Recommendation R19980037

Recommendation issued to: Civil Aviation Safety Authority

Recommendation details
Output No: R19980037
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:

Review their standard operating procedures (SOP) and airline policy to require only one crew member to make control inputs at any one time unless stated to the contrary in an emergency/abnormal procedure, and to emphasise the consequences of multiple simultaneous flight control inputs.

Initial response
Date issued: 27 November 1997
Response from: Civil Aviation Safety Authority
Action status: Closed - Accepted
Response text:

CASA has reviewed the Operational Standard "Simultaneous Opposite Direction Operations" as you have recommended.

Following Occurrence 9700052 on 5 January 1997 the instructions in AIP OPS paragraph 19.4 were changed by NOTAM to require pilots to remain on Tower frequency until instructed to change, thus enabling Tower to correct the kind of confusion evident during the occurrence. The amendment will be correctly inserted into the AIP OPS text by AIP Amendment List 20, effective 4 December 1997.

Given the change to procedures our conclusion is that the standard expressed in the CASA Manual of Operational Standards (MOS) Part 3 Chapter 5.9 is adequate.

The MOS standard will be further reviewed in the light of any study which may be undertaken by Airservices in response to your recommendation R970150.

After dispatching a copy of the [name supplied] report to CASA the following response was received on 28 Aug 1998:

The letter requests a formal CASA response to the recommendations in a report attributed to [name supplied]. It cites the CASA/BASI MOU as the basis for advice of actions CASA intends to take in response to those recommendations.

It is our belief that this request is not consistent with the MOU between our two organisations. That MOU lays out a basis for CASA to respond to safety deficiencies identified by BASI and recommendations made by BASI to rectify those deficiencies. It does not require CASA to address recommendations made by a third party.

It was our understanding that BASI would be forwarding a draft investigation report to CASA for comment. That report would be along the lines of the outline we had informally discussed early in July, and would at your discretion incorporate such findings of the Gleave report as you saw fit. We would of course be pleased to provide comment on such a report and indicate actions taken or planned to address any recommendations the Bureau may choose to make. We are, as you know, already addressing a number of the issues discussed at our meeting in July. If you have any questions on this issue please don't hesitate to call.

Last update 01 April 2011