AF447 Analysis II: Tales of the Unexpected

Aimée Turner reports on the growing dependence on computer systems and asks whether they are leading to ‘automation addiction’ in the cockpit
The issue of pilots’ ability to respond to the unexpected loss or malfunction of automated aircraft systems has continued to creep up the agenda.
Following an investigation of the Colgan Air Flight 3407 crash near the US city of Buffalo in 2009, the co-pilot was found to have punched in incorrect information into the aircraft’s computers which led to it slowing to an unsafe speed, triggering a stall alert.

Read more in our AF447 Dossier

The captain failed to react in the proper manner which was to decrease the angle-of-attack when the stick shaker activated. Instead, following the activation of both the stick shaker and the stick pusher, he countermanded by pulling back on the stick, which tipped the aircraft into an aerodynamic stall.
The report by the National Transportation Safety Board stated that ‘his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion. It is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery’.
Investigators found there were no mechanical or structural problems that would have prevented the aircraft from flying had the captain responded correctly.
Last year, French air accident investigators at the Bureau d’Enquetes et d’Analyses announced it was setting up a human factors working group following the fatal crash of Air France AF447 flying from Brazil to Paris in June 2009.
Pilot Confusion
In that accident, airspeed sensors were found to have fed wrong information into the aircraft’s computer, causing the autopilot to disengage suddenly and a stall warning to activate. Confused, thepilot at the controls pointed the aircraft’s nose up, actually causing the stall instead of preventing it.
The working group was charged with examining the conduct of the flight including the actions and reactions of the crew during the three last phases of flight, cockpit ergonomics and man-machine interfaces.
One of the interim actions during the investigation, however, was the recommendation by the BEA team that all pilots receive mandatory training in manual flying and handling a high-altitude stall.
A seminal report by an advisory committee of the US Federal Aviation Administration indicated growing concern within the aviation safety community over the lack of opportunity to maintain manual flying skills in today’s commercial airline environment.
The draft study is cited as finding pilots liable to ‘abdicate too much responsibility to automated systems’.
The study has reportedly examined 46 accidents and major incidents, 734 voluntary reports by pilots and others as well as data from more than 9,000 flights in which a safety official observed pilots in action. It is understood it will conclude that in more than 60 per cent of accidents, and 30 per cent of major incidents, pilots either struggled with manual flight operations or made mistakes with automated flight controls.
Typical mistakes cited include failure to recognise whether the autopilot or the auto-throttle had disengaged while others involved pilots failing to recover from a stall in appropriate fashion in addition to failure to monitor and maintain airspeed.
The 2010 Flight Safety Foundation’s International Aviation Safety Seminar in Milan, Italy, heard how inadequate crew knowledge of automated systems featured as a factor in more than 40 per cent of accidents and 30 per cent of serious incidents between 2001-2009
Presenting progress in her research toward what will eventually become an update to the FAA’s 1996 landmark report on the interfaces between flightcrews and modern flight deck systems, FAA human factors specialist Dr Kathy Abbott spoke of the evidence she had gathered that indicated a worrying disconnect between crews and their highly automated aircraft.
She said that probable recommendations are likely to include improved training and standard operating procedures on flight path management; encourage pilots to distinguish between  guidance and control; encourage flight crews to tell air traffic they are ‘unable to comply’” when appropriate and to ensure that Standard Operating Procedures are tailored to operator needs. So, are pilots forgetting how to fly?
Reduced Ability
Bill Voss, president of the Flight Safety Foundation, is on record as saying the industry has been tardy in recognising that one of the consequences of automation is a reduced ability of to respond to the unexpected loss or malfunction of automated aircraft systems. It is, he believes, ‘the big issue that we can no longer hide from in aviation’.
In actual fact there will be even fewer places to hide once the air traffic management systems of both Europe and the US herald an irrevocable shift toward GPS navigation.
“Those procedures have to be flown with the autopilot on,” Voss has pointed out. “You can’t afford a sneeze on those procedures.”
Voss says airlines need to have a fundamental  rethink about their operations if pilot are to be give adequate opportunities to maintain their flying skills.
As Flight International operations and safety editor David Learmount notes: “In the last 20 years almost all the business, technical and operational ground rules governing commercial aviation have radically altered, forced by changes in the market, the air traffic management and navigation environment and aircraft and avionic technology. Logically, these demand a change in training – but that change has not been delivered.”
There has, he argues, been a loss of pilot exposure to ­anything other than pre-packaged flight planning, followed by automated flight.
“When ­circumstances are unusual or non-standard, lack of resilience can lead to fatal loss of control accidents, making loss of control the biggest killer accident category this century – taking over from controlled flight into terrain in the last.”
Speaking at the Flight Safety 2011 event in London, Captain Lloyd Watson, expressed the same sentiment. He is commercial director of the UK-based Oxford Aviation Academy’s type training division and a stern critic of a pilot training system which has not changed in any substantive form since the 1950s.
Fit For Purpose?
“Training is no longer fit for purpose in today’s highly automated environment and yet the only defence we have is training and procedures,” said Watson who pointed out that P-RNAV procedures have yet to feature on any current type rating syllabus, along with head-up guidance systems or economic operations.
He believes training to operate within the modern environment should feature much earlier in a pilot’s career and that it’s high time for an update of training needs analysis.
“The problem ultimately lies in meeting minimum requirements,” Watson told the conference, especially for the self-sponsored student who will only pay what he or she has to in order to secure the necessary credentials. “Newly qualified pilots just want to get the qualification and get on the job,” said Watson who sums up the paradox as thus: “Accountants want the least cost, holders of multi-crew licences (MPL) want minimum cost but the training heads of airlines, they want the highest standards.”
Curtis Graeber, a safety and human factors expert, agrees that the training costs of retaining hand flying skills in the pilot workforce are significant. “How do we preserve those skills? It is a real dilemma because the training cost of going into a simulator and practising all the things that might go wrong is really quite high and you have to ask yourself if the safety benefit really there?”
According to Learmount, resilience is not being delivered by today’s training systems, “The only pilots who have this quality tend to either have a military background or have been employed by an airline which has a selection procedure and recurrent training ­regime that goes well beyond the legal ­requirement – which most do not.”
With many military pilots with extensive manual flying experience choosing to stay in the armed forces, airlines are finding talent thin on the ground.
A strategy designed to maintain the skills of future employees is however taking shape, including ICAO’s next-generation aviation professionals (NGAP) and IATA’s training and qualification initiative (ITQI) that is expected to launch by the end of the year.
The European Aviation Safety Agency says its ­internal group on personnel training is ­developing an automation policy while ICAO is to publish its new training standards – ICAO Pans Training 2012 – along with a handbook of evidence-based training.
Learmount reports that hopes are pinned on four initiatives: the ITQI for type and recurrent training; the ICAO MPL for ab initio and evidence-based ­training; the RAeS ICATEE for unusual attitudes and extended envelope training and the RAeS/ICAO 9625 work on flight simulation training device qualification and standards to raise the integrity of training in simulators.