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Evidence from Resource 4 pieces of evidence from this resource.

Investigation Commission of Ministry of Transport - France (1989). Final report concerning the accident which occurred on June 26th 1988 at Mulhouse-Habsheim (68) to the Airbus A 320, registered F-GFKC. Ministry of Planning, Housing, Transport and Maritime Affairs.

  1.  
  2. Evidence Type: Excerpt from Accident Report
    Evidence: "4 - RECOMMENDATIONS ... 4.3 - AIRCRAFT ... 4.3.2 - The Commission remarked that the aural announcements made by the radio altimeter and the aural warnings were transmitted only via the cockpit loudspeakers and not via the pilots' headsets. The Commission recommends: - that studies be made to see if it would not be judicious to transmit all warnings and aural announcements via the pilots' headsets." (page 64)
    Issue: displays (visual and aural) may be poorly designed (Issue #92) See Issue details
    Strength: +4
    Aircraft: unspecified
    Equipment: automation

  3.  
  4. Evidence Type: Excerpt from Accident Report
    Evidence: "2.2.3 Flight preparation by the crew ... The training given to the pilots emphasized all the protections from which the A320 benefits with respect to its lift which could have given them the feeling, which indeed is justified, of increased safety. In particular, the demonstration of the activation of the safety features and protection of this aircraft may lead one to consider flight approaching one of the limitations (especially the one related to angle of attack) as a foreseeable flight condition since lift is guaranteed. ... The choice to inhibit the automatic go-around protection (Alpha Floor) resulted from the need to eliminate this protection if flight at 100 feet or above is planned at an angle of attack higher than the one activating this protection. The inhibition in this case can only be achieved in practice by pressing and holding the two switches placed on the throttles. After 30 seconds, inhibition becomes permanent for the rest of the flight. This decision is compatible with the objectives expressed by the Captain to maintain a height of 100 feet and seems to confirm that the incursion below 100 feet was not considered by him at this stage. In effect, below 100 feet, this protection is not active." (page 50-52)
    Issue: protections may be lost though pilots continue to rely on them (Issue #15) See Issue details
    Strength: +4
    Aircraft: A320
    Equipment: automation

  5.  
  6. Evidence Type: Excerpt from Accident Report
    Evidence: "3 - CONCLUSIONS ... 3.2 - PROBABLE CAUSE ... 3.2.2 - Other Factors The Commission also remarked that the following factors contributed towards placing the crew in a situation that they were not able to fully control: ... - The A320 has new features which may have inspired some overconfidence in the mind of the Captain." (page 60)
    Issue: pilots may be overconfident in automation (Issue #131) See Issue details
    Strength: +4
    Aircraft: A320
    Equipment: automation

  7.  
  8. Evidence Type: Excerpt from Accident Report
    Evidence: "2.2.3 Flight preparation by the crew ... The training given to the pilots emphasized all the protections from which the A320 benefits with respect to its lift which could have given them the feeling, which indeed is justified, of increased safety. In particular, the demonstration of the activation of the safety features and protection of this aircraft may lead one to consider flight approaching one of the limitations (especially the one related to angle of attack) as a foreseeable flight condition since lift is guaranteed. ... The choice to inhibit the automatic go-around protection (Alpha Floor) resulted from the need to eliminate this protection if flight at 100 feet or above is planned at an angle of attack higher than the one activating this protection. The inhibition in this case can only be achieved in practice by pressing and holding the two switches placed on the throttles. After 30 seconds, inhibition becomes permanent for the rest of the flight. This decision is compatible with the objectives expressed by the Captain to maintain a height of 100 feet and seems to confirm that the incursion below 100 feet was not considered by him at this stage. In effect, below 100 feet, this protection is not active." (page 50-52)
    Issue: automation may not work well under unusual conditions (Issue #150) See Issue details
    Strength: +1
    Aircraft: A320
    Equipment: automation
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