FDAI logo   ::  Site Map  ::   
Home  |  About This Website  |  Contact Us
Home » ... » Evidence from Resource

Evidence from Resource 10 pieces of evidence from this resource.

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.

  1.  
  2. 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

  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: vertical profile visualization may be difficult (Issue #53) See Issue details
    Strength: +5
    Aircraft: B757-223
    Equipment: automation

  5.  
  6. 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

  7.  
  8. 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

  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

  11.  
  12. 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

  13.  
  14. 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

  15.  
  16. 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

  17.  
  18. 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

  19.  
  20. 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
Flight Deck Automation Issues Website  
© 1997-2013 Research Integrations, Inc.