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Evidence for an Issue 19 pieces of evidence for this issue.

mode awareness may be lacking (Issue #95) - Pilots may not be able to tell what mode or state the automation is in, how it is configured, what it is doing, and how it will behave. This may lead to reduced situation awareness and errors.

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  2. Evidence Type: Excerpt from Accident Report
    Evidence: "ANALYSIS ... It is obvious that the captain did not realize that the autothrottle was still engaged and in go-around mode but concentrated on flying the aircraft towards the runway." (page 38)
    Strength: +2
    Aircraft: DC-9-83
    Equipment: autoflight: autothrottle
    Source: Council of State appointed investigation commission - Finland (1996). Aircraft accident at Kajaani Airport, Finland, 3. November 1994. DC-9-83 registered as F-GHED operated by Air Liberte Tunisie. Translation of the Finnish original report. Helsinki: Multiprint. See Resource details

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  4. Evidence Type: Excerpt from Accident Review Study
    Evidence: In order to find the common element which links the two failures, described in the previous section, we re-examined the failures themselves. We found that the combination of “confirmation bias” i.e. a tendency to confirm an existing world view in the face of contradictory evidence (e.g. the 'fixation' error, also described above) and “selectivity” i.e. a focus on only those factors which support the current world view (e.g. the Air-Inter pilots’ concentration on the VS/FPA entry dial to the exclusion of the underlying entry mode) were common occurrences in failures caused by a lack of operator knowledge (Reason 1990). Neither was common in examples of skill-level failure i.e. the failure to execute a well-rehearsed procedure (as would be implied by an explanatory account based on mode error alone). In this context, mode errors become a symptom of the underlying problem (the operators lack of knowledge of the current system state), rather than the cause. (page 8)
    Strength: +1
    Aircraft: A320
    Equipment: automation
    Source: Hourizi, R. & Johnson, P. (2001). Beyond Mode Error: Supporting Strategic Knowledge Structures to Enhance Cockpit Safety.. In A. Blandford, J. Vanderdonkt & P. Gray (Eds.): People and Computers XV - Interaction without frontiers. Joint Proceedings of HCI2001 and ICM2001, Lille, 10-14th Sept. 2001, Springer Verlag, 229-246. See Resource details

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  6. Evidence Type: Excerpt from Survey
    Evidence: From the survey data: "I always consult the flight mode annunciator to determine which mode the autopilot/flight director is in." On the scale in which 1= Strongly Disagree, 3=Neutral, 5=Strongly Agree, the mean pilot response was 3.61 and the standard deviation was 0.99. (page 21)
    Strength: +3
    Aircraft: B757 & B767
    Equipment: automation
    Source: Hutchins, E., Holder, B., & Hayward, M. (1999). Pilot Attitudes Toward Automation. Web published at http://hci.ucsd.edu/hutchins/attitudes/index.html. See Resource details

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  8. Evidence Type: Excerpt from Survey
    Evidence: From the survey data: "It is easier to bust an altitude in an automated airplane than in other planes." On the scale in which 1= Strongly Disagree, 3=Neutral, 5=Strongly Agree, the mean pilot response was 2.27 and the standard deviation was 2.67. (page 21)
    Strength: -1
    Aircraft: B757 & B767
    Equipment: automation
    Source: Hutchins, E., Holder, B., & Hayward, M. (1999). Pilot Attitudes Toward Automation. Web published at http://hci.ucsd.edu/hutchins/attitudes/index.html. See Resource details

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  10. Evidence Type: Excerpt from Survey
    Evidence: From the survey data: "I always know what mode the autopilot/flight director is in." On the scale in which 1= Strongly Disagree, 3=Neutral, 5=Strongly Agree, the mean pilot response was 3.72 and the standard deviation was 0.98. (page 20)
    Strength: -3
    Aircraft: B757 & B767
    Equipment: autoflight: autopilot
    Source: Hutchins, E., Holder, B., & Hayward, M. (1999). Pilot Attitudes Toward Automation. Web published at http://hci.ucsd.edu/hutchins/attitudes/index.html. See Resource details

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  12. Evidence Type: Excerpt from Accident Report
    Evidence: "21.42 - Preferred hypotheses On the basis of the foregoing, the commission considered the following hypotheses as explanations for the pivotal event: 21.421 - Hypothesis No. 1: the abnormally high rate of descent was the result of an unintentional command on the part of the crew because they believed the vertical mode selected on the auto-pilot to be other than that which was actually selected." (page 204)
    Strength: +4
    Aircraft: A320-100
    Equipment: autoflight: autopilot
    Source: Investigation Commission of Ministry of Transport - France (1993). Rapport de la Commission d'Enquete sur l'Accident survenu le 20 Janvier 1992 pres du Mont Saite Odile (Bas Rhin) a l/Airbus A.320 Immatricule F-GGED Exploite par lay Compagnie Air Inter. Official English translation from the Ministere de l'Equipement, des Transports et du Tourisme, France. Ministere de l'Equipement, des Transports et du Tourisme. See Resource details

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  14. Evidence Type: Excerpt from Experiment
    Evidence: "Conclusions... Most pilots showed a lack of awareness of the commanded descent mode and were confused by the resulting aircraft states. All but one of the subjects [11/12 = 92%] allowed the aircraft to deviate significantly from the intended glide path, with ten pilots allowing the aircraft to reach altitudes where ground impact either happened or would be difficult to avoid. This indicates that pilots had a serious lack of autopilot mode and aircraft state awareness when given the displays used in the study." (page 20)
    Strength: +5
    Aircraft: A320
    Equipment: autoflight
    Source: Johnson, E.N. & Pritchett, A.R. (1995). Experimental Study Of Vertical Flight Path Mode Awareness. Cambridge, MA: Massachusetts Institute of Technology, Department of Aeronautics and Astronautics. See Resource details

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  16. Evidence Type: Excerpt from Survey
    Evidence: 18 of the 30 (60%) respondents reported a 4 (= agree) or 5 (= strongly agree) with pc095 mode awareness may be lacking
    Strength: +3
    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: 9 of the 30 (30%) respondents reported a 1 (=strongly disagree) or a 2 (=disagree) with pc095 mode awareness may be lacking
    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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  20. Evidence Type: Excerpt from Accident Report
    Evidence: "The Safety Board thus concludes that the crew erred in both their actions and recollections regarding the AP mode selection. It is probable that the flightcrew did begin, or intended to begin, the climb with the ATS N1 mode/AP IAS mode selections. However, when the captain selected 320 kn into the ATS speed window he may have either intentionally or unintentionally pulled the ATS speed selector knob. This action would have changed the ATS selection from the N1 mode to the airspeed mode. This in turn would have caused the AP IAS Hold mode to disengage and revert automatically to the vertical speed mode of operation. In any case, the DFDR indicates that the AP was in the vertical speed mode from about 16,000 ft upward. The Safety Board cannot explain why corresponding indications on the mode selection panels failed to alert the flightcrew to these selections. ... 3. Conclusions ... 3.1 Findings ... 6. The autopilot commanded an increasing angle of attack while attempting to maintain a preselected vertical speed which exceeded the limit thrust performance capability of the aircraft at higher altitudes." (page 21-22)
    Strength: +2
    Aircraft: DC10-30
    Equipment: autoflight
    Source: National Transportation Safety Board (1980). Aeromexico DC-10-30 over Luxembourg, November 11, 1979. Aircraft Accident Report NTSB/AAR-80-10. Washington, DC: National Transportation Safety Board. See Resource details

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  22. Evidence Type: Excerpt from Incident Study
    Evidence: In our review of 282 automation-related ASRS incident reports, we found 2 reports (1%) supporting issue095 (mode awareness may be lacking).
    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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  24. 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: FMS VNAV
    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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  26. Evidence Type: Excerpt from resource
    Evidence: "Need to reactivate the approach. In 14 cases (26% of all 54 approaches flown in the course of this study), the participating pilot forgot to remind the pilot-not-flying (PNF) to activate the approach. The problem was not noticed by the PF until he selected managed speed, which Ied to a surprising increase rather than the expected decrease in thrust and speed, as the automation had not been instructed to slow the aircraft to the approach speed." (page 396)
    Strength: +2
    Aircraft: A320
    Equipment: automation & FMS
    Source: Sanchez-Ku, M.L., & Arthur, Jr. W. (2000). A dyadic protocol for training complex skills: A replication using female participants. Human Factors, 42(3), 512-520. See Resource details

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  28. Evidence Type: Excerpt from resource
    Evidence: "Four pilots forgot to activate managed navigation after initiating the go-around, which was necessary to make the airplane fly to the Raffs intersection and enter the holding pattern. In those four cases, the instructor had to intervene to ensure that the aircraft would get back on course. In addition, five pilots activated managed navigation too late to recover fully. They were only about two miles from the holding fix when they realized, based on indications on the map display, that the airplane was still in the runway-track mode. Another two pilots activated managed navigation (NAV) fairly late once they realized that, in this particular context, the dashed lines displayed in the MCP heading window did not indicate that managed NAV was active." (page 397)
    Strength: +1
    Aircraft: A320
    Equipment: automation & FMS
    Source: Sanchez-Ku, M.L., & Arthur, Jr. W. (2000). A dyadic protocol for training complex skills: A replication using female participants. Human Factors, 42(3), 512-520. See Resource details

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  30. Evidence Type: Excerpt from Experiment
    Evidence: "Further problems with mode awareness were observed in the context of those scenario events that made it difficult but not impossible to anticipate system behavior. In the case of the go-around below 100ft AGL, all pilots failed to anticipate and realize that the autothrust system did not arm when they selected TOGA power. In this case, the pilots had an expectation of system behavior in response to their input. As mentioned by pilots in the debriefing, they all expected the autothrust system to arm because it does so in all other cases where TOGA power is applied." (page 61)
    Strength: +5
    Aircraft: A320
    Equipment: autoflight: autothrust
    Source: Sarter, N.B. & Woods, D.D. (1995). Strong, Silent, and Out-of-the-loop: Properties of Advanced (Cockpit) Automation and Their Impact on Human-Automation Interaction. CSEL Report 95-TR-01. See Resource details

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  32. Evidence Type: Excerpt from Observational Study
    Evidence: "Most Frequently Observed Problems ... Awareness of automatic transition to ALT HOLD mode upon level-off, and requirements to reengage a climb mode for subsequent altitude change" (page 315)
    Strength: +1
    Aircraft: B737-300
    Equipment: autoflight: autopilot
    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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  34. Evidence Type: Excerpt from Survey
    Evidence: "In order to identify what kinds of problems occur in automated aircraft, a review of accident and incident reports from a number of European and US sources was completed. Reports were selected on the basis of keyword searches for terms relating to human factors, training and automation, and were then classified using a taxonomy developed in ECOTTRIS to identify various operational, behavioural, design contributory and general automation factors. "Analysis of frequency of factors and linkages between factors was carried out and yielded the following results: deficiency in CRM was a contributory factor in incidents and accidents (identified in 39% of all reports) and this could be linked with incorrect settings, monitoring and vigilance, inadequate knowledge of aircraft systems, experience and flight handling. Furthermore, complacency was found in 13% of reports and improper use of systems occurred in 15% of reports. In this part of the study, mode awareness was identified as a factor in only 6% of reports."
    Strength: +1
    Aircraft: various
    Equipment: automation
    Source: Sherman, P.J., Helmreich, R.L., & Merritt, A. (1997). National culture and flight deck automation: Results of a multination survey. International Journal of Aviation Psychology, 7(4), 311-329. Lawrence Erlbaum Associates. See Resource details

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  36. Evidence Type: Excerpt from Survey
    Evidence: Statement 7: "I always know what mode the autopilot/flight director is in." From the histograph of the responses in Phase 1 of the study, 68% of the pilots agreed or strongly agreed with the statement and in Phase 2 of the study, 72% of the pilots agreed or strongly agreed with the statement while only 20% disagreed or strongly disagreed in Phase 1, and 13% disagreed or strongly disagreed in Phase 2. The neutral responses were 12% in Phase 1 and 15% in Phase 2. (page 28)
    Strength: +1
    Aircraft: B757
    Equipment: autoflight: autopilot
    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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  38. Evidence Type: Excerpt from Survey
    Evidence: Statement 7: "I always know what mode the autopilot/flight director is in." From the histograph of the responses in Phase 1 of the study, 68% of the pilots agreed or strongly agreed with the statement and in Phase 2 of the study, 72% of the pilots agreed or strongly agreed with the statement while 20% disagreed or strongly disagreed in Phase 1, and 13% disagreed or strongly disagreed in Phase 2. The neutral responses were 12% in Phase 1 and 15% in Phase 2. (page 28)
    Strength: -3
    Aircraft: B757
    Equipment: autoflight: autopilot
    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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