FISHER INSTITUTE

1. Glass Cockpit &Advanced Technology – A Progress for Flight Safety?presentation by ERAN RAMOTHead of Aviation ResearchThe Fisher Institute Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

2. Glass Cockpit Introduction 1982 B767, A310… Glass cockpit Cockpit full of glass Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

3. The GLASS COCKPIT (G/C) Innovation • Advanced Technology (A/T) Aircraft • Intensive Computerization • New cockpit layout • Heavier and Improved Automation: • For the Operators • For Systems Functioning (fail > ops > fail > safe…) • Electronically Generated Multi-Function / Multi-Colored / Color Coded Displays • TWO MEN CREW (pilots? “observers”?) Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

4. Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

5. Scope of Survey 27 fatal accidents, between 1982 & 2002 Accumulated experience of 20 years All - in Advanced Technology (A/T), Glass-Cockpit (G/C) airliners Conducted by Cpt. (El Al) G. Livny, ret. Col., Chief of Safety Branch, IAF 16 years in G/C-A/T airliners > > > > Conclusions & Recommendations Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

6. Investigated Issues • Mis-understanding & Mis-interpreting of Aircraft Behavior • Failure of Spatial Orientation • Canalizing Effects • Accedence of Maneuvering Envelope • (Unique Mental Factors) • Technical Failure • Organization’s, Manufacturer’s, Regulator’s Contribution and Responsibilities Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

7. Accident Rate – General Trend, A/T-G/C Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

8. Distribution of Accidents… C T R Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

9. Distribution of Accidents… The Naked Pilot by David Beaty, (93 major acc. 1959 – 1983) 45.6 • 21.4 Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

10. Accidents Types • CFIT – Controlled Flight Into Terrain • LOC – Los Of Control • Human Factor = FDC • Technical (Horizontal, Vertical Stab., Thrust Rev.) • Mid-Air & On-Ground Collision • Hard Landing / Overrun Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

11. Distribution of Accidents… Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

12. Major Areas & Factors Flight Deck Crew (FDC) – the HUMAN FACTOR • SOP and S/A • Crew Resource Management (CRM) • Misperception • Logics of Operation, (over-)Computerized • Flying Skills (“Stick & Rudder”) • By-Passed by Systems (“out of the loop”) Also: Mental, Over-Motivation (=Ego…) Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

13. Major Areas – SOP & S/A • Dis-orientation or Mis-orientation • 15 of 27 accidents due to Mis-orientation, resulting in CFIT or LOC: • Vertical Position, Location in the Approach, Unawareness to Pitch Att. (AOA) and Airspeed • Canalizing Effect, (initially) due Technical problem combined with workload of demanding task, with mountainous terrain • A/C Handling, Man-Machine-Interface (MMI) Systems and Automation, Logic and Surprizes Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

14. Additional / Other Factors • Glass Cockpit Related – (14 of the 27) • Inside the CTR (93%)– T/O, Trans. To CLB, Approach & landing, G/A • 67% of the CFIT; 50% of the LOC • Crew Inexperience, Wrong Switching, Failure to Detect/Select Flight Mode, Non Analyzed Failures, Data Entry • Technical Malfunction • Organization and Manufacturer • “Childhood Sicknesses”, Modifications & System “Traps”, SOP & QRH • Procedures and Training • Maintenance and Waivers • ATC – Communication, Vectoring vs Terrain & MSA • CAA – Regulation, Investigation, Lessons learned Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

15. Findings Summary • Leading risk category – CFIT, (45%) • Leading fatalities – LOC(average 1 per year…) >> Lack of Spatial Orientation << • Main primary cause – Human Factor, FDC (59%) >> Understanding, Orientation, Flying & Controlling << >> Mentality << • G/C-A/T new features has major impact – 52% Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

16. this is a test…. Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

17. Conclusions - General • Advanced technology…& computerized systems… has reduced the rate of fatal accidents significantly However, when accidents do occur… • Primary factor – Failure of Human… where the crew had no experience with aircraft malfunctions • Weak points were not detected during upgrade to A/T, especially in the area of MMI • Nonexistence of warnings about vertical (path) deviation • Effectiveness of GPWS(wrn’g) deteriorates in mountainous areas Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

18. Conclusions (cont’d) • The high level of reliability of the automation in G/C and the relative ease of flying these aircraft, induces complacency which expresses itself in loose monitoring of flight modes, failure to cross-check against…raw data, and over-reliance on the automatic modes of the aircraft during flight • Failures in basic flying skills Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

19. Conclusions (cont’d) - Manufacturer • Manufacturers contributed… by virtue of… • SOP & QRH • system Human Engineering • unpredicted malfunctions related to G/C, and the aircrews level of knowledge Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

20. Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

21. Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

22. Conclusions (cont’d) - Manufacturer • Manufacturers contributed… by virtue of… • SOP & QRH • system human engineering • unpredicted malfunctions related to G/C, and the aircrews level of knowledge • “Weak” logic: • Simultaneous appearance of Stick Shaker with Over-speed • The priority order of vocal warnings • Visual cues that failed to capture the attention of the crew. Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

23. Conclusions (cont’d)– The Airline • Faulty execution of the upgrade to advanced technology, shortcuts taken in the process • Mental factors combined into G/C aircraft included over-motivation, complacency, etc. • Low level of skills of the crewmembers in flying the aircraft, unfamiliar scenarios • Situations of uncontrolled flight in which only limited response time is available • A canalizing malfunction during VOR/DME approaches Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

24. Conclusions (cont’d)– The CAA’s • Fully responsible for orchestrating the acceptance of the new generation of advanced technology aircraft. • risk analysis, changes in aircraft design, conformance of aircrew knowledge requirements with A/T, changes in SOP and limitations • Great technological gap exists between the old-generation approach-instrumentation in airports located in mountainous areas Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

25. Few Years Later….. on 1st June 2009 Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE

26. 1st June 2009, Airbus A330-203 AF 447, Rio de Janeiro - Paris • Aircraft lost airspeed readings due pitot icing at 35,000 feet (crystal ice?) (…two years later we learned…) • Following a series of flight-controls “quarrelling” inputs the aircraft entered a steady stall that was not recovered • Aircraft impacted the ocean at 16deg. pitch up & ~11,000fpm rate-of-descent (~120kts) Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

27. The (AF447) accident resulted from the following Succession of Events: • ..Temporary inconsistency between the measured airspeeds >>> reconfiguration to alternate (control) law • ..Inappropriate control inputs • ..The crew not making the connection between the loss of indicated airspeeds and the appropriate procedure, • ..Late identification of the flight path and insufficient correction • ..Not identifying the approach to stall, the lack of an immediate reaction (not to) exit from the flight envelope, • ..Failure to diagnose the stall situation and, consequently, the lack of any actions that would have made recovery possible Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

28. …and Just recently …on July 2013 S F O Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE

29. 6 July 2013, Boeing 777-200ER HL7742, San FranciscoInt’l apt (SFO) • Aircraft was vectored to Visual App & Lndrwy 28L (ILS was us) • Cleared (by App. Cont.) for high-energy approach profile (fast & high: 180kts to 5 miles) • At 1600’ autopilot mode changed unexpectedly to FLCH and behaved like “TOGA”. • PF disconnected autopilot and retarded throttles to IDLE • At 500’ aircraft was positioned on glide-path (VASI) & 2kts slower then 137 bug-speed (acceptable margin) • 39 sec. later the aft fuselage struck the seawall • Stick-shaker was on • thrust levers were full forward Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

30. The (HL7742) accident resulted from the following Probable Cause: • The flight crew’s failure to monitor and maintain a minimum safe airspeed • Contributing to this failure were • (1) inconsistencies in the aircraft’s automation logic • (2) auto-throttle logic that unexpectedly disabled the aircraft’s minimum airspeed protection. Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE

31. Significant contributing factors to the accidents were • (1) inadequate warning systems to alert the flight crew that • the auto-throttle had stopped maintaining the set “bug” airspeed, and… • stopped providing stall protection • (2) (lack of) low speed alerting system… in an approach-to- landing configuration; • (3) the flight crew’s failure to execute a timely go-around (as) required by the company’s procedures and, instead, continued an un-stabilized approach • (4) air traffic control instructions and procedures that led to an excessive pilot workload during a high-energy final approach. Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE

32. RECCOMENDATIONS - Survey • To CAA’s • Prepare for the procurement of new generation aircraft: regulations, modification of requirements with regard to proficiency • Adapt standard of cockpit design in advanced technology aircraft • Avoid concessions on safety requirements • Upgrade the…requirements concerning approach-guidance (systems)…near mountainous areas • Modify the standards of communicationprocedures… (for bad wx)… in and around the airport Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

33. Reccomendations - Survay(cont’d) • To the Airlines • Assess the risks … in the operation of a new technology and prepare for them • Adjust the absorption rate … to the human resources available… retraining and training capabilities • Adapt the assignments…to the difficulty level of the mission • Define specific limits to the period required for the adaptation of crewmembers • Focus points… and procedures… for S/A and CRM in G/C aircraft • Modify the subjects… of training in simulators • Augment the aircrew knowledge and understanding Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

34. Reccomendations - Survay(cont’d) • To the Manufacturer • Analyze the… rapid loss of control over aircraft • Keep the pilot “within the automation loop” • Develop means (to train for “non-advised”) malfunctions in simulators • Improve the quality of the operational instructions (SOP) • Improve the quality of the audio…and reduce the environmental noise Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

35. Reccomendations – AF447 Initial Reccomendations(after ~5 months) • Extend…rapidly… to 90 days the…transmission time for …flight recorders of airplanes performing… flights over maritime areas • Study the possibility…for airplanes …to regularly transmit basic flight parameters… Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

36. Reccomendations – AF447 (cont’d) > > > > > > Final Report (after 3 years)> > > > > > • EASAensure, in type rating and recurrent training programs… understanding… differencesin handling characteristics…and limits of the flight envelope • Angle-of-Attack indicator directly accessible to pilots Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

37. Reccomendations– AF447 (cont’d) To EASA • … make sure…theoretical knowledge particularly on flight mechanics, is well understood • …ensure that operators reinforce CRM training… • …better fidelity for simulators in reproducing realistic scenarios (and)…scenarios (with) effects of surprise • …require a review of the functional of display logic • stall warning • dedicated visual indications • stall warning in flight when speed measurements are very low Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

38. Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

39. Final Report AF447 – July 2012 • 5 - CHANGES MADE FOLLOWING THE ACCIDENT • 5.1 Air France • 5.1.1 Aeroplane maintenance and equipment • 5.1.2 Modifications to reference systems • 5.1.3 Crew training • 5.2 Airbus • 5.3 EASA • 5.3.1 Certification measures to improve aviation safety • 5.3.2 Rulemaking actions from EASA to improve aviation safety • 5.4 Aviation industry actions • FAA Advisory Circular (AC120-STALL) • ..Advanced theoretical training; • ..Realistic exercises on the simulator based on specific scenarios; • ..Taking into account disengagement of automatic systems; • ..Continuous training at each career stage • ..Reinforcement of application of SOP’s and effective CRM by the crew; • ..Practice in the “startle factor”; • ..Use of the “upset recovery training aid” by training centers and operators. Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

40. Racommendations - HL7742March, 2014 • FAA: Require Boeing to insert the following… into FCOM…“During a descent in FLCH…” • FAA: Require Boeing to modify low speed alert • FAA: Require Boeing to provide enhanced training guidance • FAA: Require Boeing to modify the autothrottlesystem • FAA: Determine the appropriate level of workload for pilots operating highly automated airplanes • FAA and Boeing: Develop and implement changes to the design, alerting features of training guidance…to mitigate automation “surprise” Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

41. Children of the Magenta – AA, 1997 • http://vimeo.com/64502012 • "We are not automation managers. We are captains and pilots, and by our aviator skills we have to ensure the vertical and lateral path…” • "As often as you can, when you deem the situation is right, turn off your A/P and A/T and maintain your piloting skills” Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

42. Personal Note in a Nut-Shell • Don’t let the reliability put you to sleep • Don’t let the automation steel your Job • Don’t leave the doubts out of the game • Don’t forget where the stick is ……and….. FLY THE DAMN MACHINE ! ! Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

43. THANK YOU Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE

44. Aviation safety : can it be measured? Fatal Accidents of Glass Cockpit – Lessons Learned? FISHERINSTITUTE FISHERINSTITUTE