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What is the data telling us? - Coggle Diagram
What is the data telling us?
75% of Cruise Leg incidents involved a sudden Autopilot disconnection or auto flight malfunction which was responded to by an inappropriate manual handling occurrence
Automation surprise?
63% of cruise leg reports end up with a fatality
Mode Awareness - Surprise - Manual Takeover - Degraded Manuel skills - accident
Approach and descent account for the most of our accidents with 15 and 8 cases respectively.
6 fatal accidents occurred on approach, all 6 involved the ongoing theme of complacency.
Approach and descent is the highest workload phase, with less time to recover if things go wrong
8 of 14 approach accidents occurred during the night, 5 of 8 cruise accidents occurred at night
81% of cases where decision making skills are a factor it is night time
75% of the time when decision making skills are a factor, so is SA
Are we more reliant on technology at night to make decisions for us?
Computer skills over flying skills and situational awareness were the most frequently occurring themes.
70% of accidents involving SA also included lack of manual flying kills
Further focus on manual flying skills could lead to reduced accidents as there is a clear link between the inability to fly the plane manually when automation data output is incorrect
Mode awareness (12), Degraded Manual Skills (8) and Degraded Situational awareness (4) are the three most common responses to a trigger.
67% of mode awareness instances arise from an incorrect data input, 63% of Degraded manual skills are due to an incorrect data input while 75% of SA accidents are from an incorrect data output.
75% of mode awareness incidents/accidents occur during the descent/approach phase.
75% degraded SA incidents occur in the approach
Mode awareness and SA (and their impacts) can be linked to the 'surprise' effect
Mode Awareness occurs most commonly on the approach / descent phase (9/12 cases).
Why? Mode awareness not a problem in the cruise as nothin is happening/modes staying constant
Mode awareness only occurs in the cruise 3/12 cases
Strong relationship of Mode awareness incidents associated with computer skills over flying skills, situational awareness and complacency
10 of 12 mode awareness accidents/incidents involve comp skills over flying skills.
10 of 12 reports where mode awareness is seen as a factor, situational awareness is also seen as a factor
Mode awareness can be heavily linked to situational awareness as they are definitively similar - mode awareness relating specifically to the computer and situational awareness relating to the pilots perception of his/her environment
8 of 12 mode awareness accidents/incidents involve complacency
Majority of incidents occurred due to abnormalities within the cockpit (ie. AP or GS failure)
On top of this, several incidents then lead onto flight crew's lack of knowledge of automation systems
Not completely removing complacency and decision making but explain why others are more important
Emphasis more on mode awareness, automation surprise, etc