Table Judged Reasons for Failure in Events Cited 22 XIV




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U.S. Department

of Transportation


Research and Innovative Technology

Administration


Volpe National Transportation

Systems Center


A Review of Human-Automation Interaction Failures and Lessons Learned





NASA Airspace Systems Program


Final Report

October 2006


Thomas B. Sheridan and Eric D. Nadler



Notice

This document is disseminated under the sponsorship of the Department of Transportation in the interest of information exchange. The United States Government assumes no liability for its contents or use thereof.




Notice

The United States Government does not endorse products or manufacturers. Trade or manufacturers’ names appear herein solely because they are considered essential to the objective of this report.








TABLE OF CONTENTS

Table 1. Judged Reasons for Failure in Events Cited 22 xiv

Table 1. Judged Reasons for Failure in Events Cited 22 xiv

1.0 INTRODUCTION AND SCOPE 1

2.0 FAILURE EVENTS INVOLVING AIRCRAFT 3


2.1 Korean Airlines Flight 007 747 Shot Down by Soviet Air Defense Command (flaw in mode indication) 3

2.2 China Airlines 747 Engine Malfunction Near California (over-reliance on autopilot after fatiguing flight) 3

2.3 Simmons Airlines ATR-72 Crash Near Chicago (icing disengaged autopilot, surprise manual recovery failed) 4

2.4 Lockheed L-1011 Crash Over the Florida Everglades (automation state change not communicated to pilot) 4

2.5 A300 Accident Over the Florida Coast (state transition not communicated to pilot) 4

2.6 A300 Crash in Nagoya (pilot misunderstanding of how automation worked) 5

2.7 Non-identified General Aviation Crash (pilot impatience, lack of training or judgment) 5

2.8 American Airlines B-757 Crash Over Cali, Columbia (confusion over FMS waypoint codes) 6

2.9 A320 Crash in Bangalore, India (control mode error, misunderstanding the automation) 6

2.10 Aero Peru 613 Crash (pitot tubes taped for painting: sloppy maintenance, poor inspection by pilot) 7

2.11 2002 Midair Collision Over Uerberlingen, Germany (pilot decision to follow ATM advice rather than TCAS resolution advisory) 7

2.12 2004 Roller Coaster Ride of Malaysia Airlines B777 (unanticipated software failure) 8

2.13 October 2005 British Airways A319 Electronics Failure (unanticipated and unreplicated software problem) 8

2.14 Embraer Test Flight: One-Minute Blackout of Computer Displays (presumably due to a software glitch) 8

2.15 2003 Crash of Air Midwest/U.S. Airways Express Beech 1900D (shortcutting of required maintenance procedures) 8

2.16 John Denver Crash into the Pacific (cutting corners in manufacture, poor human interface) 9

2.17 U.S. Soldier in Afghanistan Inadvertently Calls for Air Strike on Own Position (ignorance of reset operation) 9

2.18 Loss of Black Hawk Helicopters to Friendly Fire (ill-defined procedures and traffic management responsibilities) 9

2.19 Upset in Descent of NASA M2F2 Lifting Body (design led to pilot control reversal) 10

2.20 Concorde Crash Precipitated by Runway Debris (control tower automation may reduce controller vigilance of airport surface) 10
  1   2   3   4   5   6   7   8   9   ...   18

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