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Evidence from Resource 14 pieces of evidence from this resource.

Inagaki, T., Takae, Y., & Moray, N. (1999). Automation and human interface for takeoff safety. In R.S. Jensen, B. Cox, J.D. Callister, & R. Lavis (Eds.), Proceedings of the 10th International Symposium on Aviation Psychology, 402-407. Columbus, OH: The Ohio State University.

  1.  
  2. Evidence Type: Excerpt from Experiment
    Evidence: "the captain appeared engaged in a state we will call automation fixation. People have grown accustomed to technology working in only fixed ways and they may routinely have to try several tactics to get it to do what they want it to do. Therefore they may engage in a persistence behavior (continuing to repeatedly try different things) which is frequently eventually successful. Engaging in this type of automation fixation may have very negative consequences, however, if the circumstances are such that a wiser course of action would be to give up and do the task in another way (e.g. fly the aircraft manually). Even after all of the problems encountered by this crew, the captain remained intent on trying to program the FMS to fly the approach path." (page 881)
    Issue: pilots may be reluctant to assume control (Issue #26) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  3.  
  4. Evidence Type: Excerpt from Experiment
    Evidence: "Once the pilots did detect the turn, they spent the next several minutes trying to determine the nature of their navigation difficulty and then correct the problem. This incident is typical of the out-of-the-loop performance problem that has been noted to occur with automated systems. Not only did it take the pilots some time to figure out there was a problem, they also were sufficiently out-of-the-loop such that they had significant difficulty in ascertaining just how they ended up in that position (to understand what the current system state actually was) and trying to figure out how to rectify it. The pilots had significant difficulty in trying to correct the state they found themselves in and their confusion was evident." (page 881)
    Issue: pilots may be out of the loop (Issue #2) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  5.  
  6. Evidence Type: Excerpt from Experiment
    Evidence: "…In a time critical situation, it appears that the flight crew trusted the automation to carry out its task (fly to the designated point “R”), as it had many times before... In the Cali accident, the fact that the pilots had become loaded with very demanding tasks that required the use of separate, non-integrated sources of information may have contributed to their lack of vigilance in monitoring the automation during the turn." (page 881)
    Issue: information integration may be required (Issue #9) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  7.  
  8. Evidence Type: Excerpt from Experiment
    Evidence: "…In a time critical situation, it appears that the flight crew trusted the automation to carry out its task (fly to the designated point “R”), as it had many times before... In the Cali accident, the fact that the pilots had become loaded with very demanding tasks that required the use of separate, non-integrated sources of information may have contributed to their lack of vigilance in monitoring the automation during the turn." (page 881)
    Issue: pilots may be overconfident in automation (Issue #131) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  9.  
  10. Evidence Type: Excerpt from Experiment
    Evidence: "In this case, the pilots entered “R” to direct the aircraft to fly to a fix on the approach named Rozo. While “R” was the designation for Rozo indicated on the approach chart it was not the designation used for that point in the FMS database. The "R" they actually selected was assigned to another point in Columbia named Romeo. This was a central error in this accident that sent the aircraft into a 180 degree bank to the left towards Romeo. It was a simple error for the pilots to make, likely induced by the fact that “R” was the expected designation for Rozo and was presented on the charts as such. A poorly understood FMS naming convention led to the designation of R for Romeo and not Rozo in the FMS database. (Romeo was nearer to the larger airport in Columbia, Bogota, and therefore received the designator R. Thus Rozo was assigned its full name in the database.)" (page 880)
    Issue: automation may adversely affect pilot workload (Issue #79) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  11.  
  12. Evidence Type: Excerpt from Experiment
    Evidence: "In this case, the pilots entered “R” to direct the aircraft to fly to a fix on the approach named Rozo. While “R” was the designation for Rozo indicated on the approach chart it was not the designation used for that point in the FMS database. The "R" they actually selected was assigned to another point in Columbia named Romeo. This was a central error in this accident that sent the aircraft into a 180 degree bank to the left towards Romeo. It was a simple error for the pilots to make, likely induced by the fact that “R” was the expected designation for Rozo and was presented on the charts as such. A poorly understood FMS naming convention led to the designation of R for Romeo and not Rozo in the FMS database. (Romeo was nearer to the larger airport in Columbia, Bogota, and therefore received the designator R. Thus Rozo was assigned its full name in the database.)" (page 880)
    Issue: database may be erroneous or incomplete (Issue #110) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  13.  
  14. Evidence Type: Excerpt from Experiment
    Evidence: "Last minute runway assignments can create a significant problem for pilots when they necessitate reprogramming the FMS to execute and/or display the new approach... The requirement to reprogram the FMS and cross check the entries at the last minute certainly played a role in this accident." (page 880)
    Issue: automation may adversely affect pilot workload (Issue #79) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  15.  
  16. Evidence Type: Excerpt from Experiment
    Evidence: "In this accident, the pilots received a clearance to Runway 19, a runway they were not expecting, and they chose to accept that clearance (possibly in an effort to land as quickly as possible or possibly due to a confirmation bias as they had previously set-up the FMS for Runway 1 per information from the company dispatcher and in accordance with previous experience into the Cali airport.) At that point they needed to find and review the necessary approach charts and perform a number of steps to program the new approach into the FMS. This process was complicated, however, by the fact that an earlier entry to go direct to the Cali VOR had removed the points from the display that were need for creating the proper path. That is, the Tulua VOR (ULQ) was no longer displayed." (page 880)
    Issue: insufficient information may be displayed (Issue #99) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  17.  
  18. Evidence Type: Excerpt from Experiment
    Evidence: "A particular deficiency of the FMS, in terms of its ability to support the SA requirements of the pilot, is its presentation of vertical information. The flight path displayed provides only the programmed lateral path of the aircraft. No direct display of either the vertical path of the aircraft nor its relationship to surrounding terrain is provided...The pilots demonstrated a lack of awareness of the proximity and altitude of surrounding terrain that would have alerted them to the danger of continuing their descent. A direct display of vertical path information and its relation to surrounding terrain is not provided by the displays. This state of affairs allowed the crew to continue their descent without questioning its advisability (at least as far as the cockpit voice recorder reveals). Particularly in light of the fact that the lateral path was so clearly and saliently displayed, the lack of salience of vertical information on the FMS was a significant factor in this accident."
    Issue: insufficient information may be displayed (Issue #99) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  19.  
  20. Evidence Type: Excerpt from Experiment
    Evidence: "…theCali accident demonstrated that there can be substantial differences in the points and nomenclature used between the two information sources. As a result, determining a correlation between identical points on the two different navigation sources can be both difficult and time consuming. In this accident, the points on the desired flight path were named CF19 and FF19 in the FMSgenerated data, and D21 and D16 on the map. It takes considerable calculation to determine that they actually represent the same points, and these calculations are often time-consuming." (page 879)
    Issue: database may be erroneous or incomplete (Issue #110) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  21.  
  22. Evidence Type: Excerpt from Experiment
    Evidence: "This example is also indicative of an underlying problem with the FMS display. Pilots essentially generate their own selective display of the external world, based on the commands they enter. With FMS equipped aircraft, it is possible to enter any series of waypoints and the aircraft will fly that path, however, except for flying near adverse weather, it can be very difficult to detect if the created path is potentially unsafe or incorrect…Without verifying the accuracy of the flight path by comparison with navigation charts, pilots are not able to detect these errors from simply examining the displays and such programming errors are actually fairly easy to make." (page 879)
    Issue: information integration may be required (Issue #9) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  23.  
  24. Evidence Type: Excerpt from Experiment
    Evidence: "In the Cali accident, the pilots faced the challenge of working with the FMS display which, by design, portrayed information about the location of navigational fixes but not environmental features such as terrain. The pilots entered “Direct CLO” (Direct to the Cali VOR) in response to a miscommunication with air traffic control (ATC) which led them to believe they had a clearance to proceed direct to Cali as opposed to following the usual waypoints on designated airways. Requesting and receiving a direct clearance is not uncommon in radar controlled airspace, which, based on their extensive background flying in the U.S., this aircrew was accustomed to. The action of making a direct entry into the FMS had an unfortunate side effect, however. It caused a new flight path to be presented between the aircraft’s current position and the Cali VOR (labeled CLO) and all intervening waypoints along the original path to disappear. Thus, when the aircrew received a later clearance from ATC to “report Tulua”, they could not find this waypoint (labeled ULQ) on their display or in an FMS-control device. They devoted considerable efforts in a time pressured situation in trying to find ULQ or other points on their display that corresponded to those on the new approach to runway 19. The selected display did not support the global SA needed to detect their location relevant to pertinent landmarks, nor the global SA needed to rapidly change goals (programming in a new flight path)." (page 879)
    Issue: situation awareness may be reduced (Issue #114) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  25.  
  26. Evidence Type: Excerpt from Experiment
    Evidence: "In the Cali accident, the pilots faced the challenge of working with the FMS display which, by design, portrayed information about the location of navigational fixes but not environmental features such as terrain. The pilots entered “Direct CLO” (Direct to the Cali VOR) in response to a miscommunication with air traffic control (ATC) which led them to believe they had a clearance to proceed direct to Cali as opposed to following the usual waypoints on designated airways. Requesting and receiving a direct clearance is not uncommon in radar controlled airspace, which, based on their extensive background flying in the U.S., this aircrew was accustomed to. The action of making a direct entry into the FMS had an unfortunate side effect, however. It caused a new flight path to be presented between the aircraft’s current position and the Cali VOR (labeled CLO) and all intervening waypoints along the original path to disappear. Thus, when the aircrew received a later clearance from ATC to “report Tulua”, they could not find this waypoint (labeled ULQ) on their display or in an FMS-control device. They devoted considerable efforts in a time pressured situation in trying to find ULQ or other points on their display that corresponded to those on the new approach to runway 19. The selected display did not support the global SA needed to detect their location relevant to pertinent landmarks, nor the global SA needed to rapidly change goals (programming in a new flight path)." (page 878)
    Issue: automation may adversely affect pilot workload (Issue #79) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS

  27.  
  28. Evidence Type: Excerpt from Experiment
    Evidence: "In the Cali accident, the pilots faced the challenge of working with the FMS display which, by design, portrayed information about the location of navigational fixes but not environmental features such as terrain. The pilots entered “Direct CLO” (Direct to the Cali VOR) in response to a miscommunication with air traffic control (ATC) which led them to believe they had a clearance to proceed direct to Cali as opposed to following the usual waypoints on designated airways. Requesting and receiving a direct clearance is not uncommon in radar controlled airspace, which, based on their extensive background flying in the U.S., this aircrew was accustomed to. The action of making a direct entry into the FMS had an unfortunate side effect, however. It caused a new flight path to be presented between the aircraft’s current position and the Cali VOR (labeled CLO) and all intervening waypoints along the original path to disappear. Thus, when the aircrew received a later clearance from ATC to “report Tulua”, they could not find this waypoint (labeled ULQ) on their display or in an FMS-control device. They devoted considerable efforts in a time pressured situation in trying to find ULQ or other points on their display that corresponded to those on the new approach to runway 19. The selected display did not support the global SA needed to detect their location relevant to pertinent landmarks, nor the global SA needed to rapidly change goals (programming in a new flight path)." (page 878)
    Issue: insufficient information may be displayed (Issue #99) See Issue details
    Strength: +1
    Aircraft: B757
    Equipment: automation and FMS
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