Analysis of Alerting System Failures in Commercial Aviation Accidents

The role of an alerting system is to make the system operator (e.g., pilot) aware of an impending hazard or unsafe state so the hazard can be avoided or managed successfully. A review of 46 commercial aviation accidents (between 1998 and 2014) revealed that, in the vast majority of events, either the hazard was not alerted or relevant hazard alerting occurred but failed to aid the flight crew sufficiently. For this set of events, alerting system failures were placed in one of five phases: Detection, Understanding, Action Selection, Prioritization, and Execution. This study also reviewed the evolution of alerting system schemes in commercial aviation, which revealed naive assumptions about pilot reliability in monitoring flight path parameters; specifically, pilot monitoring was assumed to be more effective than it actually is. Examples are provided of the types of alerting system failures that have occurred, and recommendations are provided for alerting system improvements

Best Practices for Evaluating Flight Deck Interfaces for Transport Category Aircraft with Particular Relevance to Issues of Attention, Awareness, and Understanding CAST SE-210 Output 2 Report 6 of 6

Attention, awareness, and understanding of the flight crew are a critical contributor to safety and the flight deck plays a critical role in supporting these cognitive functions. Changes to the flight deck need to be evaluated for whether the changed device provides adequate support for these functions. This report describes a set of diverse evaluation methods. The report recommends designing the interface-evaluation to span the phases of the device development, from early to late, and it provides methods appropriate at each phase. It describes the various ways in which an interface or interface component can fail to support awareness as potential issues to be assessed in evaluation. It summarizes appropriate methods to evaluate different issues concerning inadequate support for these functions, throughout the phases of development

How Do Different Knowledge Frameworks Help Us Learn From Aviation Line Observations?

Human performance includes actions that increase safety, as well as actions that can reduce safety. Ensuring safety in complex dynamic operations like commercial aviation depends on the ability to institute appropriate responses based on what is learned from flightcrew performance and the contexts in which it occurs. To do this systemically at the organization level requires collecting data on flightcrew performance, developing effective approaches to analyzing those data, and understanding how to translate what has been learned into policies, procedures, and practice. Systematic observation of front-line operators is a vital source of human performance data. Much has been learned from such observations, including methodological principles. Most observations have been based on a framework focused on managing safety challenges and the ensuing unsafe events. A complementary perspective focuses on flexibility and actions that promote continued safe and effective operation. We consider lessons learned about observational methods from an established framework focused on undesired actions and how these might be extended for a framework focused on desired actions

Airplane Capabilities: Translating Non-Normal Information for Operational Decision-Making

We consider how a jet transport airplane interface supports the flight crew in managing airplane system failures (or non-normals) for continued safe flight and landing. The existing state of the art starts with a list of airplane system component failures and asks the flight crew to determine, with the help of non-normal procedures, the operational consequences of those failures. As airplane systems become more complex and interconnected, the flight crew's ability to determine operational consequences will become inadequate. We describe an approach that attempts to translate airplane system failures directly into airplane "capabilities," which is a set of basic airplane functions, such as the ability to stop after landing. This paper describes the overall framework for supporting flight crews in operational decision making and the initial efforts to develop a language and display concepts

A Summary of Results from Technologies for Aircraft State Awareness Safety Enhancement 210 Output 2

In 2014, the Commercial Aviation Safety Team produced a report describing the results of an analysis intended to understand and mitigate airplane incidents and accidents associated with flight crew loss of attitude or energy state awareness. That report described several "Safety Enhancements" including a new category of "Research Safety Enhancements". This paper focuses on Safety Enhancement (SE) 210 Output 2, investigating improvements in design methods and guidelines to "assess flight crew performance in situations associated with loss of energy and/or attitude state awareness"

The Role of Alerting System Failures in Loss of Control Accidents CAST SE-210 Output 2

This report is part of a series of reports that address flight deck design and evaluation, written as a response to loss of control accidents. In particular, this activity is directed at failures in airplane state awareness in which the pilot loses awareness of the airplane's energy state or attitude and enters an upset condition. In a report by the Commercial Aviation Safety Team, an analysis of accidents and incidents related to loss of airplane state awareness determined that hazard alerting was not effective in producing the appropriate pilot response to a hazard (CAST, 2014). In the current report, we take a detailed look at 28 airplane state awareness accidents and incidents to determine how well the hazard alerting worked. We describe a five-step integrated alerting-to-recovery sequence that prescribes how hazard alerting should lead to effective flight crew actions for managing the hazard. Then, for each hazard in each of the 28 events, we determine if that sequence failed and, if so, how it failed. The results show that there was an alerting failure in every one of the 28 safety events, and that the most frequent failure (20/28) was tied to the flight crew not orienting to (not being aware of) the hazard. The discussion section summarizes findings and identifies alerting issues that are being addressed and issues that are not currently being addressed. We identify a few recent upgrades that have addressed certain alerting failures. Two of these upgrades address alerting design, but one response to the safety events is to upgrade training for approach to stall and stall recovery. We also describe issues that are not being addressed adequately: better alert integration for flight path management types of hazards, airplanes in the fleet that do not meet the current alerting regulations, a lack of innovation for addressing cases of channelized attention, and existing vulnerabilities in managing data validity

Objective Evaluation of the Somatogravic Illusion from Flight Data of an Airplane Accident

(1) Background: It is difficult for accident investigators to objectively determine whether spatial disorientation may have contributed to a fatal airplane accident. In this paper, we evaluate three methods to reconstruct the possible occurrence of the somatogravic illusion based on flight data recordings from an airplane accident. (2) Methods: The outputs of two vestibular models were compared with the “standard” method, which uses the unprocessed gravito-inertial acceleration (GIA). (3) Results: All three methods predicted that the changing orientation of the GIA would lead to a somatogravic illusion when no visual references were available. However, the methods were not able to explain the first pitch-down control input by the pilot flying, which may have been triggered by the inadvertent activation of the go-around mode and a corresponding pitch-up moment. Both vestibular models predicted a few seconds delay in the illusory tilt from GIA due to central processing and sensory integration. (4) Conclusions: While it is difficult to determine which method best predicted the somatogravic illusion perceived during the accident without data on the pilot’s pitch perception, both vestibular models go beyond the GIA analysis in taking into account validated vestibular dynamics, and they also account for other vestibular illusions. In that respect, accident investigators would benefit from a unified and validated vestibular model to better explain pilot actions in accidents related to spatial disorientation

Managing Complex Airplane System Failures Through a Structured Assessment of Airplane Capabilities

This report describes an analysis of current transport aircraft system-management displays and the initial development of a set of display concepts for providing information about aircraft system status. The new display concepts are motivated by a shift away from the current approach to aircraft system alerting that reports the status of physical components, and towards displaying the implications for mission capability. Specifically, the proposed display concepts describe transport airplane component failures in terms of operational consequences of aircraft system degradations. The research activity described in this report is an effort to examine the utility of different representations of complex systems and operating environments to support real-time decision making during off-nominal situations. A specific focus is to develop display concepts that provide more highly integrated information to allow pilots to more easily reason about the operational consequences of the off-nominal situations. The work can also serve as a foundational element to autonomy-supported decision making since we are developing ideas for integrating information from the airplane and the operational environment to support decision making

Edition. New York: Wiley-

Suppose you were assigned the task of designing software to help automobile mechanics troubleshoot engine malfunctions. How would you approach the problem to ensure that you developed a useful and usable system? Or, suppose you were asked to develop computer-based procedures to replace the paper-based procedures that operators now use to monitor and control

Objective Evaluation of the Somatogravic Illusion from Flight Data of an Airplane Accident

(1) Background: It is difficult for accident investigators to objectively determine whether spatial disorientation may have contributed to a fatal airplane accident. In this paper, we evaluate three methods to reconstruct the possible occurrence of the somatogravic illusion based on flight data recordings from an airplane accident. (2) Methods: The outputs of two vestibular models were compared with the “standard” method, which uses the unprocessed gravito-inertial acceleration (GIA). (3) Results: All three methods predicted that the changing orientation of the GIA would lead to a somatogravic illusion when no visual references were available. However, the methods were not able to explain the first pitch-down control input by the pilot flying, which may have been triggered by the inadvertent activation of the go-around mode and a corresponding pitch-up moment. Both vestibular models predicted a few seconds delay in the illusory tilt from GIA due to central processing and sensory integration. (4) Conclusions: While it is difficult to determine which method best predicted the somatogravic illusion perceived during the accident without data on the pilot’s pitch perception, both vestibular models go beyond the GIA analysis in taking into account validated vestibular dynamics, and they also account for other vestibular illusions. In that respect, accident investigators would benefit from a unified and validated vestibular model to better explain pilot actions in accidents related to spatial disorientation