Federal Aviation Administration Human Factors Team The Interfaces Between Flightcrews and Modern Flight Deck Systems June 18, 1996 Federal Aviation Administration Human Factors Team Report on: The Interfaces Between Flightcrews and Modern Flight Deck Systems June 18,1996 Foreword On April 26, 1994, an Airbus A300-600 operated by China Airlines crashed at Nagoya, Japan, killing 264 passengers and flightcrew members. Contributing to the accident were conflicting actions taken by the flightcrew and the airplane's autopilot. The crash provided a stark example ofhow a breakdown inthe flightcrew/automation interface can affect flight safety. Although this particular accident involved an A300-600, other accidents, incidents, and safety indicators demonstrate that this problem isnot confined to any one airplane type, airplane manufacturer, operator, or geographical region. This point was tragically demonstrated by the crash ofa Boeing 757 operated by American Airlines near Cali, Columbia on December 20,1995, and aNovember 12,1995 incident (very nearly a fatal accident) in which an American Airlines Douglas MD-80 descended below the minimum descent altitude on approach to Bradley International Airport, CT, clipped the tops oftrees, and landed short ofthe runway. As aresult of the Nagoya accident, as well as other incidents and accidents that appear to highlight difficulties in flightcrews interacting with flight deck automation, the FAA's Transport Airplane Directorate, under the approval ofthe Director, Aircraft Certification Service, launched a study to evaluate the flightcrew/flight deck automation interfaces of current generation transport category airplanes. This report isthe culmination ofthat study. Pagei Repon ofthe FAA Human Factors Team This page intentionally leftblank Page ii Preface from the Co-Chairpersons This report is the result ofastudy of the interfaces between the flightcrew and the automated systems on highly automated airplanes. It primarily focuses on the interfaces that affect flight path management. The report was produced by ateam ofhighly qualified individuals from the FAA and the European Joint Aviation Authorities, assisted by expert technical advisors from the Ohio State University, the University ofIllinois, and the University ofTexas. The co-chairs would like to commend their fellow team ' members and technical advisors for their special efforts, recognizing that everyone involved had to fit this extensive study into already difficult schedules. We also wish to thank the manufacturers, operators, pilots' associations, and researchers who met with us for supporting this important safety initiative. ^^VgE^r ^^/pjfcr! Dr. Kathy Abbott Stephen M. Slotte Co-chair, Donald K. Stimson Co-chair, Co-chair, Human Factors Team Human Factors Team NASA Human Factors Team FAA FAA Pageiii Reportofthe FAA Human Factors Team This page intentionally left blank Page iv FAA Human Factors Team Co-Chairpewniw Katfay Abbott -"Donald Stimson National Aeronautics and Federal Aviation Administration SpaceAdministration Stephen Slotte FederalAviation Administration Federal Avfattan AHminhh—frn GeneBollin RodLalley J Sharon Hecht George Lyddane » Thomas Imrich GuyThielThtel I Joint AvhtlnH AirthnrHto. r*N«*s9*i^' Dr. Ron Pearson FrancoisFfcre. HeerfTigchelaar At«^ TenyNewman ElMrt TVrtmfc.1 AJvfanr. QX£j^£L Dr. Nadine Salter Dr. David Woods University ofIllinois , -. Ohio State University Dr. Robert Hehnreich University•oTTexas Pagev Acknowledgments The Human Factors Team thanks the many companies, organizations, and individuals who made valuable contributions to the successful completion of this study. Without their willing cooperation and desire to increase the safety of air transportation, this report would not have been possible. Specifically, the Team would like to express our gratitude to the following companies and organizations, and the individuals from these companies and organizations who participated in this study: Air France, Airbus Industrie, Airline Pilots Association, American Airlines, Allied Pilots Association, Air Transport Association of America, Boeing Commercial Airplane Group, British Airways, Crew System Ergonomics Information Analysis Center, Direction Generale de TAviation Civile (France), Douglas Aircraft Company, Federal Aviation Administration, European Joint Aviation Authorities, Fokker Aircraft B.V., Honeywell, Japan Civil Aviation Bureau, National Aeronautics and Space Administration, National Transportation Safety Board, Rijksluchtvaartdienst (Netherlands), Royal Aeronautical Society/Guild ofAir Pilots and Air Navigators, United Air Lines, and the United Kingdom Civil Aviation Authority. In addition, the Team members wish to acknowledge the contributions made towards this effort bythe following individuals: Terence Abbott David Foyle William Rogers Doug Arbuckle Richard Gifford Vic Riley Charles Billings Howard "Berk" Greene Marianne Rudisill Monica Burgess Forrest Keller Paul Schutte Katherine Burks VictorLebacqz Tim Seeley Sandi Carli AlanMidkiff David Simmon Susan Corny Kandy Mulrony Michael Shafto Bill Corwin Ev Palmer Rose Upton Sheryl Chappell Michael Palmer Earl Wiener Noel Duncan Peter Poison Lynn Williams Sharon Flint We would also like to acknowledge the anonymous independent reviewers ofinitial drafts ofthis report for their valuable input. Pagevi Contents Executive Summary , Abbreviations 15 Introduction 17 Overview ofFindings 23 Measurement ofand Incentives for Safety 27 Flightcrew Management and Direction ofAutomation 33 Flightcrew Situation Awareness 43 Communication and Coordination 57 Processes for Design, Regulatory, and Training Activities 81 Criteria, Regulatory Standards, Methods, and Tools for Design and Certification...95 Knowledge and Skills ofDesigners, Pilots, Operators, Regulators, and Researchers ,q. Cultural and Language Differences 117 Potential Barriers to Implementation ofthe Recommendations 123 Follow-On Effort and Implementation ofthe Recommendations 127 Concluding Remarks 131 Appendices Appendix A: Human Factors Team Charter Statement A-l Appendix B: Matrix ofIssues and Recommendations B-l Appendix C: Supporting Data and References C-l Appendix D: Examples ofIncidents and Accidents Involving the Flightcrew- Automation Interface rj.] Appendix E: Existing FAR Part 25 Regulations and Advisory Circulars Related toHuman Factors E_l Appendix F: Excerpts from the Aviation Safety Reporting System F-l Appendix G: Questions Use to Guide Discussions with Manufacturers and Operators q_I Pagevii Figures Figure 1 Interrelationships Between Issues and the Means to Address those Issues 19 Figure 2 Representation ofAutoflight Modes Displayed on Boeing Model 747-400 Primary Flight Display 45 Figure 3 Mode Selector Panels. .51 Figure 4 Takeoff/Go-Around and Autothrottle Quick Disconnect Switch Locations 54 Figure 5 Sample of Various Formatting Conventions for aGiven Geographic Fix 55 Figure 6 Example Design Process Incorporating Human Factors Design Principles 91 Figure 7 Proposal for FAA Human Factors Team Follow-on Effort 129 Page viii Executive Summary Advances in technology have enabled increasingly sophisticated automation to be introduced into the flight decks ofmodern airplanes. Generally, this automation was added to accomplish worthy objectives such as reducing flightcrew workload, adding additional capability, or increasing fuel economy. To alarge extent, these objectives have been achieved. Safety also stood to benefit from the increasing amounts ofhighly reliable automation. Indeed, the current generation ofhighly automated transport category airplanes has generally demonstrated an improved safety record relative to the previous generation ofairplanes. Vulnerabilities do exist, though, and further safety improvements should be made. To provide asafety target to guide the aviation industry, the Secretary of Transportation and others have expressed the view that the aviation industry should strive forthe goalofzero accidents. On April 26,1994, an Airbus A300-600 operated by China Airlines crashed at Nagoya, Japan, killing 264 passengers and flightcrew members. Contributing to the accident were conflicting actions taken by the flightcrew and the airplane's autopilot The crash provided astark example ofhow abreakdown in the flightcrew/automation interface can affect flight safety. Although this particular accident involved an A300-600, other accidents, incidents, and safety indicators demonstrate that this problem is not confined to any one airplane type, airplane manufacturer, operator, or geographical region. This point was tragically demonstrated by the crash ofaBoeing 757 operated by American Airlines near Call, Columbia on December 20,1995, and aNovember 12,1995 incident (very nearly afatal accident) in which aAmerican Airlines Douglas MD-80 descended below the minimum descent altitude on approach to Bradley International Airport, CT, clipped the tops oftrees, and landed short ofthe runway. As aresult ofthe Nagoya accident as well as other incidents and accidents that appear to highlight difficulties in flightcrews interacting with the increasing flight deck automation, the Federal Aviation Administration's (FAA) Transport Airplane Directorate, under the ' approval ofthe Director, Aircraft Certification Service, launched astudy to evaluate the flightcrew/flight deck automation interfaces ofcurrent generation transport category airplanes. The following airplane types were included inthe evaluation: Boeing: Models 737/757/767/747-400/777 Airbus: Models A300-600/A310/A320/A330/A340