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Evidence from Resource 6 pieces of evidence from this resource.

Mellor, P. (1994). CAD: Computer-Aided Disaster. High Integrity Systems, 1(2), 101-156.

  1.  
  2. Evidence Type: Excerpt from resource
    Evidence: "9.8.2 Causes of the A320 accidents ... It has been possible for the manufacturer to claim that 'all systems were performing as specified' in each of the crashes. However, when the accident sequences are analysed objectively, it is obvious that the way in which on-board computer systems functioned played at least a contributory role in each accident. ... In many cases, the systems involved have been other systems than the EFCS, in particular the FMGS with its complex modalities is implicated in several crashes. ... The A320 is not [emphasized] a simple aircraft, and the main cause of its complexity is the use of digital computers." (page 54)
    Issue: automation may be too complex (Issue #40) See Issue details
    Strength: +4
    Aircraft: A320
    Equipment: FMS

  3.  
  4. Evidence Type: Excerpt from resource
    Evidence: From the A320 accident in Habsheim, France ... "the DFDR [Digital Flight Data Recorder] listings of the early part of the flight [showed] that autothrust went into 'speed' mode on passing 460ft radion altitude , without any command from the crew, and stayed in that mode from then on until the final request for 'go-around' (TOGA) thrust." (page 32-33)
    Issue: mode transitions may be uncommanded (Issue #44) See Issue details
    Strength: +1
    Aircraft: A320
    Equipment: automation

  5.  
  6. Evidence Type: Excerpt from resource
    Evidence: "As with most accidents, this one [the A320 accident in Warsaw, Poland] was due to a combination of causes, all of which had to be present for it to occur. ... As is often the case, fault resides in the logical requirement of the interfaces between several systems on the whole aircraft, not in a malfunction in any one part." (page 53)
    Issue: automation may be too complex (Issue #40) See Issue details
    Strength: +1
    Aircraft: A320
    Equipment: automation

  7.  
  8. Evidence Type: Excerpt from resource
    Evidence: "Given the inability of the Commission of Enquiry to discover the cause of this accident [the A320 accident in Strasbourg, France], it is unlikely that it will ever be known for certain. It is perhaps symptomatic of interactively complex tightly coupled systems that it is often impossible to discover what went wrong even after the accident!" (page 49)
    Issue: automation may be too complex (Issue #40) See Issue details
    Strength: +1
    Aircraft: A320
    Equipment: automation

  9.  
  10. Evidence Type: Excerpt from resource
    Evidence: The A320 accident in Bangalore, India "would seem to be a classic case of an interactively complex system, which the crew, despite their training, partly misunderstood, together with a counter-intuitive logic of system interconnection and an inadequate interface." (page 41)
    Issue: automation may be too complex (Issue #40) See Issue details
    Strength: +1
    Aircraft: A320
    Equipment: automation

  11.  
  12. Evidence Type: Excerpt from resource
    Evidence: "In practice, there appears to be no definite evidence that straightforward EFCS software failure has contributed to any of the accidents. Instead, they have been due to unforeseen interactions between the different modes of functioning of the various on-board systems, together with the fact that the whole aircraft is so complex that the pilot has difficulty in understanding what is going on when something unexpected happens." (page 29)
    Issue: automation may be too complex (Issue #40) See Issue details
    Strength: +1
    Aircraft: A320
    Equipment: EFCS
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