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Evidence from Resource 7 pieces of evidence from this resource.

Palmer, E.A., Hutchins, E.L., Ritter, R.D., & VanCleemput, I. (1993). Altitude Deviations: Breakdown of an Error-Tolerant System. NASA Technical Memorandum 108788. Moffett Field, CA: NASA Ames Research Center.

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  2. Evidence Type: Excerpt from Incident Study
    Evidence: Table 2 summarizes the "descriptive factors assigned to altitude-deviation reports" from traditional cockpits and glass cockpits. In the traditional cockpit, 10 out of 50 (20%) reports suggested that training was a factor in the incident and in the glass cockpit, 34 out of 50 (68%) reports suggested that training was a factor in the incident. (page 7)
    Issue: training may be inadequate (Issue #133) See Issue details
    Strength: +3
    Aircraft: unspecified
    Equipment: automation

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  4. Evidence Type: Excerpt from Incident Study
    Evidence: Table 2 summarizes the "descriptive factors assigned to altitude-deviation reports" from traditional cockpits and glass cockpits. In the traditional cockpit, 16 out of 50 (32%) reports suggested that complacency was a factor in the incident and in the glass cockpit, 24 out of 50 (48%) reports suggested that complacency was a factor in the incident. (page 7)
    Issue: pilots may be overconfident in automation (Issue #131) See Issue details
    Strength: +2
    Aircraft: unspecified
    Equipment: automation

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  6. Evidence Type: Excerpt from Incident Study
    Evidence: "SAMPLE NARRATIVES FROM ASRS REPORTS The following ... ASRS narratives were chosen to illustrate the range of problems identified in the initial survey. ... [ASRS incident report # 134179] ... 'Taking off from ORD in a [large transport] with a light load and maximum takeoff power (engine anti-ice on). The first officer, just out of training, was flying the leg while I handled communications. Each of us had only done one previous leg in a [large transport]. (I have several hundred hours in [wide body transport].) The combination of cold weather, maximum power, and a nearly empty aircraft caused the airspeed to increase extremely rapidly after liftoff. The first officer was reluctant to raise the nose to the extreme angle required to maintain 250 (in this case, probably better than 25 [degrees]). When I saw the airspeed zipping through 270, I warned him to slow down and he disconnected the autothrottles, manually retarding power and raising the nose just as the flight director went to altitude capture (between 3,500 and 4,000 ft.). Attempting to level at 5,000 ft. , we overshot by 200-300 ft. (still fast), when we were cleared to 14,000 ft. (I don't really know whether we actually broke 5,300 ft. Before being cleared up.) I punched flight-level change, but the autothrottles refused to engage initially. In the confusion over exactly what was wrong, we both were slow to respond to several heading changes, which understandable annoyed the controller. Nothing really serious here, except the same old story. Both of us were engrossed in trying to figure out why this computerized marvel was doing what it was, rather than turning everything off and manually flying (which we finally did) until we could sort things out. This is a common tendency in this type of cockpit, but our familiarity with the super high performance of the LGT [large transport] was a contributing factor. It really is a handful to takeoff and level at a low altitude and seems to require an almost immediate power reduction to maintain a reasonable nose attitude at low weights.' ... In addition the problems caused by the crew's lack of familiarity with high performance of their twin-engine aircraft., [in sic] this incident illustrated two other problems. First, like the crew attempting to set of the hold at waypoint BUCKS 9incident [in sic] No. 1 [ASRS incident report #144196]), this crew mentions being distracted by attempting to determine why the autoflight system was not performing as they expected. Second, as reported in prior examples, this crew appears to have difficulty translating the departure clearance from ATC language to the language of the autoflight and FMS." (page 14-15)
    Issue: automation may demand attention (Issue #102) See Issue details
    Strength: +1
    Aircraft: LRG
    Equipment: automation

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  8. Evidence Type: Excerpt from Incident Study
    Evidence: "SAMPLE NARRATIVES FROM ASRS REPORTS The following ... ASRS narratives were chosen to illustrate the range of problems identified in the initial survey. ... [ASRS incident report # 148853] ... On an en-route descent into Dayton our clearance was direct RID VOR, direct DAYTON with a descent to 11,000 ft. The controller gave us a new clearance to cross 10 miles west of RID at 10,000 ft. The captain, being less experienced in using the flight management computer than I, wanted me to show him how to program the descent for the new restrictions. We put the restrictions in the magic box, and for some reason, almost certainly something we did improperly, the machine wanted to make the restriction 10 miles east of RID. By the time we caught the error in the midst of doing checklists and the usual cockpit duties we were too late to make the restriction. Nothing was said and there was no conflict. ... In flight training on the operation of complex systems such as the autoflight and FMSs is going to happen, but it should be done during the low-workload cruise phase of flight. Unfortunately, as the report of this incident points out, the clearances that require complex reprogramming usually occur during the already busy climb and descent phases of flight." (page 11)
    Issue: automation may demand attention (Issue #102) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: FMS

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  10. Evidence Type: Excerpt from Incident Study
    Evidence: "SAMPLE NARRATIVES FROM ASRS REPORTS The following ... ASRS narratives were chosen to illustrate the range of problems identified in the initial survey. ... 1. Crew Distracted by Programming the Flight Management System The following report from the first officer of a glass cockpit airliner describes an altitude deviation that occurred during the descent phase of flight as both pilots attempted to program a holding pattern into the flight-management system (FMS). ... [ASRS incident report # 144196] ... Descending from higher flight levels to 15,000 ft. on Center clearance had anticipated and received clearance to hold at BUCKS due to anticipated weather delay. Captain flying on autopilot using LNAV [lateral navigation] on company stored route everything routine. Captain is a check airman on this aircraft. I am 5-year airline pilot, but only 3 months experience on [glass] equipment. Captain pulled up 'hold' page on FMC [flight-management computer] and began to enter data. We were currently descending on rate of descent command to 15,000 ft. altitude as assigned. I'm reading holding data to captain as he's entering data via keypad. Both eyes off of primary flight instruments but in altitude capture mode (VNAV) [vertical navigation] and LNAV so both pilots are anticipating automatic level off at 15,000 ft. altitude. Captain apparently entered hold at PPOS [present position] instead of at BUCKS in error, and aircraft begins left turn unexpectedly. I, in confusion, not knowing he entered PPOS by mistake, stated, 'This isn't right,' and saw captain disengage autopilot to stop turn while he goes back to FMC page to find out where we should be, got to VOR/ILS [very high-frequency omnidirectional radio range/instrument landing system] mode and picked up en route chart to tune in present position. Aircraft descended below 15,000 ft.. Horn went off at approximately 14,600 ft. Captain called out 'Out of 16 for 15.' I said no (looking up) and said we were at 14,500 ft., only cleared to 15,000 ft., that was a low altitude alert not '1,000 ft. to go' horn. Immediately pulled back up. No ATC [air traffic control] communication took place by either ATC or us about event. Within 30 seconds, ATC gave us new frequency and cleared us to 13,000 ft. No conflict or discussion or awareness of event was stated by ATC. Below 15,000 ft. for about 20 seconds. Cause is obvious - both pilots' attention diverted from aircraft flight path. I suggest hold-page (not used often) be made more user friendly. Have captain tell first officer to watch flight progress while he is correcting other problems. I personally feel that although the FMS is a great tool, but shouldn't be used all the time, especially below FL180. It takes too much pilot attention, especially when newly assigned to the aircraft. Just because the technology exists doesn't mean it should be used. Better pilot training on FMC/pilot problem areas like this should be provided. Also, loss of a flight engineer's eyes is not in the interest of aviation safety. ... This incident report illustrates several problems that can occur in the altitude-change task. The crew apparently correctly received the clearance, set the altitude alert, and set up the autopilot to descend and capture the cleared altitude of 15,000 ft. If the crew had done nothing more, the aircraft was set up to level off automatically at the new altitude. Both pilots were distracted from their routine task of monitoring the altitude change by the nonroutine task of programming the flight management computer (FMC) for the upcoming holding pattern." (page 8-9)
    Issue: both pilots' attention simultaneously diverted by programming (Issue #75) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: FMS

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  12. Evidence Type: Excerpt from Incident Study
    Evidence: "SAMPLE NARRATIVES FROM ASRS REPORTS The following ... ASRS narratives were chosen to illustrate the range of problems identified in the initial survey. ... [ASRS incident report # 148853] ... On an en-route descent into Dayton our clearance was direct RID VOR, direct DAYTON with a descent to 11,000 ft. The controller gave us a new clearance to cross 10 miles west of RID at 10,000 ft. The captain, being less experienced in using the flight management computer than I, wanted me to show him how to program the descent for the new restrictions. We put the restrictions in the magic box, and for some reason, almost certainly something we did improperly, the machine wanted to make the restriction 10 miles east of RID. By the time we caught the error in the midst of doing checklists and the usual cockpit duties we were too late to make the restriction. Nothing was said and there was no conflict. ... This narrative [ASRS incident report #148853] also illustrates another factor that was observed in several reports: in-flight training, in which one pilot attempts to instruct the other pilot on the use of automatic equipment, can distract both pilots from the primary task of maintaining altitude awareness." (page 11)
    Issue: both pilots' attention simultaneously diverted by programming (Issue #75) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: automation

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  14. Evidence Type: Excerpt from Incident Study
    Evidence: "We will see in other incidents that there is often a mismatch between the pilots' intentions and the interface that is provided for communicating those intentions to the autopilot and flight management system." (page 10)
    Issue: interface may be poorly designed (Issue #39) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: FMS
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