FDAI logo   ::  Site Map  ::   
Home  |  About This Website  |  Contact Us
Home » ... » Evidence from Resource

Evidence from Resource 1 piece of evidence from this resource.

Billings, C.E. (1996). Human-Centered Aviation Automation: Principles and Guidelines. NASA Technical Memorandum 110381. National Aeronautics and Space Administration.

  1.  
  2. Evidence Type: Excerpt from Observational Study
    Evidence: "As has been noted, today's tightly coupled automation systems have become extremely complex and in many cases, relatively opaque to their operators. At the same time, these systems have limits which may or may not be clear to their operators. An example of the problems that can be created is seen in this information, extracted form a 1991 incident report: 'Flight XXX departed on schedule; heavy rain and gusty winds were experienced on takeoff and during the departure. The climbout was normal until approximately FL 240 when numerous caution/warning messages began to appear, indicating a deteriorating mechanical condition. The first ... was OVHT ENG 1 NAC, closely followed by BLEED DUCT LEAK L, ENG 1 OIL PRESSURE, FLAPS PRIMARY, FMC L, STARTER CUT OUT 1, and others. #1 generator tripped off line and the #1 engine amber "REV" indication appeared. However, no yaw control problems were noted. The maximum and minimum speed references on the airspeed (tape) came together, followed by stick shaker activation. At approximately FL 260, the cabin was climbing rapidly and could not be controlled. The Captain initiated an emergency descent and turnback to the departure airport. The crew began to perform emergency procedures and declared an emergency. During the descent, the stick shaker activated several times but ceased below FL 200. Due to the abnormal flap indication and the #1 engine reverse, airspeed during the descent was limited to 260-270 knots. The Captain called upon the two augmented crew pilots to assst during the remainder of the flight. While maintaining control of the aircraft, he directed the first officer to handle ATC communications and to accomplish multiple abnomal procedures with the help of the additional first officer. The additional captain maintained communications with the lead flight attendant and company operations as the emergency progressed and later assisted in the passenger evacuation. Fuel dumping began on descent below 10,000 feet. The fuel jettison procedure was complicated as the left dump nozzle appeared inoperative. The crew dumped 160,000 lb of fuel; this action took about 40 minutes. When the fuel dumping was completed, the captain requested vectors for a 20 mile final for runway XX. The crew extended flaps early using alternate procedures due to an abnormal leading edge indication and the FLAPS PRIMARY message ... A final approach speed of Vref + 20 and 25 [degrees] of trailing edge flaps was planned. They selected auto brakes number 4. The weather was still bad with strong, gusty winds and heavy rain causing moderate turbulence during the approach. The ILS approach and landing were normal. At touchdown, maximum reverse was selected on #2 and #3 engines and about half reverse on #4 engine... As the aircraft passed a taxiway turnoff, the tower advised that they saw fire on the left side of the aircraft... This was the first time crew members were aware of any fire... A runway turnoff was used, and the aircraft stopped on a taxiway ... (a difficult but successful evacuation followed). This incident is an example of an electronic system 'nightmare'. The crew received and had to sort out 42 EICAS messages, 12 caution/warning indications, repeated stick shaker activation and abnormal speed reference information on the promary flight display. Many of these indications were conflicting, leading the crew to suspect number one engine problems when that engine was actually functioning normally. There was no indication of fire presented to the crew a fire actually existed...' " (page 155-156)
    Issue: automation may be too complex (Issue #40) See Issue details
    Strength: +1
    Aircraft: unspecified
    Equipment: automation
Flight Deck Automation Issues Website  
© 1997-2013 Research Integrations, Inc.