Recommendation R19980031

Recommendation issued to: Airline Operators Asia-Pacific Region

Recommendation details
Output No: R19980031
Date issued: 12 June 1998
Safety action status:


The Advanced Technology Aircraft Survey - Phase Two


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.


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.



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 airline operators:

1. Include in the ground training phases of pilot endorsement courses;

(a) sufficient technical knowledge of aircraft systems; and

(b) knowledge of the design philosophies employed by aircraft system manufacturers

to give pilots sufficient systems understanding to permit analysis of system abnormalities and to determine appropriate responses in situations for which checklists are not available.

2. Consider the safety lessons from discussions of incident and accident scenarios during all initial, recurrent and CRM training programs.

Initial response
Date issued:
Response from: Airline Operators Asia-Pacific Region
Action status: No Response
Response text:
ATSB response:

ATSB Note: As this recommendation was not issued to any specific organisation, no response was expected.

Last update 01 April 2011