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Evidence from Resource 16 pieces of evidence from this resource.

Noyes, J.M. & Starr, A.F. (2000). Civil aircraft warning systems: Future directions in information management and presentation. International Journal of Aviation Psychology, 10(2), 169-188. Lawrence Erlbaum Associates.

  1.  
  2. Evidence Type: Excerpt from Survey
    Evidence: "About a minute after the turn began the captain indicated his discovery of the turn to Romeo when he asked “what happened here.” He then directed the first officer to turn to the right and, after a short discussion, they decided to proceed directly to Cali. However, because the airplane had been in a constant descent for some time, it had gone beneath the height of the terrain that was located on either side of the airplane’s flight path. Shortly thereafter, the ground proximity warning system alerted and the airplane struck terrain." (page 197)
    Issue: situation awareness may be reduced (Issue #114) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  3.  
  4. Evidence Type: Excerpt from Survey
    Evidence: "Neither pilot was aware that the captain’s execution of the FMS command to proceed “Direct to” Cali had erased intermediate fixes between their position and Cali, especially that of Tulua, the beacon that served as the initial approach fix, the entry to the approach. During the subsequent attempts to review the new approach and perform the preparations for it they were unable to locate Tulua and then understand the cause of this difficulty. Without locating it, the approach could not be executed as published." "The captain, who was managing the FMS while the first officer was the pilot flying asked, "I don't know, what's this ULQ (three letter code for Tulua)," an indication of the extent of his loss of awareness. The airplane's cockpit voice recorder indicated that from the time they accepted the offer to execute the straight in approach the workload of both pilots was quite high as they attempted to complete the many required activities. As a result, the captain was unable to take the time necessary to determine the cause of his difficulty retrieving and locating Tulua. In fact, the FMS had performed as designed but neither pilot was able to discover the cause of the problem." (page 196)
    Issue: automation may adversely affect pilot workload (Issue #79) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  5.  
  6. Evidence Type: Excerpt from Survey
    Evidence: "Yet, despite the difficulty he encountered, the captain persisted in using the FMS to locate Tulua, rather than selecting an alternative navigation method." (page 197)
    Issue: pilots may over-rely on automation (Issue #106) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  7.  
  8. Evidence Type: Excerpt from Survey
    Evidence: "The captain’s continued efforts to locate Tulua through the FMS, in addition to being ineffective, also precluded his using the little available time to employ an alternative navigation method and limited his ability to systematically analyze the nature of the difficulty as well. Because he did not understand the difficulty, he was unable to estimate the time and effort needed to rectify it. In fact, his efforts appeared to be not so much problem solving as rote repetition of keyboard interactions. Given the time pressure it would have taken extraordinary effort to carry out real problem solving." (page 197)
    Issue: situation awareness may be reduced (Issue #114) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  9.  
  10. Evidence Type: Excerpt from Survey
    Evidence: "When continual efforts were unsuccessful the crew decided to proceed directly to the final fix on the approach to Cali, a beacon named Rozo that was located just before the runway. However, rather than retrieve Rozo from the FMS data base, one of the pilots mistakenly retrieved a different beacon that was located outside Bogota, named Romeo, and then executed a command to proceed directly to it. Evidence revealed that a crewmember had asked for and retrieved all beacons in the data base coded by the abbreviation “R.” and then commanded the FMS to proceed to Romeo. The airplane turned away from its position north of Cali to Romeo, a turn that would have been clearly evident on the CRT in front of each pilot that displayed the FMS-generated predicted flight path. Of the errors the crew committed in the minutes before the accident this most demonstrates the time pressure they experienced. Little, if any, cognitive effort was needed to notice the turn as presented on the predicted flight path. Moreover, pilots of FMS-equipped aircraft are trained to consistently verify a command to the FMS that causes a course change to assure that it is correct. That they did not may be accounted for by their loss of temporal awareness: they were too busy to take the time needed to even glance at the flight path display." (page 197)
    Issue: pilots may over-rely on automation (Issue #106) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  11.  
  12. Evidence Type: Excerpt from Survey
    Evidence: "When continual efforts were unsuccessful the crew decided to proceed directly to the final fix on the approach to Cali, a beacon named Rozo that was located just before the runway. However, rather than retrieve Rozo from the FMS data base, one of the pilots mistakenly retrieved a different beacon that was located outside Bogota, named Romeo, and then executed a command to proceed directly to it. Evidence revealed that a crewmember had asked for and retrieved all beacons in the data base coded by the abbreviation “R.” and then commanded the FMS to proceed to Romeo. The airplane turned away from its position north of Cali to Romeo, a turn that would have been clearly evident on the CRT in front of each pilot that displayed the FMS-generated predicted flight path. Of the errors the crew committed in the minutes before the accident this most demonstrates the time pressure they experienced. Little, if any, cognitive effort was needed to notice the turn as presented on the predicted flight path. Moreover, pilots of FMS-equipped aircraft are trained to consistently verify a command to the FMS that causes a course change to assure that it is correct. That they did not may be accounted for by their loss of temporal awareness: they were too busy to take the time needed to even glance at the flight path display." (page 197)
    Issue: automation may adversely affect pilot workload (Issue #79) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  13.  
  14. Evidence Type: Excerpt from Survey
    Evidence: "Likewise. it can also be assumed that they would have recognized, as demonstrated in the Kansas City accident, that last minute changes in the approach presented some risk as well. In fact, the first officer’s response to the captain’s question about accepting the offer to execute the approach indicated his concern, “Yeah. We’ll have to scramble to get down. We can do it.” In fact, the airplane had been in a descent before he made this comment, and the descent continued to the accident." (page 196)
    Issue: automation may adversely affect pilot workload (Issue #79) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: FMS & ATC

  15.  
  16. Evidence Type: Excerpt from Survey
    Evidence: "Further. the pilots’ expertise with the FMS, gained from having flown the Boeing 757 for several years. May have actually detracted from their ability to effectively use the FMS. The execution of the command to proceed to Romeo was consistent with the selection of the beacon that is identified first on the computer-display unit and is the beacon that the airplane is closest to. If not explicitly taught in training, the pilots would have recognized over repeated use that beacons with a common one letter identifier were presented in descending order of their proximity to the airplane. Pilots who recognized this rule could have assumed, because they were so close to Rozo, that among those beacons identified by the abbreviation "R," Rozo would be presented first. Thus, not only would the command to proceed to Romeo have been executed by a crew that had no time available to refer to a flight path display, but also by a crew that had effectively executed such commands in the past." It can be assumed that the crew’s familiarity with the FMS extended only to a portion of FMS logic, that concerning the order of presentation of the navaids, and not to another, the coding of the navaids themselves." (page 197)
    Issue: database may be erroneous or incomplete (Issue #110) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  17.  
  18. Evidence Type: Excerpt from Survey
    Evidence: "Further. the pilots’ expertise with the FMS, gained from having flown the Boeing 757 for several years. May have actually detracted from their ability to effectively use the FMS. The execution of the command to proceed to Romeo was consistent with the selection of the beacon that is identified first on the computer-display unit and is the beacon that the airplane is closest to. If not explicitly taught in training, the pilots would have recognized over repeated use that beacons with a common one letter identifier were presented in descending order of their proximity to the airplane. Pilots who recognized this rule could have assumed, because they were so close to Rozo, that among those beacons identified by the abbreviation "R," Rozo would be presented first. Thus, not only would the command to proceed to Romeo have been executed by a crew that had no time available to refer to a flight path display, but also by a crew that had effectively executed such commands in the past." It can be assumed that the crew’s familiarity with the FMS extended only to a portion of FMS logic, that concerning the order of presentation of the navaids, and not to another, the coding of the navaids themselves." (page 197)
    Issue: understanding of automation may be inadequate (Issue #105) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  19.  
  20. Evidence Type: Excerpt from Survey
    Evidence: "When continual efforts were unsuccessful the crew decided to proceed directly to the final fix on the approach to Cali, a beacon named Rozo that was located just before the runway. However, rather than retrieve Rozo from the FMS data base, one of the pilots mistakenly retrieved a different beacon that was located outside Bogota, named Romeo, and then executed a command to proceed directly to it. Evidence revealed that a crewmember had asked for and retrieved all beacons in the data base coded by the abbreviation “R.” and then commanded the FMS to proceed to Romeo. The airplane turned away from its position north of Cali to Romeo, a turn that would have been clearly evident on the CRT in front of each pilot that displayed the FMS-generated predicted flight path. Of the errors the crew committed in the minutes before the accident this most demonstrates the time pressure they experienced. Little, if any, cognitive effort was needed to notice the turn as presented on the predicted flight path. Moreover, pilots of FMS-equipped aircraft are trained to consistently verify a command to the FMS that causes a course change to assure that it is correct. That they did not may be accounted for by their loss of temporal awareness: they were too busy to take the time needed to even glance at the flight path display." (page 197)
    Issue: situation awareness may be reduced (Issue #114) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  21.  
  22. Evidence Type: Excerpt from Survey
    Evidence: "When continual efforts were unsuccessful the crew decided to proceed directly to the final fix on the approach to Cali, a beacon named Rozo that was located just before the runway. However, rather than retrieve Rozo from the FMS data base, one of the pilots mistakenly retrieved a different beacon that was located outside Bogota, named Romeo, and then executed a command to proceed directly to it. Evidence revealed that a crewmember had asked for and retrieved all beacons in the data base coded by the abbreviation “R.” and then commanded the FMS to proceed to Romeo. The airplane turned away from its position north of Cali to Romeo, a turn that would have been clearly evident on the CRT in front of each pilot that displayed the FMS-generated predicted flight path. Of the errors the crew committed in the minutes before the accident this most demonstrates the time pressure they experienced. Little, if any, cognitive effort was needed to notice the turn as presented on the predicted flight path. Moreover, pilots of FMS-equipped aircraft are trained to consistently verify a command to the FMS that causes a course change to assure that it is correct. That they did not may be accounted for by their loss of temporal awareness: they were too busy to take the time needed to even glance at the flight path display." (page 197)
    Issue: displays (visual and aural) may be poorly designed (Issue #92) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  23.  
  24. Evidence Type: Excerpt from Survey
    Evidence: "The captain’s continued efforts to locate Tulua through the FMS, in addition to being ineffective, also precluded his using the little available time to employ an alternative navigation method and limited his ability to systematically analyze the nature of the difficulty as well. Because he did not understand the difficulty, he was unable to estimate the time and effort needed to rectify it. In fact, his efforts appeared to be not so much problem solving as rote repetition of keyboard interactions. Given the time pressure it would have taken extraordinary effort to carry out real problem solving." (page 197)
    Issue: data entry and programming may be difficult and time consuming (Issue #112) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  25.  
  26. Evidence Type: Excerpt from Survey
    Evidence: "Likewise. it can also be assumed that they would have recognized, as demonstrated in the Kansas City accident, that last minute changes in the approach presented some risk as well. In fact, the first officer’s response to the captain’s question about accepting the offer to execute the approach indicated his concern, “Yeah. We’ll have to scramble to get down. We can do it.” In fact, the airplane had been in a descent before he made this comment, and the descent continued to the accident." (page 196)
    Issue: data entry and programming may be difficult and time consuming (Issue #112) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: FMS & ATC

  27.  
  28. Evidence Type: Excerpt from Survey
    Evidence: "When continual efforts were unsuccessful the crew decided to proceed directly to the final fix on the approach to Cali, a beacon named Rozo that was located just before the runway. However, rather than retrieve Rozo from the FMS data base, one of the pilots mistakenly retrieved a different beacon that was located outside Bogota, named Romeo, and then executed a command to proceed directly to it. Evidence revealed that a crewmember had asked for and retrieved all beacons in the data base coded by the abbreviation “R.” and then commanded the FMS to proceed to Romeo. The airplane turned away from its position north of Cali to Romeo, a turn that would have been clearly evident on the CRT in front of each pilot that displayed the FMS-generated predicted flight path. Of the errors the crew committed in the minutes before the accident this most demonstrates the time pressure they experienced. Little, if any, cognitive effort was needed to notice the turn as presented on the predicted flight path. Moreover, pilots of FMS-equipped aircraft are trained to consistently verify a command to the FMS that causes a course change to assure that it is correct. That they did not may be accounted for by their loss of temporal awareness: they were too busy to take the time needed to even glance at the flight path display." (page 197)
    Issue: automation behavior may be unexpected and unexplained (Issue #108) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  29.  
  30. Evidence Type: Excerpt from Survey
    Evidence: "Neither pilot was aware that the captain’s execution of the FMS command to proceed “Direct to” Cali had erased intermediate fixes between their position and Cali, especially that of Tulua, the beacon that served as the initial approach fix, the entry to the approach. During the subsequent attempts to review the new approach and perform the preparations for it they were unable to locate Tulua and then understand the cause of this difficulty. Without locating it, the approach could not be executed as published." "The captain, who was managing the FMS while the first officer was the pilot flying asked, "I don't know, what's this ULQ (three letter code for Tulua)," an indication of the extent of his loss of awareness. The airplane's cockpit voice recorder indicated that from the time they accepted the offer to execute the straight in approach the workload of both pilots was quite high as they attempted to complete the many required activities. As a result, the captain was unable to take the time necessary to determine the cause of his difficulty retrieving and locating Tulua. In fact, the FMS had performed as designed but neither pilot was able to discover the cause of the problem." (page 196)
    Issue: automation behavior may be unexpected and unexplained (Issue #108) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS

  31.  
  32. Evidence Type: Excerpt from Survey
    Evidence: "In addition, the selection of the beacon Romeo and the execution of the command to proceed to that beacon revealed an additional, heretofore unrecognized, deficiency of the FMS. Neither pilot knew the rules governing the coding of data in the FMS-navigation data base and in fact, until this accident, few pilots were aware that the rules used to identify beacons, navaids, and fixes on navigation charts did not consistently match those used on corresponding data stored in FMS-navigation data bases. The abbreviation "R" that was used for Rozo and prominently displayed on the chart of the approach to Cali did not correspond to Rozo in the data base. In the data base "R" indicated Romeo." (page 197)
    Issue: database may be erroneous or incomplete (Issue #110) See Issue details
    Strength: +1
    Aircraft: Boeing 757
    Equipment: automation & FMS
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