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Recommendation issued to: Civil Aviation Safety Authority

Recommendation details
Output No: R19980029
Date issued: 12 June 1998
Safety action status:
Background:

SUBJECT

The Advanced Technology Aircraft Survey - Phase Two


OBJECTIVES

The objectives of the phase 2 study were to:

Determine specific types of human/system interface problems that are occurring on advanced aircraft in service within the Asia-Pacific region;
Collect information on flight-deck errors;
Assess the severity of errors;
Identify design-induced errors; and
Identify areas where pilots inappropriately manipulate automated systems.


SCOPE

The report dealt with information supplied by respondents to the Advanced Technology Aircraft Safety Survey and provided a detailed analysis of the answers to both the 'open' and 'closed' questions.

The accompanying analysis did not include the responses to closed questions by Second Officers or McDonnell Douglas pilots due to their disproportionately low representation within the sample. However, all written comments made by all respondents have been included and analysed.

The survey covers a range of technologies from the early 1980s to the present. However, the survey sought pilots' perceptions of the technology that they were using. Despite any differences in technology, the Bureau believes that the survey results are applicable to aviation in the Asia Pacific region.


SUMMARY OF RECOMMENDATIONS

Introduction

The following recommendations are organised according to their corresponding chapter. Where applicable recommendations have been address to:

Airservices Australia;

The Civil Aviation Safety Authority (Australia);

Aircraft design authorities; and

Airlines within the Asia-Pacific region.

However, this does not restrict the applicability of the recommendation to the above mentioned agencies. BASI encourages foreign agencies, both government and civil, to adopt all, or any, of the following recommendations in the interests of improving aviation safety throughout the international aviation industry.

The objectives of this project are largely proactive. Our task has been to determine specific errors and assess the severity of those errors. Consequently some of the following recommendations are phrased in a proactive sense. Regulatory authorities, aircraft manufacturers and airline operators are now required to do the same, basing their response on the evidence provided by 1268 pilots, many of whom are line pilots with considerable experience. Our concern is that appropriate mechanisms and mindset are not yet in place to assess proactive recommendations. This is the greatest challenge currently before the aviation industry.

List of Relevant Recommendations by Report Chapter:

1. Air Traffic Control

R980024 to Airservices Australia
R980025 to the Civil Aviation Safety Authority
R980026 to airline operators within the Asia-Pacific Region

2. Automation

R980027 to airline operators within the Asia-Pacific Region

3. Crew Resource Management

R980028 to airline operators within the Asia-Pacific Region

4. Flying Skills

R980029 to the Civil Aviation Safety Authority

5. General

R980030 to The Civil Aviation Safety Authority
R980031 to airline operators within the Asia-Pacific Region
R980032 to design authorities and airline operators within the Asia-Pacific Region

6. Modes

R980033 to aircraft design authorities
R980034 to airline operators within the Asia-Pacific Region
R980035 to the Civil Aviation Safety Authority

7. Situational Awareness

R980036 to airline operators within the Asia-Pacific Region

8. System design

R980037 to airline operators within the Asia-Pacific Region
R980038 to aircraft design authorities


9. Training

R980039 to the Civil Aviation Safety Authority
R980040 to airline operators within the Asia-Pacific Region

Output text

The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority:

Ensure that all recurrent and rating renewal simulator exercises are appropriate considering the level of automation fitted to the aircraft type. Such exercises should reflect the level of serviceability which the pilot may be expected to encounter during line operations.

Initial response
Date issued: 16 April 1999
Response from: Civil Aviation Safety Authority
Action status: Closed - Partially Accepted
Response text:

Before responding to specific recommendations, the following general comments are offered.

As a result of the survey, BASI has made numerous recommendations to airlines and aircraft design authorities as well as CASA and Airservices. Some seem to be rather utopian, in that they may be beyond current capabilities in automation. Nevertheless, it is important that perceived deficiencies are documented and that the various agencies concerned are alerted.

As far as the recommendations made to CASA are concerned, I am having difficulty as to CASA's ability to come to terms with some of the fundamental problems identified. One of the drawbacks of CASA's move more towards an auditing function is a lessening of the intimate knowledge that we previously had of particular operators. Further, as the CASA legislative framework moves towards less prescriptive legislation, it may be more difficult to manage to the degree suggested in some of the BASI identified issues. The content of simulator exercises along with the detailed qualifications and recency of instructors are examples.

Recommendation R980029. "The Civil Aviation Safety Authority ensure that all recurrent and rating renewal simulator exercises are appropriate considering the level of automation fitted to the aircraft type. Such exercises should reflect the level of serviceability which the pilot may be expected to encounter during line operations".

CASA Response

The requirements specified in Civil Aviation Regulations and Civil Aviation Orders for flight reviews and ratings are normally met by the airline CAR 217 check and training organisation being approved by CASA to institute a cyclic training program. This is a matrix of ground, flight and simulator training exercises which covers all regulatory requirements. It includes the syllabus of training and the standards to be achieved, and forms part of the approved Training and Checking ManuaL

CASA has some reservations as to mandating that all simulator exercises reflect the automation features available. Operators vary in their approach to automation, with some requiring manual flight and the use of raw data during certain manoeuvres. The CASA assessment of simulator exercises is a quality check to ensure that the overall program covers the syllabus and that the end product achieves the regulatory requirement. Obviously, an exercise which is manifestly inappropriate in the use of automation would not be approved. As to exercises reflecting the serviceability expected during line operations, the reality is that the simulator presents the only means of practicing many abnormal procedures which may arise from failures which occur infrequently. It would not be productive to limit exercises to the everyday aircraft serviceability rate.

ATSB response:

Portion of letter dispatched to CASA on 19 November 1999:

"R980029 - The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority:

Ensure that all recurrent and rating renewal simulator exercises are appropriate considering the level of automation fitted to the aircraft type. Such exercises should reflect the level of serviceability which the pilot may be expected to encounter during line operation

Response classification: OPEN

The Bureau does not consider that the CASA response adequately addresses this recommendation. The response appears to ignore proposed changes to the regulatory framework, specifically:
1. CASR 61 - Pilot Licences;
2. CASR 121 - Commercial Air Transportation (Aeroplanes);
3. CASR 133 - Commercial Air Transportation (Rotorcraft); and
4. CASR 135 - Air Transport Operations - <10 seats

CASA stated that "It would not be productive to limit (simulator) exercises to the everyday aircraft serviceability rate". The Bureau's recommendation does not propose to limit the exercises as such, but proposes that they "should reflect the level of serviceability which the pilot may be expected to encounter during line operations".

CASA also stated that its assessment of simulator exercises is a "quality check to ensure that the overall program covers the syllabus and that the end product achieves the regulatory requirement". However, the response did not:
1. make any reference to CRM training, as proposed in Subpart N of CASR 121A;
2. address the considerations relating to advanced technology aircraft in respect to Subpart E of CASR 121A - All Weather Operations;
3. address how such syllabi shall be formulated under the proposed CASR 61, 121, 133 or 135;
4. address the proposal to mandate (operators') Quality Systems under CASR 121A.035, which refers to CASR 119.05; and
5. address how it intends to define objective training standards under the proposed CASR's (61 and subpart N of 121A).

The Bureau therefore requests that CASA further review R19980029 in light of the above comments and provide the Bureau with a further response as soon as practical.

Further responses, as indicated, to the above recommendations are requested at your earliest convenience. In addition, for the purpose submitting a clear indication of whether CASA accepts, partially accepts or rejects recommendations made by the Bureau, it would be appreciated if a clear statement to this effect could be made on each recommendation before any further comment is offered. Guidance on this protocol can be found in the current Memorandum of Understanding between CASA and the Bureau."

 
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Last update 01 April 2011