NTSB update on Asiana 214
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- because it is just not possible to train a human to that degree.
Enthusiasts amateur pilots on asvim flight simulation forum learn and handle very high fidelity 737/777 flight simulation (made by PMDG) in no time at all.
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Enthusiasts amateur pilots on asvim flight simulation ...
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You could not put somebody in the cockpit who isn't even a real pilot.
But this is a good point, folks purchase a $100 simulation from PMDG, which is very detailed by the way and includes typical equipment failures, and can read a 200 page manual (to effectively teach a typical Boeing autopilot you need say only 20 pages out of it) and can operate successfully such simulation, there are thousands of them and the VATSIM international network is a testimony of how popular this hobby is. You don't hear anything about how impossibly complex it is, it isn't, it is simple. If a 10000 hr ATP pilot can't perform at the same level as a 20-hr amateur (who has no FO to help out) than I wonder what else. By the way FGD135, you would have to ask other XXXX 777 pilots what do they think about the complexity of their aircraft, your lonely voice doesn't really count, it is your opinion only, you probably even aren't Boeing rated.
But this is a good point, folks purchase a $100 simulation from PMDG, which is very detailed by the way and includes typical equipment failures, and can read a 200 page manual (to effectively teach a typical Boeing autopilot you need say only 20 pages out of it) and can operate successfully such simulation, there are thousands of them and the VATSIM international network is a testimony of how popular this hobby is. You don't hear anything about how impossibly complex it is, it isn't, it is simple. If a 10000 hr ATP pilot can't perform at the same level as a 20-hr amateur (who has no FO to help out) than I wonder what else. By the way FGD135, you would have to ask other XXXX 777 pilots what do they think about the complexity of their aircraft, your lonely voice doesn't really count, it is your opinion only, you probably even aren't Boeing rated.
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My lonely voice, olasek? Add these lonely voices:
What will be the legacy of Asiana Airlines Flight 214? - CNN.com
The "one change that I would like to see: Improving the human-machine interface," said former NTSB chairman Deborah A.P. Hersman, who oversaw the crash investigation.
"The Asiana crash involved an inherently safe aircraft that performed as designed and a very experienced crew," Hersman said.
"But it demonstrated that commercial pilots are trained to rely heavily on sophisticated automation, which can become a trap if they don't understand what the system is doing behind the control panel."
At a December hearing, the safety board heard evidence that the Asiana pilots were confused by autopilot modes, believing the auto-throttle would maintain the plane's speed.
"Automation has unquestionably made aviation safer and more efficient. But the more complex automation becomes, the more challenging it is to ensure that the pilots adequately understand it," current safety board acting chairman Christopher Hart said last month.
"In this instance, the flight crew over-relied on automated systems that they did not fully understand. As a result, they flew the aircraft too low and too slow and collided with the seawall at the end of the runway."
The NTSB ruled that "complexities of the auto-throttle and autopilot" systems contributed to the accident.
"The Asiana crash involved an inherently safe aircraft that performed as designed and a very experienced crew," Hersman said.
"But it demonstrated that commercial pilots are trained to rely heavily on sophisticated automation, which can become a trap if they don't understand what the system is doing behind the control panel."
At a December hearing, the safety board heard evidence that the Asiana pilots were confused by autopilot modes, believing the auto-throttle would maintain the plane's speed.
"Automation has unquestionably made aviation safer and more efficient. But the more complex automation becomes, the more challenging it is to ensure that the pilots adequately understand it," current safety board acting chairman Christopher Hart said last month.
"In this instance, the flight crew over-relied on automated systems that they did not fully understand. As a result, they flew the aircraft too low and too slow and collided with the seawall at the end of the runway."
The NTSB ruled that "complexities of the auto-throttle and autopilot" systems contributed to the accident.
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Hi again, safetypee:
I was initially motivated to immediately respond to your post by acknowledging your recognition of my comments about the need to ‘review’ and ‘not everything is training’ – but I decided to put it aside and re-read once again, later. Well, it IS later now, and I have re-read your post – but I don’t think that our views are diverging quite as much as you might think. Please don’t misunderstand my intent here … I am fully aware that the last time I was correct about EVERYTHING must have been a very long time ago, as I don’t remember such a time … and … I also fully recognize that there is almost always more than one way to solve any given problem … and not everyone will agree with the method I choose, and that disagreement certainly doesn’t mean that I’m correct and everyone else is incorrect.
Because I am, and have been, for a long time (a very long time), an educator of one type or another, I think it is logical, for me anyway, to be prone to look at the “training” issue(s), or those issues that might well be resolved through training, at least initially – and, I think, logically conclude that “training” may indeed provide the necessary correction or, at least, provide some degree of correction for the issue under assessment. BUT, I think that I probably should define my understanding of the way I use the term “training.”
There are many who feel that “training” is what occurs in order to provide someone with an understanding of how “something” works. Simple things requiring less training and more complex things requiring not only more training, but usually training that is more sophisticated. But, in either case, once the individual grasps the fundamentals of the workings of that “something” the value of training has been recognized and is of little further use. I am NOT one of those kinds of training advocates. Of course, teaching individuals how “something” works is fundamentally necessary – whether that “something” is uncomplicated and straight forward or is vastly more complex and convoluted. But once that basic training is completed, I come from the position that the “real” training is only just begun. When I explain this specific aspect of my beliefs, I find it often useful to use “sports analogies.”
In the US, the sport of baseball is considered to be one of the country’s most recognizable “pastimes.” Certainly, teaching someone to play baseball for the first time is or can be quite challenging – but it happens across the country, in most towns and cities, in almost every vacant field. But once the youngsters who have learned “the basics” of the game get older and more understanding of the sport, additional “training” is almost universally appropriate. Even when the best of those youngsters have played the game in their town’s vacant lot, in the schools’ playgrounds, in the universities’ professional looking fields – and have decided to become “professional” baseball players … those now professionals spend 4 to 8 weeks, every year, prior to baseball season beginning, gathering for what is known here as “spring training.”
Certainly, one could easily recognize that these now-professional baseball players are not in “need” of any additional training – and, in fact, many of them conduct their own training for their own hometown “little leagues” for the new generation of players wanting to learn the game. EVEN then, these professional players, after spending that month or two at the beginning of each baseball season, go through a warm-up training session, including batting practice and fielding practice for an hour or so before EVERY game they play. It’s certainly not to “teach” these professionals anything new about the game … Certainly, these professionals do not need additional training on how to swing a bat, how to run the bases, how to catch or throw a baseball … it is rather an opportunity to, once again, review the mind-muscle interconnects, revise and “wakeup” some nerve endings, to more easily acquire the increased vigilance, the more heightened awareness, and the more attentive observations that often makeup the differences that often determine who wins and who loses a given baseball game.
The kind of “training” that I believe should be undertaken by professional pilots, would be much like the “training” undertaken by professional baseball players each year … however, certainly not to the extent or the time involvement as baseball players, and also not so much to “learn” new skills (although, in piloting, there ARE times when new or modernized equipment finds its way into the cockpit – and ground school or a bulletin added to an operating manual just may not fill the requirement as completely as what may be necessary!), as it would be to once again, review the mind-muscle interconnects, review how to revise and “wakeup” necessary nerve endings, to practice the acquisition of an increased vigilance, a heightened awareness, and an attentive observation of what is presented inside and outside of the cockpit – which, similar to what happens in baseball, but here, providing a reminder of what a refreshed diligence looks and feels like, which, in turn, just may determine the degree of efficiency and the level of safety with which any given flight may be conducted.
Of course, pilots don’t have a simulator session or a “practice flight” immediately prior to each scheduled flight – nor is it really necessary to warm the muscles and increase the adrenaline flow – as it is when preparing to engage in a physically demanding game – although, in a more perfect world it might not be completely out-of-the-question to suggest such a practice …
No, my desire with regard to such training is two-fold – just as baseball training is two-fold. First, to teach newly required skills, when and where necessary. Second, and at least as importantly (and often much more so), to provide a regularly accomplished, professional overview of what kinds of skill sets may require review and practice for each individual in such training, and an assessment of what kinds of tasks might be or should be revisited, a review of what kind of complications might be or should be included in such a skills revisiting – focusing on the full length and breadth of piloting skills, and most commonly, provide an opportunity for each pilot to revisit all of the above with a mind-set devoted to the tasks, the skills required to perform them, and an opportunity to practice, practice, practice – of which, as professional athletes of all sports regularly remind us – one never can get too much!
This is not to ignore the kinds of issues that may complicate any normal flight operation. Threats to the safe operation or safe completion of the flight can be, and when important or recently experienced, should be reviewed during such training, as should be the rather continuous “management of errors” training. Of course, as I’ve said somewhat regularly, pilots are humans, and humans make errors – and as such, we should expect pilots to make errors – AND we should train those pilots (and revisit that training on as frequent a basis as deemed appropriate) on how to recognize and correct those errors when they do occur. Again, a knowledgeable review of recently recognized errors occurring during flight could easily be included within any robust training session.
So, I hope I have provided you with a more clear view of my objective when I say I am a full and vigorous supporter of pilot training – including the equipment that is used to conduct that training. The goal I have in mind for such training is to rid pilots of the “rust” that may occur after some amount of time away from dealing with some functions that are not often seen or are encountered infrequently – but, because of the consequences of improper or incomplete addressing could create unwanted and potentially dangerous situations. It is my sincere belief that regardless of the kinds of instrumentation or the location or particular display type of some informative instrument, gauge, or light, with proper, regular, and appropriate training, there should be very few, if any, instrument display or location that will regularly contribute to accidents or incidents. Additionally, I think such training sessions, provides the instructor with a front-row seat to ensure that line pilots are not misunderstanding or applying incomplete or inaccurate applications of something out of a training syllabus or manual. Close scrutiny of what happens during training sessions is not only appropriate ... it could easily be the only recognition of an improper understanding of control applications, habit patterns, or some other flight parameter or practice that might cause problems - and if noted during training could be corrected and prevent some untold degree of grief.
Again, ALL accidents and incidents should always be carefully and diligently examined and considered. When, if, or where it becomes known that some instrument, display, system, or system operation does, in fact, either complicate or confuse the pilots using that system, we should take all necessary steps to repair or replace or, if necessary, re-invent that particularly offensive equipment. And then train the pilots correctly, completely, and regularly on how to use that replacement equipment!
I was initially motivated to immediately respond to your post by acknowledging your recognition of my comments about the need to ‘review’ and ‘not everything is training’ – but I decided to put it aside and re-read once again, later. Well, it IS later now, and I have re-read your post – but I don’t think that our views are diverging quite as much as you might think. Please don’t misunderstand my intent here … I am fully aware that the last time I was correct about EVERYTHING must have been a very long time ago, as I don’t remember such a time … and … I also fully recognize that there is almost always more than one way to solve any given problem … and not everyone will agree with the method I choose, and that disagreement certainly doesn’t mean that I’m correct and everyone else is incorrect.
Because I am, and have been, for a long time (a very long time), an educator of one type or another, I think it is logical, for me anyway, to be prone to look at the “training” issue(s), or those issues that might well be resolved through training, at least initially – and, I think, logically conclude that “training” may indeed provide the necessary correction or, at least, provide some degree of correction for the issue under assessment. BUT, I think that I probably should define my understanding of the way I use the term “training.”
There are many who feel that “training” is what occurs in order to provide someone with an understanding of how “something” works. Simple things requiring less training and more complex things requiring not only more training, but usually training that is more sophisticated. But, in either case, once the individual grasps the fundamentals of the workings of that “something” the value of training has been recognized and is of little further use. I am NOT one of those kinds of training advocates. Of course, teaching individuals how “something” works is fundamentally necessary – whether that “something” is uncomplicated and straight forward or is vastly more complex and convoluted. But once that basic training is completed, I come from the position that the “real” training is only just begun. When I explain this specific aspect of my beliefs, I find it often useful to use “sports analogies.”
In the US, the sport of baseball is considered to be one of the country’s most recognizable “pastimes.” Certainly, teaching someone to play baseball for the first time is or can be quite challenging – but it happens across the country, in most towns and cities, in almost every vacant field. But once the youngsters who have learned “the basics” of the game get older and more understanding of the sport, additional “training” is almost universally appropriate. Even when the best of those youngsters have played the game in their town’s vacant lot, in the schools’ playgrounds, in the universities’ professional looking fields – and have decided to become “professional” baseball players … those now professionals spend 4 to 8 weeks, every year, prior to baseball season beginning, gathering for what is known here as “spring training.”
Certainly, one could easily recognize that these now-professional baseball players are not in “need” of any additional training – and, in fact, many of them conduct their own training for their own hometown “little leagues” for the new generation of players wanting to learn the game. EVEN then, these professional players, after spending that month or two at the beginning of each baseball season, go through a warm-up training session, including batting practice and fielding practice for an hour or so before EVERY game they play. It’s certainly not to “teach” these professionals anything new about the game … Certainly, these professionals do not need additional training on how to swing a bat, how to run the bases, how to catch or throw a baseball … it is rather an opportunity to, once again, review the mind-muscle interconnects, revise and “wakeup” some nerve endings, to more easily acquire the increased vigilance, the more heightened awareness, and the more attentive observations that often makeup the differences that often determine who wins and who loses a given baseball game.
The kind of “training” that I believe should be undertaken by professional pilots, would be much like the “training” undertaken by professional baseball players each year … however, certainly not to the extent or the time involvement as baseball players, and also not so much to “learn” new skills (although, in piloting, there ARE times when new or modernized equipment finds its way into the cockpit – and ground school or a bulletin added to an operating manual just may not fill the requirement as completely as what may be necessary!), as it would be to once again, review the mind-muscle interconnects, review how to revise and “wakeup” necessary nerve endings, to practice the acquisition of an increased vigilance, a heightened awareness, and an attentive observation of what is presented inside and outside of the cockpit – which, similar to what happens in baseball, but here, providing a reminder of what a refreshed diligence looks and feels like, which, in turn, just may determine the degree of efficiency and the level of safety with which any given flight may be conducted.
Of course, pilots don’t have a simulator session or a “practice flight” immediately prior to each scheduled flight – nor is it really necessary to warm the muscles and increase the adrenaline flow – as it is when preparing to engage in a physically demanding game – although, in a more perfect world it might not be completely out-of-the-question to suggest such a practice …
No, my desire with regard to such training is two-fold – just as baseball training is two-fold. First, to teach newly required skills, when and where necessary. Second, and at least as importantly (and often much more so), to provide a regularly accomplished, professional overview of what kinds of skill sets may require review and practice for each individual in such training, and an assessment of what kinds of tasks might be or should be revisited, a review of what kind of complications might be or should be included in such a skills revisiting – focusing on the full length and breadth of piloting skills, and most commonly, provide an opportunity for each pilot to revisit all of the above with a mind-set devoted to the tasks, the skills required to perform them, and an opportunity to practice, practice, practice – of which, as professional athletes of all sports regularly remind us – one never can get too much!
This is not to ignore the kinds of issues that may complicate any normal flight operation. Threats to the safe operation or safe completion of the flight can be, and when important or recently experienced, should be reviewed during such training, as should be the rather continuous “management of errors” training. Of course, as I’ve said somewhat regularly, pilots are humans, and humans make errors – and as such, we should expect pilots to make errors – AND we should train those pilots (and revisit that training on as frequent a basis as deemed appropriate) on how to recognize and correct those errors when they do occur. Again, a knowledgeable review of recently recognized errors occurring during flight could easily be included within any robust training session.
So, I hope I have provided you with a more clear view of my objective when I say I am a full and vigorous supporter of pilot training – including the equipment that is used to conduct that training. The goal I have in mind for such training is to rid pilots of the “rust” that may occur after some amount of time away from dealing with some functions that are not often seen or are encountered infrequently – but, because of the consequences of improper or incomplete addressing could create unwanted and potentially dangerous situations. It is my sincere belief that regardless of the kinds of instrumentation or the location or particular display type of some informative instrument, gauge, or light, with proper, regular, and appropriate training, there should be very few, if any, instrument display or location that will regularly contribute to accidents or incidents. Additionally, I think such training sessions, provides the instructor with a front-row seat to ensure that line pilots are not misunderstanding or applying incomplete or inaccurate applications of something out of a training syllabus or manual. Close scrutiny of what happens during training sessions is not only appropriate ... it could easily be the only recognition of an improper understanding of control applications, habit patterns, or some other flight parameter or practice that might cause problems - and if noted during training could be corrected and prevent some untold degree of grief.
Again, ALL accidents and incidents should always be carefully and diligently examined and considered. When, if, or where it becomes known that some instrument, display, system, or system operation does, in fact, either complicate or confuse the pilots using that system, we should take all necessary steps to repair or replace or, if necessary, re-invent that particularly offensive equipment. And then train the pilots correctly, completely, and regularly on how to use that replacement equipment!
Last edited by AirRabbit; 18th Aug 2014 at 18:24.
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Simple
Isn't this a pretty simple matter.
Clear day, perfect visibility, no cross wind, no wind shear, ... on and on ...
All mechanical systems operating as designed.
Seawall not excessively high.
... what could possibly be attributed to a disaster like this?
Clear day, perfect visibility, no cross wind, no wind shear, ... on and on ...
All mechanical systems operating as designed.
Seawall not excessively high.
... what could possibly be attributed to a disaster like this?
Per Ardua ad Astraeus
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Originally Posted by olasek
By the way, what's TEM - Tunneling Electron Microscope.
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Originally Posted by MrDK
Isn't this a pretty simple matter.
Clear day, perfect visibility, no cross wind, no wind shear, ... on and on ...
All mechanical systems operating as designed.
Seawall not excessively high.
... what could possibly be attributed to a disaster like this?
Clear day, perfect visibility, no cross wind, no wind shear, ... on and on ...
All mechanical systems operating as designed.
Seawall not excessively high.
... what could possibly be attributed to a disaster like this?
1) an extremely difficult to read set of instruments, to the extent that it created an inability to accurately understand what was being displayed resulting in confusion about what was happening, or was recognized at some point but physical action was not taken due to an expectation that the “automatics” would be properly applied and correct any noted anomaly with the approach path and/or airspeed; or
2) the pilot flying was inadequately and/or incompletely trained in manual operation the airplane with or without assistance provided by whatever automatic systems which may have been desired or which were unsuccessfully or improperly attempted to engage.
Either scenario was very likely exacerbated by fatigue of both pilots after a transpacific flight from Asia to the US (San Francisco).
The presentation of airspeed in the tape format, making it much more difficult for pilots to monitor airspeed (and become aware of incorrect airspeed);
...an extremely difficult to read set of instruments, to the extent that it created an inability to accurately understand what was being displayed...
When do we get to 'nearly impossible'?
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When do we get to 'nearly impossible'?
Just get the workload and/or stress level up high enough, and the tape will be nearly impossible to use.
A cinch to read when unstressed and relaxed, but, as I said earlier, the airspeed effectively becomes invisible when the chips are really down.
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Originally Posted by OK465
Well we've gone from 'not as easy' to 'difficult' to 'much more difficult' to 'extremely difficult'....
When do we get to 'nearly impossible'?
When do we get to 'nearly impossible'?
Originally Posted by FDG135
Gidday OK465, that's an easy one.
Just get the workload and/or stress level up high enough, and the tape will be nearly impossible to use.
A cinch to read when unstressed and relaxed, but, as I said earlier, the airspeed effectively becomes invisible when the chips are really down.
Just get the workload and/or stress level up high enough, and the tape will be nearly impossible to use.
A cinch to read when unstressed and relaxed, but, as I said earlier, the airspeed effectively becomes invisible when the chips are really down.
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.So what are your credentials in this? Your Boeing ratings?
.My lonely voice, olasek? Add these lonely voices:
2) the pilot flying was inadequately and/or incompletely trained in manual operation
aterpster, Re “What was wrong with design?
What was wrong with system approval?
What was wrong with the "approach procedure?"
Under the vast umbrella of hindsight, weaknesses can be identified in most processes. The skills in design and approval, and for procedures stem from lessons learnt – how do we learn from hindsight?
The NTSB identifies “the complexities of the autothrottle and autopilot flight director systems” as a contribution, but then qualifies this with inadequacies in documentation. Complexity can add significant mental workload, which in turn accentuates the opportunity for error, as might the need to recall documented descriptions/warnings or trained-for ‘gotchas’ from memory.
Certification requirements clearly state the need for awareness and the predictable of, and an unambiguous system operation (25.1302), and that “systems and controls, including indications and annunciations must be designed to minimise crew errors, which could create additional hazards” (25.1309).
There is extensive explanation and guidance on these issues in the lengthy AMC 25.1302; a document, AFAIR which was not initially adopted by the FAA in the harmonisation process with EASA.
The design and approval of these aspects ultimately comes down to judgement by skilled humans (equally subject to error as are crews); however the industry does enjoy some safeguard from the process of continued airworthiness for systems (hindsight), but less so for operations.
Judgement is subject to bias; there are examples either side of acceptable boundaries; the US (NTSB/FAA) appears to rate the effectiveness of human intervention higher than other regulators, e.g. advisory nature of landing distance margins vs EASA/Airbus use of Operational Performance margins.
Judgement might also be influenced by the availability of human intervention vs system failure, e.g. B777 off-runway landing due to fuel-icing resulted in a mandated system modification, the non-fatal outcome being due to exceptional human intervention. Conversely the Asiana accident involving a system weakness focusses on the less than adequate human intervention and unfortunate outcome, and thereafter chooses to ‘improve’ the human, yet the aspects of human behaviour in both accidents have similar (same) cognitive roots (perception, judgement).
With increasing complexity the greater is the need for ‘generalities’. There is no universal ‘Truth’, only those local truths formed by individual perception; e.g. the truth of how the Asiana crew perceived the approach vs our truth of the event with hindsight.
The difference between College Professors and Pilots involves theory vs practice. Scientific truths are formed because they can be repeated, checked, and verified; in aviation you only get one attempt at an approach in specific (non repeatable) circumstances.
If only we could revisit the circumstances of our last error; instead we have to rely on learning how to avoid the next adverse situation from the results of the previous one.
What was wrong with system approval?
What was wrong with the "approach procedure?"
Under the vast umbrella of hindsight, weaknesses can be identified in most processes. The skills in design and approval, and for procedures stem from lessons learnt – how do we learn from hindsight?
The NTSB identifies “the complexities of the autothrottle and autopilot flight director systems” as a contribution, but then qualifies this with inadequacies in documentation. Complexity can add significant mental workload, which in turn accentuates the opportunity for error, as might the need to recall documented descriptions/warnings or trained-for ‘gotchas’ from memory.
Certification requirements clearly state the need for awareness and the predictable of, and an unambiguous system operation (25.1302), and that “systems and controls, including indications and annunciations must be designed to minimise crew errors, which could create additional hazards” (25.1309).
There is extensive explanation and guidance on these issues in the lengthy AMC 25.1302; a document, AFAIR which was not initially adopted by the FAA in the harmonisation process with EASA.
The design and approval of these aspects ultimately comes down to judgement by skilled humans (equally subject to error as are crews); however the industry does enjoy some safeguard from the process of continued airworthiness for systems (hindsight), but less so for operations.
Judgement is subject to bias; there are examples either side of acceptable boundaries; the US (NTSB/FAA) appears to rate the effectiveness of human intervention higher than other regulators, e.g. advisory nature of landing distance margins vs EASA/Airbus use of Operational Performance margins.
Judgement might also be influenced by the availability of human intervention vs system failure, e.g. B777 off-runway landing due to fuel-icing resulted in a mandated system modification, the non-fatal outcome being due to exceptional human intervention. Conversely the Asiana accident involving a system weakness focusses on the less than adequate human intervention and unfortunate outcome, and thereafter chooses to ‘improve’ the human, yet the aspects of human behaviour in both accidents have similar (same) cognitive roots (perception, judgement).
With increasing complexity the greater is the need for ‘generalities’. There is no universal ‘Truth’, only those local truths formed by individual perception; e.g. the truth of how the Asiana crew perceived the approach vs our truth of the event with hindsight.
The difference between College Professors and Pilots involves theory vs practice. Scientific truths are formed because they can be repeated, checked, and verified; in aviation you only get one attempt at an approach in specific (non repeatable) circumstances.
If only we could revisit the circumstances of our last error; instead we have to rely on learning how to avoid the next adverse situation from the results of the previous one.
aterpster, FDG135, the ‘procedural aspects’ concern the reported need to fly higher than the ideal flight path to avoid traffic patterns below, which AFAIR was shown not to be warranted.
Thus all approaches had to adjust the vertical profile from high to lower to achieve stabile conditions later in the approach.
With ILS available the magnitude of the deviation is more easily identifiable than for visual assessment, and although PAPI is available this has a range limitation vs visibility, and is an ‘on-off’ display vs an analogue ILS display. These seemingly minor factors, unstable approach, lack of ILS, can in combination contribute to workload and reduce the time available for adjusting the approach.
Thus all approaches had to adjust the vertical profile from high to lower to achieve stabile conditions later in the approach.
With ILS available the magnitude of the deviation is more easily identifiable than for visual assessment, and although PAPI is available this has a range limitation vs visibility, and is an ‘on-off’ display vs an analogue ILS display. These seemingly minor factors, unstable approach, lack of ILS, can in combination contribute to workload and reduce the time available for adjusting the approach.
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1) an extremely difficult to read set of instruments, to the extent that it created an inability to accurately understand what was being displayed resulting in confusion about what was happening, or was recognized at some point but physical action was not taken due to an expectation that the “automatics” would be properly applied and correct any noted anomaly with the approach path and/or airspeed;
Are any such reports available?
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There is extensive explanation and guidance on issues in the lengthy AMC 25.1302; a document, AFAIR which was not initially adopted by the FAA in the harmonisation process with EASA. The design and approval of these aspects ultimately comes down to judgement by skilled humans (equally subject to error as are crews); however the industry does enjoy some safeguard from the process of continued airworthiness for systems (hindsight), but less so for operations.
Judgement is subject to bias; there are examples either side of acceptable boundaries; the US (NTSB/FAA) appears to rate the effectiveness of human intervention higher than other regulators, e.g. advisory nature of landing distance margins vs EASA/Airbus use of Operational Performance margins. Judgement might also be influenced by the availability of human intervention vs system failure, e.g. B777 off-runway landing due to fuel-icing resulted in a mandated system modification, the non-fatal outcome being due to exceptional human intervention.
“…the Asiana accident involving a system weakness focusses on the less than adequate human intervention and unfortunate outcome, and thereafter chooses to ‘improve’ the human, yet the aspects of human behaviour in both accidents have similar (same) cognitive roots (perception, judgement).”
An Analogy: Let’s presume a young lad has a habit of running into the house from the garage, and does so under an open step ladder. It’s “cool” to run right under that thing and it’s a shorter route to the kitchen. This young lad does this almost every day for months. However, one day, he starts to run into the kitchen, again under the step ladder, but this time he smacks his head on the support arms holding the ladder legs firmly in place. He rubs his head a bit, and proceeds on into the kitchen. A few days later, the lad once again, finishes his play in the garage and, again, starts to run into the kitchen. Again, he smacks his head on the same portion of the ladder. Again, he rubs his head and proceeds into the kitchen.
Later that week, again the lad finishes his play, jumps up and runs toward the kitchen via his usual path under the open step ladder. But, this time as he approaches the open ladder, he ducks his head and slips under the support arms without hitting them and smiles as he runs into the kitchen. His cognitive state has been modified – and the modification impetus was the physical annoyance of beginning to hit his head. Very likely, in addition to recognizing the discomfort experienced, he must have analyzed why he began hitting his head – the ladder had not changed – it had not been moved – it had not been touched. Therefore, the “something” that changed simply had to be “himself.” Further analysis is likely to have led to his recognition that he was growing taller, and would have to alter his posture to be able to pass under the same ladder without hitting his head. In short, he “learned” something.
It doesn’t take the proverbial “rocket scientist” to recognize that the same realization could have been reached had someone else observed the lad’s regular actions and noticed that he was getting older and growing taller. That observant person could have informed the lad of the potential problems, and either let him reach his own conclusions, or that person could have explained the changing situation sufficiently well such that the lad could have understood the practical application of the situation – he was changing and the ladder was not – and to continue the practice, he would have to make a modification to his behavior … ducking under the support arms was one acceptable alternative. There certainly is a potential that reflective thought could lead to eventually recognizing the problem as continuing as he continues to grow taller – and depending on his desire to avoid discomfort in the future, it is increasingly likely that he would recognize future circumstances, and make a decision to more radically modify his behavior – in terms of modifying his path into the kitchen, avoiding the ladder completely. If this recognition takes place, the lad has “learned” something else, and once again we see a modification of the cognitive basis of human performance. It IS possible to affect the cognitive aspects of human performance.
With increasing complexity the greater is the need for ‘generalities’.
To increase the potentials for recalling a specific set of responses, it is necessary to understand that had this person has to have been provided the opportunity to be exposed to varying degrees of complex situations in a theoretical or training scenario, where the leader or instructor has the opportunity to “walk through” the confrontation, from initial presentation, through the addressing of individual steps or sequence of applications of knowledge or skill, and doing so on numerous occasions (where the number of such exposures would likely be directly related to the anticipated actual complexity of the circumstance) the person will have been provided a method for recalling, reflecting on, and choosing to act – or potentially selecting the specific action to be taken from a sequence of potential actions previously seen and “practiced” – on which the decision to act can be relied upon to be applicable with a reasonable expectation of a satisfactory outcome.
Clearly, structuring the opportunities for exposure to critical circumstances in a non-threatening environment, will allow this person to more logically, more quickly, and more confidently recall and select the most logical sequence of actions to neutralize any potential threat or problem when or if something like that should occur. Contrary to the supposition presented, the specific requirement is for detailed responses based on observed circumstances, and relying on “generalities” is, at best, a recipe for failure.
There is no universal ‘Truth’, only those local truths formed by individual perception; e.g. the truth of how the Asiana crew perceived the approach vs our truth of the event with hindsight.
The difference between College Professors and Pilots involves theory vs practice. Scientific truths are formed because they can be repeated, checked, and verified; in aviation you only get one attempt at an approach in specific (non repeatable) circumstances.
If only we could revisit the circumstances of our last error; instead we have to rely on learning how to avoid the next adverse situation from the results of the previous one.
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Instruments and controls in airliners are so well designed, under lab conditions, that under a normal workload pilots can monitor and attend most of them and perform all other required tasks.
When the workload of the "other tasks" goes though the roof, that is when we find out which instruments and controls are badly designed.
When the workload of the "other tasks" goes though the roof, that is when we find out which instruments and controls are badly designed.
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When the workload of the "other tasks" goes though the roof,
For some even nice sunny weather, perfectly functioning aircraft and they are already perspiring. Imagine their workload when this aircraft was actually malfunctioning ...
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... which instruments and controls are badly designed.
Surely (if this is the case) many 777 pilots must have filed complains about this difficult and confusing machine following countless 1000's of flights and landings.
Are any such reports available?
Are any such reports available?
Firstly, and as I have been saying for several weeks now, the pilots, under normal and low workloads, don't notice how poorly the airspeed is communicated via the tape.
It is only when the stress and work load starts to get up towards the "emergency" levels that the brain, in a process similar to "task shedding", starts to avoid referring to the airspeed tape. This is because of how much brain power is required to use the tape.
So, for 99.95% of flights, everything in the cockpit is too relaxed, and the pilots just don't notice the problem.
Secondly, on those rare occasions when the crisis level has gotten into, or close to the emergency levels, the pilots, for the reason given above, don't refer to the airspeed.
This means that, if they survive the emergency, they have no recollection at all of what the airspeed was doing during the critical moments. They can't then file a report about it, because it's as though it never happened.
Of the 4 stall-crashes to passenger aircraft since 2009 (all to aircraft with the speed tape), 5 of the pilots survived. If they were questioned as to their recollections of the airspeed, you would find them giving only a blank look.
This should answer your question as to why there are not thousands of reports about the inadequacy of the airspeed tape.
Last edited by FGD135; 19th Aug 2014 at 05:11.