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All Evidence from Accidents 75 matching pieces of evidence found.


  1.  
  2. Evidence Type: Excerpt from Accident Report
    Evidence: "Aeronautica Civil believes that the discrepancy between the approach chart and FMS presentation of data for the same approach can hinder the ability of pilots to execute an instrument approach, especially since flightcrews are expected to rely on both the FMS-generated display and the approach chart for information regarding the conduct of the approach. When two methods of presenting approach information depict important information differently or one readily show it at all, that information can be counterproductive to flightcrew performance in general, and their ability to prepare for an approach in particular. The lack of coordinated standards for the development and portrayal of aeronautical charts and FMS data bases and displays has led to a situation in which, not only are the charts and displays different in appearance, but the basic data are different. This lack of commonality is confusing, time consuming, and increases pilot workload during a critical phase of flight, the approach phase." (page 43) "3.0 Conclusions 3.1 Findings ... 7. Numerous important differences existed between the display of identical navigation data on approach charts and on FMS-generated displays, despite the fact that the same supplier provided AA with the navigational data. ... 3.3 Contributing Factors Contributing to the cause of the accident were: ... 4. FMS-generated navigational information that used a different naming convention from that published in navigational charts." (pages 55-57) (page 43)
    Issue: database may be erroneous or incomplete (Issue #110) See Issue details
    Strength: +2
    Aircraft: B757-223
    Equipment: FMS
    Source: Aeronautica Civil of the Republic of Colombia (1996). Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995. Santafe de Bogota, DC, Colombia: Aeronautica Civil of the Republic of Colombia. See Resource details

  3.  
  4. Evidence Type: Excerpt from Accident Report
    Evidence: "The evidence suggests several explanations for this deficiency in the flightcrew's situational awareness: ... - Terrain information was not shown on the electronic horizontal situation indicator (EHSI) or graphically portrayed on the approach chart " (page 35) "3. CONCLUSIONS ... 3.2 Probable Cause Aeronautica Civil determines that the probable causes of this accident were: ... 3. The lack of situational awareness of the flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids." (page 57) (page 35, 57)
    Issue: insufficient information may be displayed (Issue #99) See Issue details
    Strength: +5
    Aircraft: B757-223
    Equipment: automation
    Source: Aeronautica Civil of the Republic of Colombia (1996). Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995. Santafe de Bogota, DC, Colombia: Aeronautica Civil of the Republic of Colombia. See Resource details

  5.  
  6. Evidence Type: Excerpt from Accident Report
    Evidence: "3. CONCLUSIONS ... 3.3 Contributing Factors Contributing to the cause of the accident were: ... 3. FMS logic that dropped all intermediate fixes from the display(s) in the event of execution of a direct routing." (page 57)
    Issue: insufficient information may be displayed (Issue #99) See Issue details
    Strength: +3
    Aircraft: B757-223
    Equipment: FMS
    Source: Aeronautica Civil of the Republic of Colombia (1996). Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995. Santafe de Bogota, DC, Colombia: Aeronautica Civil of the Republic of Colombia. See Resource details

  7.  
  8. Evidence Type: Excerpt from Accident Report
    Evidence: "However, unlike charts, the FMS-generated displays do not present associated information, such as terrain, and do not display navaids that are behind the airplane unless specifically directed to by a flightcrew member. As a result, pilots who are accustomed to relying exclusively on FMS-generated displays for navigation, can, over time, fail to recognize the relative proximity of terrain and can lose the ability to quickly determine that a fix or beacon is behind them. The evidence suggests that this partially explains the difficulty of the AA965 flightcrew in locating the ULQ. " (page 38)
    Issue: manual skills may be lost (Issue #65) See Issue details
    Strength: +2
    Aircraft: B757-223
    Equipment: FMS
    Source: Aeronautica Civil of the Republic of Colombia (1996). Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995. Santafe de Bogota, DC, Colombia: Aeronautica Civil of the Republic of Colombia. See Resource details

  9.  
  10. Evidence Type: Excerpt from Accident Report
    Evidence: "2. ANALYSIS ... 2.4 Awareness of Terrain ... the history of flight indicates that the AA965 flightcrew did not effectively use all navigation information that was available to them and that they relied almost exclusively on their EHSI for navigation." (page 38)
    Issue: pilots may be overconfident in automation (Issue #131) See Issue details
    Strength: +4
    Aircraft: B757-223
    Equipment: automation
    Source: Aeronautica Civil of the Republic of Colombia (1996). Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995. Santafe de Bogota, DC, Colombia: Aeronautica Civil of the Republic of Colombia. See Resource details

  11.  
  12. Evidence Type: Excerpt from Accident Report
    Evidence: "3. CONCLUSIONS ... 3.2 Probable Cause ... Aeronautica Civil determines that the probable causes of this accident were: ... 4. Failure of the flightcrew to revert to basic radio navigation at the time when the FMS-assisted navigation became confusing and demanded an excessive workload in a critical phase of the flight." (page 57)
    Issue: pilots may over-rely on automation (Issue #106) See Issue details
    Strength: +5
    Aircraft: B757-223
    Equipment: FMS
    Source: Aeronautica Civil of the Republic of Colombia (1996). Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995. Santafe de Bogota, DC, Colombia: Aeronautica Civil of the Republic of Colombia. See Resource details

  13.  
  14. Evidence Type: Excerpt from Accident Report
    Evidence: "The evidence suggests several explanations for this deficiency in the flightcrew's situational awareness: ... - Terrain information was not shown on the electronic horizontal situation indicator (EHSI) or graphically portrayed on the approach chart " (page 35) "3.0 Conclusions ... 3.2 Probable Cause Aeronautica Civil determines that the probable causes of this accident were: ... 3. The lack of situational awareness of the flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids." (page 57) (page 35,57)
    Issue: situation awareness may be reduced (Issue #114) See Issue details
    Strength: +5
    Aircraft: B757-223
    Equipment: displays
    Source: Aeronautica Civil of the Republic of Colombia (1996). Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995. Santafe de Bogota, DC, Colombia: Aeronautica Civil of the Republic of Colombia. See Resource details

  15.  
  16. Evidence Type: Excerpt from Accident Report
    Evidence: "2. ANALYSIS ... 2.5 Automation ... Aeronautica Civil believes that the circumstances of this accident demonstrate the need for airlines to revise the procedures used to operate FMS-equipped aircraft, and the training they provide to pilots in the application of those procedures. Giving pilots information on the FMS sufficient to pass a flight test, and relying on sustained use of the equipment thereafter to gain fluency in its use is counter to safe operating practices. Therefore, Aeronautica Civil urges the FAA to evaluate the curricula and flight check requirements used to train and certificate pilots to operate FMS-equipped aircraft, and revise the curricula and flight check requirements to assure that pilots are fully knowledgeable in the logic underlying the FMS or similar aircraft computer system before being granted airman certification to operate the aircraft." (page 46)
    Issue: training may be inadequate (Issue #133) See Issue details
    Strength: +2
    Aircraft: B757-223
    Equipment: FMS
    Source: Aeronautica Civil of the Republic of Colombia (1996). Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995. Santafe de Bogota, DC, Colombia: Aeronautica Civil of the Republic of Colombia. See Resource details

  17.  
  18. Evidence Type: Excerpt from Accident Report
    Evidence: "The flightcrew's situation awareness was ... compromised by a lack of information regarding the rules which governed the logic and priorities of the navigation data base in the FMS." (page 32) "... pilots are not given much information about the logic underlying much of the performance of the FMS, or shown many of the numerous options available to achieve identical goals in the FMS. This accident demonstrates that proficiency in the use of the FMS, without knowledge of the logic underlying such critical features as the design and programmed priorities of its navigation data base, can lead to its misuse. Such priorities in the system logic may result in one waypoint or fix being easily called up via the CDU by inputting simply the first letter of the name, and then selecting the nearest waypoint, at the top of the display, while another, equally important waypoint, can never be called up unless it is spelled out properly on the CDU keyboard. Such partially understood logic may partially account for the finding that use of the FMS often increases workload during periods of already high workload." (page 32)
    Issue: understanding of automation may be inadequate (Issue #105) See Issue details
    Strength: +2
    Aircraft: B757-233
    Equipment: FMS
    Source: Aeronautica Civil of the Republic of Colombia (1996). Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995. Santafe de Bogota, DC, Colombia: Aeronautica Civil of the Republic of Colombia. See Resource details

  19.  
  20. Evidence Type: Excerpt from Accident Report
    Evidence: "The evidence suggests several explanations for this deficiency in the flightcrew’s situational awareness: ... · Terrain information was not shown on the electronic horizontal situation indicator (EHSI) or graphically portrayed on the approach chart " (page 35) "3. CONCLUSIONS ... 3.2 Probable Cause Aeronautica Civil determines that the probable causes of this accident were: ... 3. The lack of situational awareness of the flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids." (page 57) (page 35, 57)
    Issue: vertical profile visualization may be difficult (Issue #53) See Issue details
    Strength: +5
    Aircraft: B757-223
    Equipment: automation
    Source: Aeronautica Civil of the Republic of Colombia (1996). Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995. Santafe de Bogota, DC, Colombia: Aeronautica Civil of the Republic of Colombia. See Resource details

  21.  
  22. Evidence Type: Excerpt from Accident Report
    Evidence: "Flight deck workload remained high as the first officer obtained details of the actual weather at East Midlands and attempted without success to programme the flight management system to display the landing pattern at East Midlands. This last activity engaged the first officer's attention for 2 minutes." (page 5)
    Issue: automation may demand attention (Issue #102) See Issue details
    Strength: +5
    Aircraft: B737-400
    Equipment: FMS
    Source: Air Accident Investigation Branch, Department of Transport - England (1990). Report on the accident to Boeing 737-400 G-OBME near Kegworth, Leicestershire on 8 January 1989; British Midlands Ltd; AAIB Report 4/90. AAIB Report 4/90. London: Department of Transport. See Resource details

  23.  
  24. Evidence Type: Excerpt from Accident Report
    Evidence: "3. Conclusions (a) Findings ... 15. The change from hybrid electro-mechanical instruments to LED displays for engine indications has reduced conspicuity, particularly in respect of the engine vibration indicators. No additional vibration alerting system was fitted that could have highlighted to the pilots which of the two engines was vibrating excessively." (page 143)
    Issue: displays (visual and aural) may be poorly designed (Issue #92) See Issue details
    Strength: +4
    Aircraft: B737-400
    Equipment: displays
    Source: Air Accident Investigation Branch, Department of Transport - England (1990). Report on the accident to Boeing 737-400 G-OBME near Kegworth, Leicestershire on 8 January 1989; British Midlands Ltd; AAIB Report 4/90. AAIB Report 4/90. London: Department of Transport. See Resource details

  25.  
  26. Evidence Type: Excerpt from Accident Report
    Evidence: "A last factor which may have influenced this crew's behavior, given the stressful nature of the events, is the flight simulator training which they would have experienced. In the simulator virtually all engine problems result in an engine shutdown. Since this crew would have been under both practical and psychological pressure to come up with a programme of action, it cannot be regarded as surprising that the actions they embarked upon were those they had practised in the flight simulator. 2.1.4 Flight crew training The performance of flight crews in emergency situations may be regarded as a product of their natural ability and their training. It is possible to identify three aspects of the circumstances of this accident where a different pattern of training could have favourably influenced to outcome. The ability of the pilots to extract information from the EIS must be questioned, and so must the apparent lack of coordination between the flight deck and the cabin crew. The most important issue, however, concerns the preparation of pilots generally to cope with unforeseen situations which are not covered in their emergency checklists. ... No EIS equipped flight simulator was available at that stage and so the first few flights of pilots who were new to the EIS system were supervised under normal line checking procedures. The result of this pattern of training was that the first time that a pilot was likely to see abnormal indications on the EIS was in-flight in an aircraft with a failing engine." (page 108)
    Issue: training may be inadequate (Issue #133) See Issue details
    Strength: +4
    Aircraft: B737-400
    Equipment: automation
    Source: Air Accident Investigation Branch, Department of Transport - England (1990). Report on the accident to Boeing 737-400 G-OBME near Kegworth, Leicestershire on 8 January 1989; British Midlands Ltd; AAIB Report 4/90. AAIB Report 4/90. London: Department of Transport. See Resource details

  27.  
  28. Evidence Type: Excerpt from Accident Report
    Evidence: "ANALYSIS ... It is obvious that the captain did not realize that the autothrottle was still engaged and in go-around mode but concentrated on flying the aircraft towards the runway." (page 38)
    Issue: mode awareness may be lacking (Issue #95) See Issue details
    Strength: +2
    Aircraft: DC-9-83
    Equipment: autoflight: autothrottle
    Source: Council of State appointed investigation commission - Finland (1996). Aircraft accident at Kajaani Airport, Finland, 3. November 1994. DC-9-83 registered as F-GHED operated by Air Liberte Tunisie. Translation of the Finnish original report. Helsinki: Multiprint. See Resource details

  29.  
  30. Evidence Type: Excerpt from Accident Report
    Evidence: "ANALYSIS ... When the captain took over the controls, he put his right hand on the throttle levers. According to the DFDR the go-around mode was activated at the height of approximately 120 ft which must indicate that the captain or first officer pushed at least one of the two TOGA buttons on the thrust levers. The captain told he had no intention to make a go around. No signs of go-around can be seen in the DFDR elevator control data. According to the investigation commission the TOGA button push must have been unintentional or a so called substitution error ie. [in sic] either pilot has intended to switch off the autothrottle but has selected the TOGA button." (page 38)
    Issue: mode selection may be incorrect (Issue #145) See Issue details
    Strength: +2
    Aircraft: DC-9-83
    Equipment: autoflight: autothrottle
    Source: Council of State appointed investigation commission - Finland (1996). Aircraft accident at Kajaani Airport, Finland, 3. November 1994. DC-9-83 registered as F-GHED operated by Air Liberte Tunisie. Translation of the Finnish original report. Helsinki: Multiprint. See Resource details

  31.  
  32. Evidence Type: Excerpt from Accident Report
    Evidence: "The purpose of this study was to determine how increasing levels of cockpit automation affect the amount of the time pilots spend performing various activities. Three activities—looking outside of the cockpit, hand flying, andcommunicating—were of particular interest. Our data (reported in Damos, John, and Lyall, in press) concerning looking outside the cockpit support Wiener’s (1993) concerns; pilots of automated aircraft spend more time heads down than pilots of traditional aircraft during approach (below 10,000 ft). Our data, however, indicate that the increase in heads down time only occurs during approach to landings at airports with high traffic density. Similarly, our results show a decrease in hand flying with increased levels of automation and agree with the survey results of McClumpha et al. (1991). However, our results do not support completely those of Costley et al. (1989) and Veinott and Irwin (1993) about the effects of increasing levels of automation on communication. Our analyses only showed a significant effect of automation on flightrelated communication. Additionally, although our analyses showed a significant effect of automation, the differences between the aircraft are relatively small and may have few operational implications."
    Issue: automation may demand attention (Issue #102) See Issue details
    Strength: -5
    Aircraft: 737/200, 737/300
    Equipment: automation
    Source: Endsley, M.R. & Strauch, B. (1997). Automation and situation awareness: The accident at Cali, Columbia. In R.S. Jensen & L. Rakovan (Eds.), Proceedings of the 9th International Symposium on Aviation Psychology, 877-881. Columbus, OH: The Ohio State University. See Resource details

  33.  
  34. Evidence Type: Excerpt from Accident Report
    Evidence: "Perhaps the most interesting findings concern the effect of automation on the time spent reading the enroute charts and approach plates. Arguably, the EFIS provides more easily assimilated positional information that should decrease the amount of time needed to study charts and plates. Our data provide limited evidence that EFIS decreased the proportion of time spent reading enroute charts and no evidence that it decreased the amount of time spent studying approach plates."
    Issue: automation may demand attention (Issue #102) See Issue details
    Strength: -5
    Aircraft: 737/200, 737/300
    Equipment: automation
    Source: Endsley, M.R. & Strauch, B. (1997). Automation and situation awareness: The accident at Cali, Columbia. In R.S. Jensen & L. Rakovan (Eds.), Proceedings of the 9th International Symposium on Aviation Psychology, 877-881. Columbus, OH: The Ohio State University. See Resource details

  35.  
  36. Evidence Type: Excerpt from Accident Report
    Evidence: "The purpose of this study was to determine how increasing levels of cockpit automation affect the amount of the time pilots spend performing various activities. Three activities—looking outside of the cockpit, hand flying, andcommunicating—were of particular interest. Our data (reported in Damos, John, and Lyall, in press) concerning looking outside the cockpit support Wiener’s (1993) concerns; pilots of automated aircraft spend more time heads down than pilots of traditional aircraft during approach (below 10,000 ft). Our data, however, indicate that the increase in heads down time only occurs during approach to landings at airports with high traffic density. Similarly, our results show a decrease in hand flying with increased levels of automation and agree with the survey results of McClumpha et al. (1991). However, our results do not support completely those of Costley et al. (1989) and Veinott and Irwin (1993) about the effects of increasing levels of automation on communication. Our analyses only showed a significant effect of automation on flightrelated communication. Additionally, although our analyses showed a significant effect of automation, the differences between the aircraft are relatively small and may have few operational implications."
    Issue: inter-pilot communication may be reduced (Issue #139) See Issue details
    Strength: -5
    Aircraft: 737/200, 737/300
    Equipment: automation
    Source: Endsley, M.R. & Strauch, B. (1997). Automation and situation awareness: The accident at Cali, Columbia. In R.S. Jensen & L. Rakovan (Eds.), Proceedings of the 9th International Symposium on Aviation Psychology, 877-881. Columbus, OH: The Ohio State University. See Resource details

  37.  
  38. Evidence Type: Excerpt from Accident Report
    Evidence: "The purpose of this study was to determine how increasing levels of cockpit automation affect the amount of the time pilots spend performing various activities. Three activities—looking outside of the cockpit, hand flying, andcommunicating—were of particular interest. Our data (reported in Damos, John, and Lyall, in press) concerning looking outside the cockpit support Wiener’s (1993) concerns; pilots of automated aircraft spend more time heads down than pilots of traditional aircraft during approach (below 10,000 ft). Our data, however, indicate that the increase in heads down time only occurs during approach to landings at airports with high traffic density. Similarly, our results show a decrease in hand flying with increased levels of automation and agree with the survey results of McClumpha et al. (1991). However, our results do not support completely those of Costley et al. (1989) and Veinott and Irwin (1993) about the effects of increasing levels of automation on communication. Our analyses only showed a significant effect of automation on flightrelated communication. Additionally, although our analyses showed a significant effect of automation, the differences between the aircraft are relatively small and may have few operational implications."
    Issue: manual skills may be lost (Issue #65) See Issue details
    Strength: +5
    Aircraft: 737/200, 737/300
    Equipment: automation
    Source: Endsley, M.R. & Strauch, B. (1997). Automation and situation awareness: The accident at Cali, Columbia. In R.S. Jensen & L. Rakovan (Eds.), Proceedings of the 9th International Symposium on Aviation Psychology, 877-881. Columbus, OH: The Ohio State University. See Resource details

  39.  
  40. Evidence Type: Excerpt from Accident Report
    Evidence: "2.2.3 Flight preparation by the crew ... The training given to the pilots emphasized all the protections from which the A320 benefits with respect to its lift which could have given them the feeling, which indeed is justified, of increased safety. In particular, the demonstration of the activation of the safety features and protection of this aircraft may lead one to consider flight approaching one of the limitations (especially the one related to angle of attack) as a foreseeable flight condition since lift is guaranteed. ... The choice to inhibit the automatic go-around protection (Alpha Floor) resulted from the need to eliminate this protection if flight at 100 feet or above is planned at an angle of attack higher than the one activating this protection. The inhibition in this case can only be achieved in practice by pressing and holding the two switches placed on the throttles. After 30 seconds, inhibition becomes permanent for the rest of the flight. This decision is compatible with the objectives expressed by the Captain to maintain a height of 100 feet and seems to confirm that the incursion below 100 feet was not considered by him at this stage. In effect, below 100 feet, this protection is not active." (page 50-52)
    Issue: automation may not work well under unusual conditions (Issue #150) See Issue details
    Strength: +1
    Aircraft: A320
    Equipment: automation
    Source: Investigation Commission of Ministry of Transport - France (1989). Final report concerning the accident which occurred on June 26th 1988 at Mulhouse-Habsheim (68) to the Airbus A 320, registered F-GFKC. Ministry of Planning, Housing, Transport and Maritime Affairs. See Resource details

  41.  
  42. Evidence Type: Excerpt from Accident Report
    Evidence: "4 - RECOMMENDATIONS ... 4.3 - AIRCRAFT ... 4.3.2 - The Commission remarked that the aural announcements made by the radio altimeter and the aural warnings were transmitted only via the cockpit loudspeakers and not via the pilots' headsets. The Commission recommends: - that studies be made to see if it would not be judicious to transmit all warnings and aural announcements via the pilots' headsets." (page 64)
    Issue: displays (visual and aural) may be poorly designed (Issue #92) See Issue details
    Strength: +4
    Aircraft: unspecified
    Equipment: automation
    Source: Investigation Commission of Ministry of Transport - France (1989). Final report concerning the accident which occurred on June 26th 1988 at Mulhouse-Habsheim (68) to the Airbus A 320, registered F-GFKC. Ministry of Planning, Housing, Transport and Maritime Affairs. See Resource details

  43.  
  44. Evidence Type: Excerpt from Accident Report
    Evidence: "CHAPTER 2.2 - ANALYSIS OF FACTORS CONTRIBUTING DIRECTLY TO THE ACCIDENT [ p. 217] ... 22.336 - Conclusion In conclusion, the design of the rotary selector switch and the window displaying the vertical flight path control parameters means that the coherence between the selection of vertical mode and the selected value is critical. Also, the probability of confusion in this area seems to be considerable, particularly for a crew new to the aircraft. The spatial distribution between the mode selector switch and the value selector switch tends to accentuate the natural weakness in the human operator's cognitive process. " (page 230)
    Issue: interface may be poorly designed (Issue #39) See Issue details
    Strength: +3
    Aircraft: A320-100
    Equipment: autoflight
    Source: Investigation Commission of Ministry of Transport - France (1993). Rapport de la Commission d'Enquete sur l'Accident survenu le 20 Janvier 1992 pres du Mont Saite Odile (Bas Rhin) a l/Airbus A.320 Immatricule F-GGED Exploite par lay Compagnie Air Inter. Official English translation from the Ministere de l'Equipement, des Transports et du Tourisme, France. Ministere de l'Equipement, des Transports et du Tourisme. See Resource details

  45.  
  46. Evidence Type: Excerpt from Accident Report
    Evidence: "21.42 - Preferred hypotheses On the basis of the foregoing, the commission considered the following hypotheses as explanations for the pivotal event: 21.421 - Hypothesis No. 1: the abnormally high rate of descent was the result of an unintentional command on the part of the crew because they believed the vertical mode selected on the auto-pilot to be other than that which was actually selected." (page 204)
    Issue: mode awareness may be lacking (Issue #95) See Issue details
    Strength: +4
    Aircraft: A320-100
    Equipment: autoflight: autopilot
    Source: Investigation Commission of Ministry of Transport - France (1993). Rapport de la Commission d'Enquete sur l'Accident survenu le 20 Janvier 1992 pres du Mont Saite Odile (Bas Rhin) a l/Airbus A.320 Immatricule F-GGED Exploite par lay Compagnie Air Inter. Official English translation from the Ministere de l'Equipement, des Transports et du Tourisme, France. Ministere de l'Equipement, des Transports et du Tourisme. See Resource details

  47.  
  48. Evidence Type: Excerpt from Accident Report
    Evidence: "3 - CONCLUSIONS ... 3.2 - PROBABLE CAUSE ... 3.2.2 - Other Factors The Commission also remarked that the following factors contributed towards placing the crew in a situation that they were not able to fully control: ... - The A320 has new features which may have inspired some overconfidence in the mind of the Captain." (page 60)
    Issue: pilots may be overconfident in automation (Issue #131) See Issue details
    Strength: +4
    Aircraft: A320
    Equipment: automation
    Source: Investigation Commission of Ministry of Transport - France (1989). Final report concerning the accident which occurred on June 26th 1988 at Mulhouse-Habsheim (68) to the Airbus A 320, registered F-GFKC. Ministry of Planning, Housing, Transport and Maritime Affairs. See Resource details

  49.  
  50. Evidence Type: Excerpt from Accident Report
    Evidence: "2.2.3 Flight preparation by the crew ... The training given to the pilots emphasized all the protections from which the A320 benefits with respect to its lift which could have given them the feeling, which indeed is justified, of increased safety. In particular, the demonstration of the activation of the safety features and protection of this aircraft may lead one to consider flight approaching one of the limitations (especially the one related to angle of attack) as a foreseeable flight condition since lift is guaranteed. ... The choice to inhibit the automatic go-around protection (Alpha Floor) resulted from the need to eliminate this protection if flight at 100 feet or above is planned at an angle of attack higher than the one activating this protection. The inhibition in this case can only be achieved in practice by pressing and holding the two switches placed on the throttles. After 30 seconds, inhibition becomes permanent for the rest of the flight. This decision is compatible with the objectives expressed by the Captain to maintain a height of 100 feet and seems to confirm that the incursion below 100 feet was not considered by him at this stage. In effect, below 100 feet, this protection is not active." (page 50-52)
    Issue: protections may be lost though pilots continue to rely on them (Issue #15) See Issue details
    Strength: +4
    Aircraft: A320
    Equipment: automation
    Source: Investigation Commission of Ministry of Transport - France (1989). Final report concerning the accident which occurred on June 26th 1988 at Mulhouse-Habsheim (68) to the Airbus A 320, registered F-GFKC. Ministry of Planning, Housing, Transport and Maritime Affairs. See Resource details

  51.  
  52. Evidence Type: Excerpt from Accident Report
    Evidence: "3. Conclusions ... 3.1 Findings ... B. Aircraft ... 3. The aircraft automatics comprises, for basic landing configuration if the aircraft [sic] ..., the programme which subjects actuation of all braking devices to some specific conditions. Ground spoilers, when selected, will extend provided that either shock absorbers are compressed at both main landing gears ..., or wheel speed [sic] are above 72 kts at both main landing gears. Engine reversers, when selected, will deploy provided that shock absorbers are compressed at both main landing gears. ... D. Crew ... 6. The steering technique applied in the course of aircraft landing in the touchdown phase utilized the lateral bank as a countermeasure to balance lateral wind component. It resulted in touchdown on one main undercarriage leg only and in false impression on the part of the crew that touchdown was efficient. In reality the immediate start of operation of braking devices was not possible." (page 42)
    Issue: automation may not work well under unusual conditions (Issue #150) See Issue details
    Strength: +2
    Aircraft: A320-211
    Equipment: automation
    Source: Main Commission Aircraft Accident Investigation - Poland (1994). Report on the accident to Airbus A320-211 Aircraft in Warsaw on 14 September 1993. See Resource details

  53.  
  54. Evidence Type: Excerpt from Accident Report
    Evidence: "3. Conclusions ... 3.1 Findings ... B. Aircraft ... 4. In emergency, the crew is unable to override the lock-out and to operate ground spoilers and engine thrust reversers" ... also on page 44: "3.2 Causes of Accident ... Actions of the flight crew were also affected by design features of the aircraft which limited the feasibility of applying available braking systems as well as by insufficient information in the aircraft operations manual (AOM) relating to the increase of the landing distance." (page 40 (44))
    Issue: pilots have responsibility but may lack authority (Issue #12) See Issue details
    Strength: +5
    Aircraft: A320-211
    Equipment: flight controls: brakes & spoilers
    Source: Main Commission Aircraft Accident Investigation - Poland (1994). Report on the accident to Airbus A320-211 Aircraft in Warsaw on 14 September 1993. See Resource details

  55.  
  56. Evidence Type: Excerpt from Accident Report
    Evidence: "3. Conclusions ... 3.1 Findings ... B. Aircraft ... 4. In emergency, the crew is unable to override the lock-out and to operate ground spoilers and engine thrust reversers" (page 40)
    Issue: pilots have responsibility but may lack authority (Issue #12) See Issue details
    Strength: +4
    Aircraft: A320-211
    Equipment: automation
    Source: Main Commission Aircraft Accident Investigation - Poland (1994). Report on the accident to Airbus A320-211 Aircraft in Warsaw on 14 September 1993. See Resource details

  57.  
  58. Evidence Type: Excerpt from Accident Report
    Evidence: "3. Conclusions ... 3.1 Findings ... D. Crew ... 6. The steering technique applied in the course of aircraft landing in the touchdown phase utilized the lateral bank as a countermeasure to balance lateral wind component. It resulted in touchdown on one main undercarriage leg only and in false impression on the part of the crew that touchdown was efficient. In reality the immediate start of operation of braking devices was not possible." (page 42)
    Issue: understanding of automation may be inadequate (Issue #105) See Issue details
    Strength: +2
    Aircraft: A320-211
    Equipment: automation
    Source: Main Commission Aircraft Accident Investigation - Poland (1994). Report on the accident to Airbus A320-211 Aircraft in Warsaw on 14 September 1993. See Resource details

  59.  
  60. Evidence Type: Excerpt from Accident Report
    Evidence: "... the Court itself has drawn attention to the most probable cause for the engagement of idle/open descent mode was that instead of selecting a vertical speed of 700 feet per minute at the relevant time i.e. about 35 seconds before the first impact, the pilot CM.2 had inadvertently selected an altitude of 700 feet. The vertical speed and altitude selection knobs of the Flight Control Unit (FCU) are close to each other, and instead of operating the vertical speed knob, the pilot CM. 2 had inadvertently operated the altitude selection knob. The altitude of 700 feet that got selected in this manner was lower than the aircraft altitude at that time and therefore the aircraft had gone into open/idle descent mode. That this is the most probable cause for engagement of idle/open descent mode is recognised by the Court in para 14 at page 310 of the report where it has discussed this matter, and in recommendation N0. 29 where the Court has specifically suggested a design change with respect to the two knobs." (page iv)
    Issue: controls of automation may be poorly designed (Issue #37) See Issue details
    Strength: +5
    Aircraft: A320
    Equipment: autoflight FCU
    Source: Ministry of Civil Aviation - India (1990). Report on Accident to Indian Airlines Airbus A-320 Aircraft VT-EPN at Bangalore, February 14, 1990. Ministry of Civil Aviation, Government of India. See Resource details

  61.  
  62. Evidence Type: Excerpt from Accident Report
    Evidence: "3 FINDINGS: ... xxix) The aircraft during approach never went to the speed mode which is the proper mode for landing and one of the Flight Directors remained engaged till the time the aircraft crashed. If Capt. Gopujkar [PF] would have also disengaged his Flight Director when Capt. Fernandez [PNF] disengaged his Flight Director 21 seconds prior to the crash, the speed mode would have been activated and engine power would have started building up from that instant to restore the speed and the accident could have possibly been averted." (page 61)
    Issue: mode selection may be incorrect (Issue #145) See Issue details
    Strength: +2
    Aircraft: A320
    Equipment: autoflight
    Source: Ministry of Civil Aviation - India (1990). Report on Accident to Indian Airlines Airbus A-320 Aircraft VT-EPN at Bangalore, February 14, 1990. Ministry of Civil Aviation, Government of India. See Resource details

  63.  
  64. Evidence Type: Excerpt from Accident Report
    Evidence: "3 FINDINGS ... 19. Basically alpha floor functioning is built as a protection against wind shear, but the pilots seem to be under the impression that the protection from this system will be available to increase power of the engines in any emergency without any time delay and a false sense of faith has been reposed on this system." (page 39)
    Issue: pilots may be overconfident in automation (Issue #131) See Issue details
    Strength: +1
    Aircraft: A320
    Equipment: automation
    Source: Ministry of Civil Aviation - India (1990). Report on Accident to Indian Airlines Airbus A-320 Aircraft VT-EPN at Bangalore, February 14, 1990. Ministry of Civil Aviation, Government of India. See Resource details

  65.  
  66. Evidence Type: Excerpt from Accident Report
    Evidence: "4. CAUSES ... The AAIC determined that the following factors, as a chain or a combination thereof, caused the accident: ... 6. The CAP and F/O did not sufficiently understand the FD mode change and the AP override function. It is considered that unclear descriptions of the AFS (Automatic Flight System) in the FCOM prepared by the aircraft manufacturer contributed to this." (page 4.1)
    Issue: automation information in manuals may be inadequate (Issue #140) See Issue details
    Strength: +4
    Aircraft: A300B4-622R
    Equipment: autoflight
    Source: Ministry of Transport Japan, Aircraft Accident Investigation Commission (1996). China Airlines Airbus Industrie A300B4-622R, B1816, Nagoya Airport, April 26, 1994. Report 96-5. Ministry of Transport. See Resource details

  67.  
  68. Evidence Type: Excerpt from Accident Report
    Evidence: "4. CAUSES ... The AAIC determined that the following factors, as a chain or a combination thereof, caused the accident: ... 5. There was no warning and recognition function to alert the crew directly and actively to the onset of the abnormal out-of-trim condition." (page 4.1)
    Issue: behavior of automation may not be apparent (Issue #83) See Issue details
    Strength: +3
    Aircraft: A300B4-622R
    Equipment: autoflight
    Source: Ministry of Transport Japan, Aircraft Accident Investigation Commission (1996). China Airlines Airbus Industrie A300B4-622R, B1816, Nagoya Airport, April 26, 1994. Report 96-5. Ministry of Transport. See Resource details

  69.  
  70. Evidence Type: Excerpt from Accident Report
    Evidence: "4. CAUSES ... The AAIC determined that the following factors, as a chain or a combination thereof, caused the accident: 1. The F/O inadvertantly triggered the Go [in sic] lever It is considered that the design of the GO lever contributed to it: normal operation of the thrust lever allows the possibility of an inadvertent triggering of the GO lever." (page 4.1)
    Issue: controls of automation may be poorly designed (Issue #37) See Issue details
    Strength: +5
    Aircraft: A300B4-622R
    Equipment: autoflight
    Source: Ministry of Transport Japan, Aircraft Accident Investigation Commission (1996). China Airlines Airbus Industrie A300B4-622R, B1816, Nagoya Airport, April 26, 1994. Report 96-5. Ministry of Transport. See Resource details

  71.  
  72. Evidence Type: Excerpt from Accident Report
    Evidence: "It is recognized that the CAP and the F/O completed classroom, simulator and flight training based on the training syllabus prepared by China Airlines in accordance with Taiwanese civil aviation laws. However, it is recognized that this training was not necessarily sufficient to understand the sophisticated and complicated AFS system." (page 3.44)
    Issue: training may be inadequate (Issue #133) See Issue details
    Strength: +4
    Aircraft: A300B4-622R
    Equipment: autoflight
    Source: Ministry of Transport Japan, Aircraft Accident Investigation Commission (1996). China Airlines Airbus Industrie A300B4-622R, B1816, Nagoya Airport, April 26, 1994. Report 96-5. Ministry of Transport. See Resource details

  73.  
  74. Evidence Type: Excerpt from Accident Report
    Evidence: "4. CAUSES ... The AAIC determined that the following factors, as a chain or a combination thereof, caused the accident: ... 6. The CAP and F/O did not sufficiently understand the FD mode change and the AP override function. It is considered that unclear descriptions of the AFS (Automatic Flight System) in the FCOM prepared by the aircraft manufacturer contributed to this." (page 4.1)
    Issue: understanding of automation may be inadequate (Issue #105) See Issue details
    Strength: +5
    Aircraft: A300B4-622R
    Equipment: autoflight
    Source: Ministry of Transport Japan, Aircraft Accident Investigation Commission (1996). China Airlines Airbus Industrie A300B4-622R, B1816, Nagoya Airport, April 26, 1994. Report 96-5. Ministry of Transport. See Resource details

  75.  
  76. Evidence Type: Excerpt from Accident Report
    Evidence: "3.1.2.2 Analysis of Flight Conditions ... The procedure for performing an approach by disengaging GO AROUND mode once engaged and then engaging LAND mode is unusual in the final phase of approach. However, the fact that the crew did not change modes as intended seems to have been due to their lack of understanding of the Automatic Flight System (AFS)". (page 3.10)
    Issue: understanding of automation may be inadequate (Issue #105) See Issue details
    Strength: +4
    Aircraft: A300B4-600R
    Equipment: autoflight
    Source: Ministry of Transport Japan, Aircraft Accident Investigation Commission (1996). China Airlines Airbus Industrie A300B4-622R, B1816, Nagoya Airport, April 26, 1994. Report 96-5. Ministry of Transport. See Resource details

  77.  
  78. Evidence Type: Excerpt from Accident Report
    Evidence: The stall warning system installed in the accident airplane did not provide an adequate warning to the pilots because ice contamination was present on the airplane’s airfoils, and the system was not designed to account for aerodynamic degradation or adjust its warning to compensate for the reduced stall warning margin caused by the ice. (page 178)
    Issue: automation may lack reasonable functionality (Issue #109) See Issue details
    Strength: +4
    Aircraft: Embraer EMB-120RT
    Equipment:
    Source: National Transportation Safety Board (1998). In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997. Aircraft Accident Report NTSB/AAR-98/04. Washington, DC: National Transportation Safety Board. See Resource details

  79.  
  80. Evidence Type: Excerpt from Accident Report
    Evidence: Require the manufacturers and operators of all airplanes that are certificated to operate in icing conditions to install stall warning/protection systems that provide a cockpit warning (aural warning and/or stick shaker) before the onset of stall when the airplane is operating in icing conditions. (A-98-96) (page 183)
    Issue: automation may lack reasonable functionality (Issue #109) See Issue details
    Strength: +3
    Aircraft: Embraer EMB-120RT
    Equipment:
    Source: National Transportation Safety Board (1998). In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997. Aircraft Accident Report NTSB/AAR-98/04. Washington, DC: National Transportation Safety Board. See Resource details

  81.  
  82. Evidence Type: Excerpt from Accident Report
    Evidence: Require all manufacturers of transport-category airplanes to incorporate logic into all new and existing transport-category airplanes that have autopilots installed to provide a cockpit aural warning to alert pilots when the airplane’s bank and/or pitch exceeds the autopilot’s maximum bank and/or pitch command limits. (A-98-98) (page 183)
    Issue: automation may lack reasonable functionality (Issue #109) See Issue details
    Strength: +2
    Aircraft: Embraer EMB-120RT
    Equipment:
    Source: National Transportation Safety Board (1998). In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997. Aircraft Accident Report NTSB/AAR-98/04. Washington, DC: National Transportation Safety Board. See Resource details

  83.  
  84. Evidence Type: Excerpt from Accident Report
    Evidence: If the pilots of Comair flight 3272 had received a ground proximity warning system, autopilot, or other system-generated cockpit warning when the airplane first exceeded the autopilot’s maximum bank command limits with the autopilot activated, they might have been able to avoid the unusual attitude condition that resulted from the autopilot’s sudden disengagement. (page 179)
    Issue: automation may lack reasonable functionality (Issue #109) See Issue details
    Strength: +2
    Aircraft: Embraer EMB-120RT
    Equipment:
    Source: National Transportation Safety Board (1998). In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997. Aircraft Accident Report NTSB/AAR-98/04. Washington, DC: National Transportation Safety Board. See Resource details

  85.  
  86. Evidence Type: Excerpt from Accident Report
    Evidence: "3. CONCLUSIONS 3.1 Findings ... 2. Thrust from all three engines was at an autothrottle limiting value for several minutes during which pitch and attitude increased and airspeed decreased. ... 6. The autopilot commanded an increasing angle of attack while attempting to maintain a preselected vertical speed which exceeded the limit thrust performance capability of the aircraft at higher altitudes." (page 22)
    Issue: automation may not work well under unusual conditions (Issue #150) See Issue details
    Strength: +5
    Aircraft: DC10
    Equipment: autoflight
    Source: National Transportation Safety Board (1980). Aeromexico DC-10-30 over Luxembourg, November 11, 1979. Aircraft Accident Report NTSB/AAR-80-10. Washington, DC: National Transportation Safety Board. See Resource details

  87.  
  88. Evidence Type: Excerpt from Accident Report
    Evidence: "3. CONCLUSIONS 3.1 Findings ... 10. The lateral control deflections required to maintain level flight under conditions of thrust asymmetry and decreasing airspeed exceeded the limits of the autopilot's lateral control authority, causing the airplane to roll and yaw to the right. The captain lost control of the airplane when, after disengaging the autopilot, he failed to make the proper flight control corrections to recover the airplane." (page 33-34)
    Issue: automation may not work well under unusual conditions (Issue #150) See Issue details
    Strength: +2
    Aircraft: B747-SP
    Equipment: autoflight: autopilot
    Source: National Transportation Safety Board (1986). China Airlines B-747-SP, 300 NM Northwest of San Francisco, February 19, 1985. Aircraft Accident Report NTSB/AAR-86-03. Washington, DC: National Transportation Safety Board. See Resource details

  89.  
  90. Evidence Type: Excerpt from Accident Report
    Evidence: "... the flight instruments remain the primary tools at high altitudes for maintaining level, stabilized flight in large airplanes. The captain's statement corroborated the fact that he was relying on these instruments for that purpose. Under these conditions, therefore, the primary instrument for attitude control was the attitude director indicator, which may not have concerned the captain initially since it depicted either a wings-level attitude or a very slight left-wing-down bank. With regard to heading, over the period between 1011:09 to about 1014:00, the heading increased about 4 degrees, a change so slight as to be almost imperceptible. Thus, except for airspeed, which concerned the captain greatly, the only thing in the cockpit that would have depicted the worsening control situation was the control wheel's increasing left-wing-down deflection. However, this was an area which was not included in the captain's regular instrument scan pattern, and since he was not `hands on', he was not aware of the deflection." (page 30)
    Issue: behavior of automation may not be apparent (Issue #83) See Issue details
    Strength: +4
    Aircraft: B747-SP-09
    Equipment: autoflight
    Source: National Transportation Safety Board (1986). China Airlines B-747-SP, 300 NM Northwest of San Francisco, February 19, 1985. Aircraft Accident Report NTSB/AAR-86-03. Washington, DC: National Transportation Safety Board. See Resource details

  91.  
  92. Evidence Type: Excerpt from Accident Report
    Evidence: "2. ANALYSIS AND CONCLUSIONS 2.1 Analysis ... Although formal training provided adequate opportunity to become familiar with this new concept of aircraft control [control wheel steering], operational experience was limited by company policy. Company operational procedures did not permit operation of the aircraft in CWS; they required all operations to be conducted in the command modes. This restriction might have compromised the ability of pilots to use and understand the unique CWS features of the new autopilot." (page 14-21)
    Issue: company automation policies and procedures may be inappropriate or inadequate (Issue #166) See Issue details
    Strength: +1
    Aircraft: L1011
    Equipment: autoflight: autopilot
    Source: National Transportation Safety Board (1973). Eastern Airlines, Incorporated, L-1011, N31OEA, Miami, Florida, December 29, 1972. Aircraft Accident Report NTSB/AAR-73-14. Washington, DC: National Transportation Safety Board. See Resource details

  93.  
  94. Evidence Type: Excerpt from Accident Report
    Evidence: "The J-4101 was a new airplane placed into service in the United States by ACA in May 1993. Both pilots had low fly time and experience in the airplane and in any airplane equipped with an electronic flight instrument system (EFIS) ... The National Transportation Safety Board determines the probable causes of this accident to be: ... (3) Flightcrew inexperience in "glass cockpit" automated aircraft" (page 73)
    Issue: crew assignment may be inappropriate (Issue #142) See Issue details
    Strength: +4
    Aircraft: J4101
    Equipment: automation
    Source: National Transportation Safety Board (1994). Stall and Loss of Control on Final Approach, Atlantic Coast Airlines, Inc., United Express Flight 6291, Jetstream 4101, N304UE, Columbus, Ohio, January 7, 1994. Aircraft Accident Report NTSB/AAR-94/07. Washington, DC: National Transportation Safety Board. See Resource details

  95.  
  96. Evidence Type: Excerpt from Accident Report
    Evidence: The GPWS unit installed in the airplane was a Mark I system, which only provided a generic "pull up" warning and did not provide a specific message about the reason for the alert. A Mark II system would have provided the warning "too low flaps." The Safety Board considers it unlikely that the captain’s decision to land would have been affected even if he had received the more specific warning, as he was already aware that the flaps were not extended. However, the captain’s statement that he interpreted the alerts as a high sink rate warning, and not as a configuration warning, illustrates the potential for misinterpretation of the less specific warning messages provided by the Mark I GPWS. (page 48)
    Issue: insufficient information may be displayed (Issue #99) See Issue details
    Strength: +4
    Aircraft: Douglas DC-9
    Equipment:
    Source: National Transportation Safety Board (1997). Wheels-Up Landing, Continental Airlines Flight 1943, Douglas DC-9 N10556, Houston, Texas, February 19, 1996. Aircraft Accident Report NTSB/AAR-97/01. Washington, DC: National Transportation Safety Board. See Resource details

  97.  
  98. Evidence Type: Excerpt from Accident Report
    Evidence: "3. CONCLUSIONS ... 3.1 Findings ... 10. The lateral control deflections required to maintain level flight under conditions of thrust asymmetry and decreasing airspeed exceeded the limits of the autopilot's lateral control authority, causing the airplane to roll and yaw to the right. The captain lost control of the airplane when, after disengaging the autopilot, he failed to make the proper flight control corrections to recover the airplane." (page 34)
    Issue: manual operation may be difficult after transition from automated control (Issue #55) See Issue details
    Strength: +5
    Aircraft: B747-SP-09
    Equipment: autoflight
    Source: National Transportation Safety Board (1986). China Airlines B-747-SP, 300 NM Northwest of San Francisco, February 19, 1985. Aircraft Accident Report NTSB/AAR-86-03. Washington, DC: National Transportation Safety Board. See Resource details

  99.  
  100. Evidence Type: Excerpt from Accident Report
    Evidence: "The Safety Board thus concludes that the crew erred in both their actions and recollections regarding the AP mode selection. It is probable that the flightcrew did begin, or intended to begin, the climb with the ATS N1 mode/AP IAS mode selections. However, when the captain selected 320 kn into the ATS speed window he may have either intentionally or unintentionally pulled the ATS speed selector knob. This action would have changed the ATS selection from the N1 mode to the airspeed mode. This in turn would have caused the AP IAS Hold mode to disengage and revert automatically to the vertical speed mode of operation. In any case, the DFDR indicates that the AP was in the vertical speed mode from about 16,000 ft upward. The Safety Board cannot explain why corresponding indications on the mode selection panels failed to alert the flightcrew to these selections. ... 3. Conclusions ... 3.1 Findings ... 6. The autopilot commanded an increasing angle of attack while attempting to maintain a preselected vertical speed which exceeded the limit thrust performance capability of the aircraft at higher altitudes." (page 21-22)
    Issue: mode awareness may be lacking (Issue #95) See Issue details
    Strength: +2
    Aircraft: DC10-30
    Equipment: autoflight
    Source: National Transportation Safety Board (1980). Aeromexico DC-10-30 over Luxembourg, November 11, 1979. Aircraft Accident Report NTSB/AAR-80-10. Washington, DC: National Transportation Safety Board. See Resource details

  101.  
  102. Evidence Type: Excerpt from Accident Report
    Evidence: "The Safety Board thus concludes that the crew erred in both their actions and recollections regarding the AP mode selection. It is probable that the flightcrew did begin, or intended to begin, the climb with the ATS N1 mode/AP IAS mode selections. However, when the captain selected 320 kn into the ATS speed window he may have either intentionally or unintentionally pulled the ATS speed selector knob. This action would have changed the ATS selection from the N1 mode to the airspeed mode. This in turn would have caused the AP IAS Hold mode to disengage and revert automatically to the vertical speed mode of operation. In any case, the DFDR indicates that the AP was in the vertical speed mode from about 16,000 ft upward. ... 3. Conclusions ... 3.1 Findings ... 6. The autopilot commanded an increasing angle of attack while attempting to maintain a preselected vertical speed which exceeded the limit thrust performance capability of the aircraft at higher altitudes." (page 21-22)
    Issue: mode selection may be incorrect (Issue #145) See Issue details
    Strength: +5
    Aircraft: DC10-30
    Equipment: autoflight
    Source: National Transportation Safety Board (1980). Aeromexico DC-10-30 over Luxembourg, November 11, 1979. Aircraft Accident Report NTSB/AAR-80-10. Washington, DC: National Transportation Safety Board. See Resource details

  103.  
  104. Evidence Type: Excerpt from Accident Report
    Evidence: "The Safety Board concludes that one of the causal factors of the accident was the captain's reliance on the autopilot while the airplane was decelerating. During this 3 minute 40 second period, the captain allowed himself to remain removed from the `control loop' by leaving the autopilot engaged. As a result, he was not aware of the increasing control inputs required to maintain level flight." (page 30)
    Issue: pilots may be out of the loop (Issue #2) See Issue details
    Strength: +5
    Aircraft: B747-SP-09
    Equipment: autoflight: autopilot
    Source: National Transportation Safety Board (1986). China Airlines B-747-SP, 300 NM Northwest of San Francisco, February 19, 1985. Aircraft Accident Report NTSB/AAR-86-03. Washington, DC: National Transportation Safety Board. See Resource details

  105.  
  106. Evidence Type: Excerpt from Accident Report
    Evidence: Had the pilots been flying the airplane manually (without the autopilot engaged) they likely would have noted the increased right-wing-down control wheel force needed to maintain the desired left bank, become aware of the airplane’s altered performance characteristics, and increased their airspeed or otherwise altered their flight situation to avoid the loss of control. Disengagement of the autopilot during all operations in icing conditions is necessary to enable pilots to sense the aerodynamic effects of icing and enhance their ability to retain control of the airplane. (page 178)
    Issue: pilots may be out of the loop (Issue #2) See Issue details
    Strength: +4
    Aircraft: Embraer EMB-120RT
    Equipment:
    Source: National Transportation Safety Board (1998). In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997. Aircraft Accident Report NTSB/AAR-98/04. Washington, DC: National Transportation Safety Board. See Resource details

  107.  
  108. Evidence Type: Excerpt from Accident Report
    Evidence: Because the pilots of Comair flight 3272 were operating the airplane with the autopilot engaged during a series of descents, right and left turns, power adjustments, and airspeed reductions, they might not have perceived the airplane’s gradually deteriorating performance. (page 145)
    Issue: pilots may be out of the loop (Issue #2) See Issue details
    Strength: +4
    Aircraft: Embraer EMB-120RT
    Equipment:
    Source: National Transportation Safety Board (1998). In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997. Aircraft Accident Report NTSB/AAR-98/04. Washington, DC: National Transportation Safety Board. See Resource details

  109.  
  110. Evidence Type: Excerpt from Accident Report
    Evidence: Require all operators of turbopropeller-driven air carrier airplanes to require pilots to disengage the autopilot and fly the airplane manually when they activate the anti-ice systems. (A-98-97) (page 183)
    Issue: pilots may be out of the loop (Issue #2) See Issue details
    Strength: +3
    Aircraft: Embraer EMB-120RT
    Equipment:
    Source: National Transportation Safety Board (1998). In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997. Aircraft Accident Report NTSB/AAR-98/04. Washington, DC: National Transportation Safety Board. See Resource details

  111.  
  112. Evidence Type: Excerpt from Accident Report
    Evidence: "2. ANALYSIS AND CONCLUSIONS ... 2.1 Analysis ... Pilots' testimony indicated that dependence on the reliability and capability of the autopilot is actually greater than anticipated in its early design and certification. This is particularly true in the cruise phase of flight. However, in this phase of flight, the autopilpot is not designed to remain correctly and safely operational without performance degradation, after a significant failure occurs. ... the following took place in this accident: ... 2. The aircraft was flown to a safe altitude, and the autopilot was engaged to reduce workload, but positive delegation of aircraft control was not accomplished." (page 21)
    Issue: pilots may be overconfident in automation (Issue #131) See Issue details
    Strength: +2
    Aircraft: L1011
    Equipment: autoflight: autopilot
    Source: National Transportation Safety Board (1973). Eastern Airlines, Incorporated, L-1011, N31OEA, Miami, Florida, December 29, 1972. Aircraft Accident Report NTSB/AAR-73-14. Washington, DC: National Transportation Safety Board. See Resource details

  113.  
  114. Evidence Type: Excerpt from Accident Report
    Evidence: "Consequently, the Safety Board can only conclude that the crew's attention must have been diverted from the control of the airplane and from instrument scan soon after engaging the autopilot. Believing that the autopilot was effectively maintaining a satisfactory climb attitude and speed, they probably were surprised at the control column vibration or the onset of stall buffet or a combination of both and consequently misinterpreted these cues as an engine problem." (page 21)
    Issue: pilots may be overconfident in automation (Issue #131) See Issue details
    Strength: +2
    Aircraft: DC-10-30
    Equipment: autoflight: autopilot
    Source: National Transportation Safety Board (1980). Aeromexico DC-10-30 over Luxembourg, November 11, 1979. Aircraft Accident Report NTSB/AAR-80-10. Washington, DC: National Transportation Safety Board. See Resource details

  115.  
  116. Evidence Type: Excerpt from Accident Report
    Evidence: "The National Transportation Safety Board determines that the probable cause of this accident was the flightcrew's (a) disregard for prescribed procedures for monitoring and controlling of airspeed during the final stages of the approach, (b)decision to continue the landing rather than to execute a missed approach, and (c) overreliance on autothrottle speed control system which had a history of recent malfunctions." (page 47)
    Issue: pilots may over-rely on automation (Issue #106) See Issue details
    Strength: +5
    Aircraft: DC-10-30
    Equipment: autoflight: autothrust (ATSC)
    Source: National Transportation Safety Board (1984). Scandinavian Airlines DC-10-30, J.F.K Airport, New York, February 2, 1984. Aircraft Accident Report NTSB/AAR-84-15. Washington, DC: National Transportation Safety Board. See Resource details

  117.  
  118. Evidence Type: Excerpt from Accident Report
    Evidence: "The Safety Board also concludes that the captain over-relied on the autopilot and that this was also causal to the accident since the autopilot effectively masked the approaching onset of the loss of control of the airplane." (page 32)
    Issue: pilots may over-rely on automation (Issue #106) See Issue details
    Strength: +5
    Aircraft: B747-SP-09
    Equipment: autoflight: autopilot
    Source: National Transportation Safety Board (1986). China Airlines B-747-SP, 300 NM Northwest of San Francisco, February 19, 1985. Aircraft Accident Report NTSB/AAR-86-03. Washington, DC: National Transportation Safety Board. See Resource details

  119.  
  120. Evidence Type: Excerpt from Accident Report
    Evidence: "The pilot's decision to retain autothrottle speed control throughout the flare and the consequent extended touchdown point on the runway contributed to the severity of the accident." (page 6)
    Issue: pilots may over-rely on automation (Issue #106) See Issue details
    Strength: +4
    Aircraft: DC-10-30CF
    Equipment: autoflight: autothrust
    Source: National Transportation Safety Board (1982). World Airways, Inc. Flight 30H McDonnell Douglas DC-10-3-CF, N113WA, Boston-Logan International Airport, Boston, Massachusetts, January 23, 1982. Washington, DC: National Transportation Safety Board. See Resource details

  121.  
  122. Evidence Type: Excerpt from Accident Report
    Evidence: "2. ANALYSIS AND CONCLUSIONS 2.1 Analysis ... Pilots' testimony indicated that dependence on the reliability and capability of the autopilot is actually greater than anticipated in its early design and certification. This is particularly true in the cruise phase of flight. However, in this phase of flight, the autopilpot is not designed to remain correctly and safely operational without performance degradation, after a significant failure occurs. ... the following took place in this accident: ... 2. The aircraft was flown to a safe altitude, and the autopilot was engaged to reduce workload, but positive delegation of aircraft control was not accomplished." (page 21)
    Issue: pilots may over-rely on automation (Issue #106) See Issue details
    Strength: +2
    Aircraft: L1011
    Equipment: autoflight: autopilot
    Source: National Transportation Safety Board (1973). Eastern Airlines, Incorporated, L-1011, N31OEA, Miami, Florida, December 29, 1972. Aircraft Accident Report NTSB/AAR-73-14. Washington, DC: National Transportation Safety Board. See Resource details

  123.  
  124. Evidence Type: Excerpt from Accident Report
    Evidence: "... the Board concludes that the autopilot, and thus the glide slope function of the approach coupler, was disconnected prior to the time the aircraft reached decision height. ... The Safety Board concludes that if the autopilot had not been disengaged until the minimum authorized altitude, or if the nonflying crewmembers had continued to monitor the flight instruments, the aircraft would have reached the runway safely." (page 6)
    Issue: pilots may under-rely on automation (Issue #146) See Issue details
    Strength: +4
    Aircraft: B707-331C
    Equipment: autoflight: autopilot
    Source: National Transportation Safety Board (1973). Trans World Airlines, Incorporated, Boeing 707-331C, N788TW, John F. Kennedy International Airport, Jamacia, New York, December 12, 1972. Washington, DC: National Technical Information Service. See Resource details

  125.  
  126. Evidence Type: Excerpt from Accident Report
    Evidence: Had the pilots been flying the airplane manually (without the autopilot engaged) they likely would have noted the increased right-wing-down control wheel force needed to maintain the desired left bank, become aware of the airplane’s altered performance characteristics, and increased their airspeed or otherwise altered their flight situation to avoid the loss of control. Disengagement of the autopilot during all operations in icing conditions is necessary to enable pilots to sense the aerodynamic effects of icing and enhance their ability to retain control of the airplane. (page 178)
    Issue: situation awareness may be reduced (Issue #114) See Issue details
    Strength: +4
    Aircraft: Embraer EMB-120RT
    Equipment:
    Source: National Transportation Safety Board (1998). In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997. Aircraft Accident Report NTSB/AAR-98/04. Washington, DC: National Transportation Safety Board. See Resource details

  127.  
  128. Evidence Type: Excerpt from Accident Report
    Evidence: Because the pilots of Comair flight 3272 were operating the airplane with the autopilot engaged during a series of descents, right and left turns, power adjustments, and airspeed reductions, they might not have perceived the airplane’s gradually deteriorating performance. (page 145)
    Issue: situation awareness may be reduced (Issue #114) See Issue details
    Strength: +4
    Aircraft: Embraer EMB-120RT
    Equipment:
    Source: National Transportation Safety Board (1998). In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997. Aircraft Accident Report NTSB/AAR-98/04. Washington, DC: National Transportation Safety Board. See Resource details

  129.  
  130. Evidence Type: Excerpt from Accident Report
    Evidence: "The Safety Board concludes that one of the causal factors of the accident was the captain's reliance on the autopilot while the airplane was decelerating. During this 3 minute 40 second period, the captain allowed himself to remain removed from the `control loop' by leaving the autopilot engaged. As a result, he was not aware of the increasing control inputs required to maintain level flight." (page 30)
    Issue: situation awareness may be reduced (Issue #114) See Issue details
    Strength: +4
    Aircraft: B747-SP-09
    Equipment: autoflight: autopilot
    Source: National Transportation Safety Board (1986). China Airlines B-747-SP, 300 NM Northwest of San Francisco, February 19, 1985. Aircraft Accident Report NTSB/AAR-86-03. Washington, DC: National Transportation Safety Board. See Resource details

  131.  
  132. Evidence Type: Excerpt from Accident Report
    Evidence: Require all operators of turbopropeller-driven air carrier airplanes to require pilots to disengage the autopilot and fly the airplane manually when they activate the anti-ice systems. (A-98-97) (page 183)
    Issue: situation awareness may be reduced (Issue #114) See Issue details
    Strength: +3
    Aircraft: Embraer EMB-120RT
    Equipment:
    Source: National Transportation Safety Board (1998). In-Flight Icing Encounter and Uncontrolled Collision with Terrain, COMAIR Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997. Aircraft Accident Report NTSB/AAR-98/04. Washington, DC: National Transportation Safety Board. See Resource details

  133.  
  134. Evidence Type: Excerpt from Accident Report
    Evidence: "2.2 Conclusions (a) Findings ... 7. The autopilot was utilized in basic CWS. 8. The flightcrew was unaware of the low force gradient input required to effect a change in aircraft attitude while in CWS. ..." (page 22-23)
    Issue: understanding of automation may be inadequate (Issue #105) See Issue details
    Strength: +5
    Aircraft: L1011
    Equipment: autoflight: autopilot
    Source: National Transportation Safety Board (1973). Eastern Airlines, Incorporated, L-1011, N31OEA, Miami, Florida, December 29, 1972. Aircraft Accident Report NTSB/AAR-73-14. Washington, DC: National Transportation Safety Board. See Resource details

  135.  
  136. Evidence Type: Excerpt from Accident Report
    Evidence: "3. CONCLUSIONS ... The flightcrew was not thoroughly knowledgeable of the aircraft's flight guidance and control system." (page 23)
    Issue: understanding of automation may be inadequate (Issue #105) See Issue details
    Strength: +4
    Aircraft: DC-10-30
    Equipment: autoflight
    Source: National Transportation Safety Board (1980). Aeromexico DC-10-30 over Luxembourg, November 11, 1979. Aircraft Accident Report NTSB/AAR-80-10. Washington, DC: National Transportation Safety Board. See Resource details

  137.  
  138. Evidence Type: Excerpt from Accident Report
    Evidence: By providing vertical guidance along a constant descent gradient to the runway, the use of on-board flight management system- and/or global positioning system-based equipment can provide most of the safety advantages of a precision approach during a nonprecision approach. (page 174)
    Issue: vertical profile visualization may be difficult (Issue #53) See Issue details
    Strength: +4
    Aircraft: Boeing 747-300
    Equipment:
    Source: National Transportation Safety Board (2000). Controlled Flight Into Terrain, Korean Air Flight 801, Boeing 747-300, HL7468, Nimitz Hill, Guam, August 6, 1997. Aircraft Accident Report NTSB/AAR-00/01. Washington, DC: National Transportation Safety Board. See Resource details

  139.  
  140. Evidence Type: Excerpt from Accident Report
    Evidence: "3.0 CONCLUSIONS 3.1 Findings ... 47. The EFIS and RMI compass displays do not contain the letters 'N', 'S', 'E' or 'W' to show cardinal headings, which might have provided directional cues to prompt the crew." (page 124)
    Issue: displays (visual and aural) may be poorly designed (Issue #92) See Issue details
    Strength: +4
    Aircraft: A310
    Equipment: EFIS
    Source: Nepal Aircraft Accident Investigation Committee (1992). Report on the Accident of Thai Airways International A310 Flight TG 311 (HS-TID) on 31 July 1992. His Majesty's Government of Nepal. See Resource details

  141.  
  142. Evidence Type: Excerpt from Accident Report
    Evidence: "3.0 CONCLUSIONS 3.1 Findings ... 40. The Captain assessed the GPWS warning as false." (page 121, 124)
    Issue: pilots may lack confidence in automation (Issue #46) See Issue details
    Strength: +2
    Aircraft: A310
    Equipment: GPWS
    Source: Nepal Aircraft Accident Investigation Committee (1992). Report on the Accident of Thai Airways International A310 Flight TG 311 (HS-TID) on 31 July 1992. His Majesty's Government of Nepal. See Resource details

  143.  
  144. Evidence Type: Excerpt from Accident Report
    Evidence: "The majority of pilots in every nation said they knew how to utilize the automation effectively (i.e., can rapidly access the FMC, feel free to select level of automation, understand all the FMC modes and features), and that they knew to include the other pilot in automation decisions and activities (i.e., more cross-checking and acknowledgment of program changes)." (page 323)
    Issue: automation may be too complex (Issue #40) See Issue details
    Strength: -1
    Aircraft: various
    Equipment: automation
    Source: Strauch, B. (1997). Automation and decision making -- lessons from the Cali accident. In Proceedings of the 41st Annual Meeting of the Human Factors and Ergonomics Society, 195-199. See Resource details

  145.  
  146. Evidence Type: Excerpt from Accident Report
    Evidence: "The majority of pilots in every nation said they knew how to utilize the automation effectively (i.e., can rapidly access the FMC, feel free to select level of automation, understand all the FMC modes and features), and that they knew to include the other pilot in automation decisions and activities (i.e., more cross-checking and acknowledgment of program changes)." (page 323)
    Issue: cross checking may be difficult (Issue #72) See Issue details
    Strength: -1
    Aircraft: various
    Equipment: automation
    Source: Strauch, B. (1997). Automation and decision making -- lessons from the Cali accident. In Proceedings of the 41st Annual Meeting of the Human Factors and Ergonomics Society, 195-199. See Resource details

  147.  
  148. Evidence Type: Excerpt from Accident Report
    Evidence: "To summarize the results: The average difference in endorsement levels across 11 items for pilots flying automated aircraft in 12 nations was 53%; for pilots flying standard and pilots flying automated aircraft within each of eight nations, it was 9%; and for pilots flying for different airlines within the same national culture, it was 14%. These results clearly implicate national culture as an important influence in attitudes toward automation." (page 323)
    Issue: cultural differences may not be considered (Issue #165) See Issue details
    Strength: +1
    Aircraft: various
    Equipment: automation
    Source: Strauch, B. (1997). Automation and decision making -- lessons from the Cali accident. In Proceedings of the 41st Annual Meeting of the Human Factors and Ergonomics Society, 195-199. See Resource details

  149.  
  150. Evidence Type: Excerpt from Accident Report
    Evidence: "The majority of pilots in every nation said they knew how to utilize the automation effectively (i.e., can rapidly access the FMC, feel free to select level of automation, understand all the FMC modes and features), and that they knew to include the other pilot in automation decisions and activities (i.e., more cross-checking and acknowledgment of program changes)." (page 323)
    Issue: inter-pilot communication may be reduced (Issue #139) See Issue details
    Strength: -1
    Aircraft: various
    Equipment: automation
    Source: Strauch, B. (1997). Automation and decision making -- lessons from the Cali accident. In Proceedings of the 41st Annual Meeting of the Human Factors and Ergonomics Society, 195-199. See Resource details
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