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Evidence for an Issue 22 pieces of evidence for this issue.

automation may be too complex (Issue #40) - Automation may be too complex in that it may consist of many interrelated components and may operate under many different modes. This makes automation difficult for pilots to understand and use safely.

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  2. Evidence Type: Excerpt from Observational Study
    Evidence: "As has been noted, today's tightly coupled automation systems have become extremely complex and in many cases, relatively opaque to their operators. At the same time, these systems have limits which may or may not be clear to their operators. An example of the problems that can be created is seen in this information, extracted form a 1991 incident report: 'Flight XXX departed on schedule; heavy rain and gusty winds were experienced on takeoff and during the departure. The climbout was normal until approximately FL 240 when numerous caution/warning messages began to appear, indicating a deteriorating mechanical condition. The first ... was OVHT ENG 1 NAC, closely followed by BLEED DUCT LEAK L, ENG 1 OIL PRESSURE, FLAPS PRIMARY, FMC L, STARTER CUT OUT 1, and others. #1 generator tripped off line and the #1 engine amber "REV" indication appeared. However, no yaw control problems were noted. The maximum and minimum speed references on the airspeed (tape) came together, followed by stick shaker activation. At approximately FL 260, the cabin was climbing rapidly and could not be controlled. The Captain initiated an emergency descent and turnback to the departure airport. The crew began to perform emergency procedures and declared an emergency. During the descent, the stick shaker activated several times but ceased below FL 200. Due to the abnormal flap indication and the #1 engine reverse, airspeed during the descent was limited to 260-270 knots. The Captain called upon the two augmented crew pilots to assst during the remainder of the flight. While maintaining control of the aircraft, he directed the first officer to handle ATC communications and to accomplish multiple abnomal procedures with the help of the additional first officer. The additional captain maintained communications with the lead flight attendant and company operations as the emergency progressed and later assisted in the passenger evacuation. Fuel dumping began on descent below 10,000 feet. The fuel jettison procedure was complicated as the left dump nozzle appeared inoperative. The crew dumped 160,000 lb of fuel; this action took about 40 minutes. When the fuel dumping was completed, the captain requested vectors for a 20 mile final for runway XX. The crew extended flaps early using alternate procedures due to an abnormal leading edge indication and the FLAPS PRIMARY message ... A final approach speed of Vref + 20 and 25 [degrees] of trailing edge flaps was planned. They selected auto brakes number 4. The weather was still bad with strong, gusty winds and heavy rain causing moderate turbulence during the approach. The ILS approach and landing were normal. At touchdown, maximum reverse was selected on #2 and #3 engines and about half reverse on #4 engine... As the aircraft passed a taxiway turnoff, the tower advised that they saw fire on the left side of the aircraft... This was the first time crew members were aware of any fire... A runway turnoff was used, and the aircraft stopped on a taxiway ... (a difficult but successful evacuation followed). This incident is an example of an electronic system 'nightmare'. The crew received and had to sort out 42 EICAS messages, 12 caution/warning indications, repeated stick shaker activation and abnormal speed reference information on the promary flight display. Many of these indications were conflicting, leading the crew to suspect number one engine problems when that engine was actually functioning normally. There was no indication of fire presented to the crew a fire actually existed...' " (page 155-156)
    Strength: +1
    Aircraft: unspecified
    Equipment: automation
    Source: Billings, C.E. (1996). Human-Centered Aviation Automation: Principles and Guidelines. NASA Technical Memorandum 110381. National Aeronautics and Space Administration. See Resource details

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  4. Evidence Type: Excerpt from Survey
    Evidence: Moreover, it is essential to be able to develop a good understanding of the characteristics and functions of other collaborators (e.g. what they can do, how they do it; how they are structured; what they cannot do). Whilst the behaviour of the computer-based systems may make perfect sense to the automation logic, it does not necessarily to the pilots: … P1: “There is one area on the 777 ... to do the VNAV approach they want you to open the speed window again. So it’s in VNAV and you open the speed window to manually set the speed, as soon as you put VNAV, the thing blanks, the speed bug jumps, it usually goes back to a lower speed ... and then you have to open it again and as soon as you open it, it’s back to whatever speed, and you watch the throttles come back. It’s messy. (page 4)
    Strength: +1
    Aircraft: B777
    Equipment: FMS VNAV
    Source: Bruseberg, A., & Johnson, P. (2004). Should Computers Function as Collaborators?. In Proceedings of HCI-Aero 2004 held in Toulouse, France September 29, 2004 to 1 October 2004. See Resource details

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  6. Evidence Type: Excerpt from Survey
    Evidence: Moreover, it is essential to be able to develop a good understanding of the characteristics and functions of other collaborators (e.g. what they can do, how they do it; how they are structured; what they cannot do). Whilst the behaviour of the computer-based systems may make perfect sense to the automation logic, it does not necessarily to the pilots: … P2: “You have situations where ... you get close to the airport and the controller now vectors you ... the guy says when you’re established give me a call... [when going] from heading back to NAV ... all that happens is that the plane swings round and it is going back to where is was going before ... you run the chance of being disorientated ... before you do that you have to have moved the plane in the system onwards to the next point so you come into position. (page 4)
    Strength: +1
    Aircraft: unspecified
    Equipment: FMS & ATC
    Source: Bruseberg, A., & Johnson, P. (2004). Should Computers Function as Collaborators?. In Proceedings of HCI-Aero 2004 held in Toulouse, France September 29, 2004 to 1 October 2004. See Resource details

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  8. Evidence Type: Excerpt from Survey
    Evidence: 27 of the 30 (90%) respondents reported a 4 (= agree) or 5 (= strongly agree) with pc45 modes may proliferate
    Strength: +5
    Aircraft: unspecified
    Equipment: automation
    Source: Lyall, E., Niemczyk, M. & Lyall, R. (1996). Evidence for flightdeck automation problems: A survey of experts. See Resource details

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  10. Evidence Type: Excerpt from Survey
    Evidence: 13 of the 30 (43%) respondents reported a 4 (= agree) or 5 (= strongly agree) with pc124 automation may be too complex and tightly coupled
    Strength: +2
    Aircraft: unspecified
    Equipment: automation
    Source: Lyall, E., Niemczyk, M. & Lyall, R. (1996). Evidence for flightdeck automation problems: A survey of experts. See Resource details

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  12. Evidence Type: Excerpt from Survey
    Evidence: 11 of the 30 (37%) respondents reported a 4 (= agree) or 5 (= strongly agree) with pc40 automation may be too complex
    Strength: +2
    Aircraft: unspecified
    Equipment: automation
    Source: Lyall, E., Niemczyk, M. & Lyall, R. (1996). Evidence for flightdeck automation problems: A survey of experts. See Resource details

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  14. Evidence Type: Excerpt from Survey
    Evidence: 1 of the 30 (3%) respondents reported a 1 (=strongly disagree) or a 2 (=disagree) with pc45 modes may proliferate
    Strength: -1
    Aircraft: unspecified
    Equipment: automation
    Source: Lyall, E., Niemczyk, M. & Lyall, R. (1996). Evidence for flightdeck automation problems: A survey of experts. See Resource details

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  16. Evidence Type: Excerpt from Survey
    Evidence: 10 of the 30 (33%) respondents reported a 1 (=strongly disagree) or a 2 (=disagree) with pc124 automation may be too complex and tightly coupled
    Strength: -2
    Aircraft: unspecified
    Equipment: automation
    Source: Lyall, E., Niemczyk, M. & Lyall, R. (1996). Evidence for flightdeck automation problems: A survey of experts. See Resource details

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  18. Evidence Type: Excerpt from Survey
    Evidence: 14 of the 30 (47%) respondents reported a 1 (=strongly disagree) or a 2 (=disagree) with pc40 automation may be too complex
    Strength: -2
    Aircraft: unspecified
    Equipment: automation
    Source: Lyall, E., Niemczyk, M. & Lyall, R. (1996). Evidence for flightdeck automation problems: A survey of experts. See Resource details

  19.  
  20. Evidence Type: Excerpt from resource
    Evidence: "9.8.2 Causes of the A320 accidents ... It has been possible for the manufacturer to claim that 'all systems were performing as specified' in each of the crashes. However, when the accident sequences are analysed objectively, it is obvious that the way in which on-board computer systems functioned played at least a contributory role in each accident. ... In many cases, the systems involved have been other systems than the EFCS, in particular the FMGS with its complex modalities is implicated in several crashes. ... The A320 is not [emphasized] a simple aircraft, and the main cause of its complexity is the use of digital computers." (page 54)
    Strength: +4
    Aircraft: A320
    Equipment: FMS
    Source: Mellor, P. (1994). CAD: Computer-Aided Disaster. High Integrity Systems, 1(2), 101-156. See Resource details

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  22. Evidence Type: Excerpt from resource
    Evidence: "As with most accidents, this one [the A320 accident in Warsaw, Poland] was due to a combination of causes, all of which had to be present for it to occur. ... As is often the case, fault resides in the logical requirement of the interfaces between several systems on the whole aircraft, not in a malfunction in any one part." (page 53)
    Strength: +1
    Aircraft: A320
    Equipment: automation
    Source: Mellor, P. (1994). CAD: Computer-Aided Disaster. High Integrity Systems, 1(2), 101-156. See Resource details

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  24. Evidence Type: Excerpt from resource
    Evidence: "In practice, there appears to be no definite evidence that straightforward EFCS software failure has contributed to any of the accidents. Instead, they have been due to unforeseen interactions between the different modes of functioning of the various on-board systems, together with the fact that the whole aircraft is so complex that the pilot has difficulty in understanding what is going on when something unexpected happens." (page 29)
    Strength: +1
    Aircraft: A320
    Equipment: EFCS
    Source: Mellor, P. (1994). CAD: Computer-Aided Disaster. High Integrity Systems, 1(2), 101-156. See Resource details

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  26. Evidence Type: Excerpt from resource
    Evidence: "Given the inability of the Commission of Enquiry to discover the cause of this accident [the A320 accident in Strasbourg, France], it is unlikely that it will ever be known for certain. It is perhaps symptomatic of interactively complex tightly coupled systems that it is often impossible to discover what went wrong even after the accident!" (page 49)
    Strength: +1
    Aircraft: A320
    Equipment: automation
    Source: Mellor, P. (1994). CAD: Computer-Aided Disaster. High Integrity Systems, 1(2), 101-156. See Resource details

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  28. Evidence Type: Excerpt from resource
    Evidence: The A320 accident in Bangalore, India "would seem to be a classic case of an interactively complex system, which the crew, despite their training, partly misunderstood, together with a counter-intuitive logic of system interconnection and an inadequate interface." (page 41)
    Strength: +1
    Aircraft: A320
    Equipment: automation
    Source: Mellor, P. (1994). CAD: Computer-Aided Disaster. High Integrity Systems, 1(2), 101-156. See Resource details

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  30. Evidence Type: Excerpt from Incident Study
    Evidence: In our review of 282 automation-related ASRS incident reports, we found 3 reports (1%) supporting issue040 (automation may be too complex).
    Strength: +1
    Aircraft: various
    Equipment: automation
    Source: Owen, G. & Funk, K. (1997). Flight Deck Automation Issues: Incident Report Analysis. http://www.flightdeckautomation.com/incidentstudy/incident-analysis.aspx. Corvallis, OR: Oregon State University, Department of Industrial and Manufacturing Engineering. See Resource details

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  32. Evidence Type: Excerpt from resource
    Evidence: "56 pilots provided comments on Automation Surprises. These responses were coded into categories based on the primary thrust of the pilot’s response. Five categories were created with ten of the responses not fitting into one of the five categories. The categories, numbers of responses in each category, and a brief summary of the comments are provided below: ...Design (9) -- As the FMS product matures, there are fewer surprises. Pilots are unaware of the underlying “obscure logic” being used in the FMS. Frustrating to enter waypoints and get error messages because they are too close to the airplane. Inserting approaches is not the same for different parts of the world. We are not given FMS conventions. Can drop out of PROF or NAV mode without a warning." (page 437)
    Strength: +1
    Aircraft: MD11
    Equipment: Automation & FMS
    Source: Parasuraman, R., Mavor, A., Wickens, C.D., Danaher, J.W., & Aalfs, C. (1998). Managing the future national airspace system: Free flight or ground-based control with increased automation (panel session). In Proceedings of the 42nd Annual Meeting of the Human Factors and Ergonomic Society, 62-66. See Resource details

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  34. Evidence Type: Excerpt from Multi-Method Study
    Evidence: "III. IMPLICATIONS OF THE RESEARCH RESULTS The results of the [three] research activities complement each other. ... The majority of observed problems with the FMS are related to factors which are known to affect human-computer interaction in variety of domains: ... B. Technology-Induced Complexity Another issue that is brought up by the results of our research is that implementing an increasing number of capabilities into the system (such as many different flight level change modes) involves the cost of increasing system complexity which makes it more difficult for the user to build an operationally effective mental model of the FMS." (page 1309)
    Strength: +1
    Aircraft: B737-300
    Equipment: FMS
    Source: Sarter, N.B. (1991). The Flight Management System - pilots' interaction with cockpit automation. In Proceedings of the IEEE International Conference on Systems, Man, and Cybernetics, 1307-1310. New York: IEEE. See Resource details

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  36. Evidence Type: Excerpt from Observational Study
    Evidence: "An example of such an inadvertent mode activation contributed to a major recent accident in the aviation domain (the Bangalore crash; e.g., Lenorovitz, 1990). In that case, the pilot put the automation into a mode called OPEN DESCENT during an approach without realizing it. In this mode, airspeed is controlled by pitch rather than thrust, i.e., throttles go to idle. In the desirable mode for this phase of flight, i.e. in SPEED mode, airspeed is controlled by thrust. As a consequence of going into OPEN DESCENT, the aircraft could not sustain the glidepath and maintain the pilot-selected target speed at the same time. The flight director bars commanded the pilot to fly the aircraft well below the required profile to try to maintain airspeed. It was not until 10 seconds before impact that the crew discovered what had happened; too late for them to recover with engines at idle. How could this happen? One contributing factor in this accident may have been that there are at least five different ways of activating the OPEN DESCENT mode." (page 5-6)
    Strength: +3
    Aircraft: A320
    Equipment: autoflight
    Source: Sarter, N.B. & Woods, D.D. (1995). How in the World Did We Ever Get into That Mode? Mode Error and Awareness in Supervisory Control. Human Factors, 37(1), 5-19. See Resource details

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  38. Evidence Type: Excerpt from Survey
    Evidence: "Pilots were asked to describe instances where FMS behavior surprised them and to indicate modes/features of FMS operation that they did not understand. There were no sharp boundaries between the incidents elicited by the two questions. Pilot reports are categorized according to their underlying theme." ... There were 10 reports [10 / 135 = 7.4%] in the category: "Multiple Methods ... Some pilots mention that, for certain tasks, there seems to be an overwhelming number of possible methods to do the job. Their reports indicate that there is a cognitive load associated with learning and deciding on which method to use for a particular task in a particular flight context." (page 307, 312)
    Strength: +1
    Aircraft: B737-300
    Equipment: FMS
    Source: Sarter, N.B. & Woods, D.D. (1992). Pilot interaction with cockpit automation: Operational experiences with the Flight Management System. International Journal of Aviation Psychology, 2(4), 303-321. Lawrence Erlbaum Associates. See Resource details

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  40. Evidence Type: Excerpt from Accident Report
    Evidence: "The majority of pilots in every nation said they knew how to utilize the automation effectively (i.e., can rapidly access the FMC, feel free to select level of automation, understand all the FMC modes and features), and that they knew to include the other pilot in automation decisions and activities (i.e., more cross-checking and acknowledgment of program changes)." (page 323)
    Strength: -1
    Aircraft: various
    Equipment: automation
    Source: Strauch, B. (1997). Automation and decision making -- lessons from the Cali accident. In Proceedings of the 41st Annual Meeting of the Human Factors and Ergonomics Society, 195-199. See Resource details

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  42. Evidence Type: Excerpt from Survey
    Evidence: In response to "Question 4. What features were the hardest for you to learn?" A respondent in Wave Two replied, "A/T functions too complex" (page 35-37)
    Strength: +1
    Aircraft: DC-9-80
    Equipment: autoflight: autothrust
    Source: Wiener, E.L. (1985). Human Factors of Cockpit Automation: A Field Study of Flight Crew Transition. NASA Contactor Report 177333. Moffett Field, CA: NASA Ames Research Center. See Resource details

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  44. Evidence Type: Excerpt from Survey
    Evidence: "INITIAL OPERATING EXPERIENCE (IOE) [On the first questionnaire, crews were asked]... Describe any problems that you had during your IOE (initial operating experience) and early months of flying the 757. Are there still areas you have trouble with, or don't understand?" In response to this question, the following comment was made by one of the pilots: " The FMS is so [emphasized] complex, it takes a while to feel comfortable in its use. However, for me, this becomes a positive thing because it reduces the tendency for complacency. 1053 " (page 72, 75)
    Strength: +1
    Aircraft: B757
    Equipment: FMS
    Source: Wiener, E.L. (1989). Human Factors of Advanced Technology ("Glass Cockpit") Transport Aircraft. NASA Contractor Report 177528. Moffett Field, CA: NASA Ames Research Center. See Resource details
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