landing, Continental Airlines Flight 1943, Douglas DC-9 N10556, Houston, Texas, February 19, 1996 EVIDENCE

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Accident Review Results

In addition to accident reports prepared by official investigating boards, we included several accident reviews in our study. These were reviews conducted by qualified individuals after the official investigations, which benefited from additional information and the perspective offered by the individual's field of technical expertise. Although we assigned lower strength ratings to evidence from such accident reviews, they were nevertheless a valuable supplement to evidence from the accident reports.

The following is a list of the accident reviews in which we found evidence related to the flight deck automation issues. The list includes links to the bibliographic information and evidence found in the reports:

Investigator(s) Short Description of Accident Review
Bruseberg, A. In order to design interaction with computer systems such as modern Flight Management Systems, we may require new interaction paradigms, since such systems become increasingly able to carry out tasks partly automatically and in parallel to the human operators who are given increasingly supervisory functions. By creating a clearer understanding of the extent to which such interaction could, or should, be viewed as a type of collaboration, we aim to formulate a new set of design principles. Cali Accident is discussed. EVIDENCE
Bruseberg, A. & Johnson, P. This paper illustrates how the perspective of considering the interaction between the Flight Management System and the (pilot) user as a collaborative activity can uncover design opportunities - by conducting an analysis of interaction failures that contributed to the Cali air accident. EVIDENCE
Endsley, M.R. & Strauch, B. Examines contributors to the loss of situation awareness by pilots in American Airlines Boeing 757 Cali, Colombia accident. EVIDENCE
Hourizi, R. & Johnson, P. In this paper, we show that errors, which occur within such complexity, cannot easily be described in terms of individual tasks and their component actions. We use this starting point to examine the dominant thinking in this field (Palmer, 1995, Palmer et al, 1993, Degani et al, 1996, Rushby 1999). We show this dominant position, which suggests that much of this ’automation surprise’ (Palmer 1995) results from mode error, is a fundamental misclassification of the human factors involved. We then show the existence of a deeper problem, which we identify as a knowledge gap (Johnson 1992) between operator and system. EVIDENCE
Mellor, P. Analysis of accident sequences in which computers have been wholly or partly to blame EVIDENCE
Strauch, B. Lessons learned about automation and decision making from the Cali accident. EVIDENCE

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