Operational Use of Flight Path Management System. Final Report
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September 8, 2013 Ms. Margaret Gilligan Associate Administrator for Aviation Safety Federal Aviation Administration 800 Independence Avenue SW Washington, DC 20591 Dear Peggy, On behalf of the PARC, I am pleased to provide the recommendations of the Flight Deck Automation Working Group. The PARC Steering Group and the Commercial Aviation Safety Team (CAST) established this joint working group to address, for current and projected operational use, the safety and efficiency of modern flight deck systems for flight path management (including energy-state management). The Working Group analyzed safety and operational data to fulfill its tasking. It generated 29 findings and 18 recommendations that are documented in the final report in the attachment. The findings address: Many of the sources of safety and operational risk mitigation in the current aviation system; Equipment design, pilot training and qualification, and airspace operations; and Lessons learned from the analyses of different sources of safety and operational data. The report provides recommendations to address the findings in each of these areas. The findings and recommendations are summarized in the Executive Summary of the attached report. This material represents years of effort by the working group and is a significant body of work that should be invaluable to the FAA moving forward. The PARC expects this to have a positive effect on the aviation community through improved guidance material and policy for aircraft systems, training and flight operations. The PARC is thankful for the effective leadership provided by Kathy Abbott, Dave McKenney, and Paul Railsback in their efforts leading the Flight Deck Automation Working Group through the extensive coordination efforts with CAST in finalizing the report and recommendations. Please do not hesitate to contact me if you have any questions. Sincerely, Dave Nakamura Chairman Performance-based operations Aviation Rulemaking Committee Cc: PARC members David McKenney Paul Railsback This page intentionally left blank Report of the PARC/CAST Flight Deck Automation WG This page intentionally left blank Page ii Table of Contents 1 Executive Summary .....................................................................................................1 2 Introduction................................................................................................................11 2.1 Background........................................................................................................11 2.2 Tasking of This Working Group ........................................................................13 2.3 Methods, Processes and Sources of Data...........................................................14 3 Findings and Observations.........................................................................................21 3.1 Technical and Operational Environment – Changes .........................................21 3.2 Operational Experience: Results from the Front Line .......................................29 3.2.1 Pilots Mitigate Risk..................................................................................... 29 3.2.2 Manual Flight Operations ........................................................................... 31 3.2.3 Managing Malfunctions.............................................................................. 34 3.2.4 Pilot Use of, and Interaction with, Automated Systems ............................. 36 3.2.5 Communication between Pilots in a Flightcrew ......................................... 44 3.2.6 Communication between Flightcrews and Air Traffic Services ................. 48 3.3 Flight Operational Philosophies, Procedures and Policies ................................53 3.3.1 Flightcrew Procedures – Standard Operating Procedures .......................... 53 3.3.2 Policies for use of Flight Path Management Systems ................................. 55 3.4 Task/Workload Management .............................................................................57 3.4.1 Prioritization of Tasks................................................................................. 58 3.4.2 Workload Management ............................................................................... 59 3.4.3 Information Management ............................................................................ 60 3.4.4 Time Management ...................................................................................... 60 3.4.5 Allocation of Tasks between Pilot Flying and Pilot Monitoring ................ 61 3.4.6 Future Considerations ................................................................................. 62 3.5 Pilot Knowledge and Skills ................................................................................63 3.5.1 Vulnerabilities in Pilot Knowledge and Skills ............................................ 63 3.5.2 Pilot Training and Qualification ................................................................. 68 3.5.3 Instructor Training and Qualification ......................................................... 75 3.5.4 Other Factors and Future Considerations ................................................... 76 3.6 Flight Deck Equipment Design ..........................................................................77 3.6.1 Equipment Design Complexity and Integration ......................................... 77 3.6.2 Equipment Design Standardization............................................................. 79 3.6.3 Flight Deck System Design Processes ........................................................ 81 3.7 Air Traffic and Airspace Considerations ...........................................................86 3.7.1 Airspace/Air Traffic Procedures ................................................................. 86 3.7.2 Air Traffic Personnel .................................................................................. 90 3.8 Regulators’ Knowledge, Skills and Processes ...................................................91 3.9 Data Collection and Analysis.............................................................................95 3.9.1 Data Availability......................................................................................... 95 3.9.2 Data Sources ............................................................................................... 97 3.9.3 Data Organization, Analysis, and Use ........................................................ 99 4 Recommendations....................................................................................................107 Page iii Report of the PARC/CAST Flight Deck Automation WG 5 Concluding Remarks ................................................................................................129 Acronyms and Abbreviations ..........................................................................................131 Appendix A Terms of Reference .....................................................................................133 Appendix B Topics for Discussion with Manufacturers and Operators ..........................135 Appendix C Keywords used for ASRS Event Retrieval..................................................141 Appendix D Accident and Major Incident Reports Used in Flight Deck Automation Working Group Analyses................................................................................................................143 Appendix E Bibliography ................................................................................................171 Appendix F Categorization Scheme for Reviewing Accident and Incident Data ...........179 Appendix G Results of Analyses .....................................................................................191 Working Group Process...............................................................................................191 Accidents, Major Incidents, ASRS Incidents, and LOSA Data ...................................195 ASRS Incident Factor Analyses...................................................................................228 Accident/Major Incident Factor Analysis ....................................................................230 Co-Occurrence Analyses .............................................................................................231 LOSA Analysis ............................................................................................................233 Appendix H Status of Recommendations in 1996 FAA report on the Interfaces between Flightcrews and Modern Flight Deck Systems ................................................................243 Page iv List of Figures Figure 1. Overall Tasking of the Flight Deck Automation Working Group. ............................... 15 Figure 2. US Aircraft Fleet Growth. ............................................................................................. 23 Figure 3. Growth in US TRACON Operations............................................................................. 23 Figure 4. Growth in US Air Carriers International Available Seat Miles (ASM) by Region....... 24 Figure 5. NextGen Summary. ....................................................................................................... 26 Figure 6. Evolving Pilot Knowledge and Skills............................................................................ 27 Figure 7. Manual Handling/Flight Control Errors. ....................................................................... 32 Figure 8. Aircraft Malfunctions.