ASAGA STUDY Guillaume ADAM & Johan CONDETTE
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1 Bureau d Enquêtes et D Analyses pour la sécurité de l aviation civile ASAGA STUDY Guillaume ADAM & Johan CONDETTE guillaume.adam@bea-fr.org johan.condette@bea-fr.org
2 1. CONTEXT 2. INCIDENTS AND ACCIDENTS 3. TRAINING 4. SURVEY 5. SIMULATIONS/EYES TRACKING 2
3 CONTEXT ASAGA stands for Airplane State Awareness during Go-Around 25 accidents or serious incidents in 25 years worldwide (Source : ICAO Eccairs) Aggregation of FAA/TSB/NTSB/CAST and BEA data Low numbers and no big difference between the 2 main manufacturers (Boeing / Airbus) Upward trend recently: A330 in Tripoli - A310 in Monterrey - B777 at CDG 3
4 CONTEXT Study finished in Report under publication. Participants : Manufacturers :Airbus and Boeing (NTSB limited participation) Airlines : XL, CRS, AF Authorities : DGAC - EASA-FAA - ICAO Research University : ISAE (Toulouse engineering school) Human Factors : Dedale and Jean Pinet (former Head of Airbus Traing Center) 4
5 Methodology: CONTEXT 5
6 1. CONTEXT 2. INCIDENTS AND ACCIDENTS 3. TRAINING 4. SURVEY 5. EYES TRACKING 6
7 Accidents and Incidents 25 accidents and serious incidents in 25 years Hundreds of deaths Superpowered Twin jet Aircraft that are light because end of flight Always N engines. NO N-1 major events Mainly IMC THE KEY : DISTURBING EVENT / SURPRISE STARTLE EFFECT ATM impact Issue in AP AT/ATHR system or TRIM PNF/PM not monitoring 7
8 Accidents and Incidents Elements of typical scenarii are : Scenario 1: Disturbing factor (Startle effect / AP / Automatism), Go-around, Strong/excessive thrust, somatogravic illusions, chanellized attention, No CRM anymore, abnormal Pitch/Thrust, nose down inputs, «CFIT» Ex: Boeing 777 at CDG or Boeing 757 at Gardermoen (Norway) Scenario 2 : Approach with speed reducing, startle effect, combination of GA, low speed and pitch Stabilizer in pitch-up position. Sole recovery is to reduce power during GA. Ex: Boeing 737 at Bornemouth and Amsterdam 8
9 1. CONTEXT 2. INCIDENTS AND ACCIDENTS 3. TRAINING 4. SURVEY 5. EYES TRACKING 9
10 TRAINING ATM Straight-in GA path ALTITUDE expressed in TIME vs Aircraft Performance (ex: JFK go-around altitude A380 serious incident) Silencing ATC during GA ATC risk knowledge when vectoring either in HDG or ALT Flight crew Pilot selection, recurrent trainings and checkings: monitoring abilities MCC not connected with TR: Beech 200/B737 Issue in HDG/altitude versus FMS trajectory during go-around Basics during GA : Pitch / Thrust 10
11 TRAINING Flight crew Special Attention on this so-called «Normal Procedure» GA is rarely performed in real Too many N-1 training at the expense of N accidents During Training Introduction of unexpected disturbance Risk of channelized attention (suspicion on VFE/ALT) Addionnal possible improvements Unlike what is said, simulators CAN be improved Standards for simulator assessment / somatogravic illusions Video Recorder on Simulator and Aircraft 11
12 1. CONTEXT 2. INCIDENTS AND ACCIDENTS 3. TRAINING 4. SURVEY 5. EYES TRACKING 12
13 SURVEY Conducted throughout France and a bit in UK Web orientated Unexpected Success : very high rate of answers/ Around 850 pilots answered. Population is CPT/FO/TRI/TRE 6 months to be assessed with 3 experts!!! 13
14 SURVEY Results: compliants with ASAGA scenarii provide clues to suspected contributive factor highlighted during investigation and ASAGA study 14
15 Results: SURVEY GA rarely performed especially on long haul aircraft. Lack of real practice GA : difficult to be performed by pilots expecially PM/PNF ATM «last minute» procedure High workload (mostly PM) / Signifiant time constraint Automation : management, conflict, FMA mode reversion and quick multiple change Poor CRM when messed-up AP - Pitch monitoring / Flaps and Gear retraction error GA trajectory follow-up ATM, VFE, GA altitude capture Somatogravic effect 15
16 1. CONTEXT 2. INCIDENTS AND ACCIDENTS 3. TRAINING 4. SURVEY 5. EYES TRACKING 16
17 SIMULATIONS/EYES TRACKING 9 Months to be prepared. 3 Months to select virgin crew. 2 Months to be performed 13 Simulator sessions on B 777 / A unexpected GA GA always disturbed : HDG/ALT, IMC below DH, Runway occupied Based on REAL scenario Significant means to assess the video 17
18 Scenario BDX LYS Take-off from BORDEAUX to SAU 18
19 Scenario BDX LYS 36L ILS Lyon St Exupery approach Go-Around #1 : Manual GA, ATC surprise Low energy, low altitude 200ft : go-around required heading (340 instead of 355) altitude (2500ft instead of 5000ft) 19
20 Scenario LYS - MRS Marseille 31 R ILS approach Go-Around #2: Manual GA, crew decision low energy, low altitude 15/20 kts gusts of wind (tail-wind) GA on crew decision Tail wind issue ATC requires 2000ft (instead of 3500ft) 20
21 Scenario LYS - MRS Marseille LOC/DME 13L under AP Go-Around #3: AP go around, First officer is PF IMC Too low visibility 21
22 Briefing : 30 min SIMULATIONS/EYES TRACKING 22
23 Briefing : 30 min SIMULATIONS/EYES TRACKING
24 SIMULATIONS/EYES TRACKING
25 Briefing : 30 min SIMULATIONS/EYES TRACKING
26 SIMULATIONS/EYES TRACKING Briefing: Flight preparation in the cockpit + eye tracker: 40 Flight scenario: 2h15 Debriefing: 1h30 Objective measurements: Eye tracking, video recording ocular activity, crew s action & communication 26
27 Areas of interest 27
28 Typical visual circuit (heat map) 28
29 Visual circuit over time me 29
30 Results : SIMULATIONS/EYES TRACKING 30
31 Results : SIMULATIONS/EYES TRACKING 31
32 Results : SIMULATIONS/EYES TRACKING 32
33 SIMULATIONS/EYES TRACKING Go-Around #1 duration: from ATC clearance untill the A/C was stabilized (Alt=2500ft, Head= 340o) Mean duration: 1 07 on Boeing - no overshoot Feedback from crew: very surprised No Crew performed GA maneuver as strictly defined by SOP correct actions but in the wrong order limited CRM (lack of communication, cross check/monitoring) Trajectory: 7 crews: to start dialing the MCP (alt, head) 3 crews: immediate actions but wrong MCP dialing Altitude overshoot, wrong lateral trajectory 33
34 SIMULATIONS/EYES TRACKING TIME and surprise make the GA difficult to perform Difficuties when Full thrust/toga versus Time. Limited Thrust help the crew NO PNF/PM visual circuit homogeneity On the contrary, PF visual circuit homogeneity 34
35 SIMULATIONS/EYES TRACKING FCU/MCP excessive attention PM/PNF to pay 50% of his attention on FCU/MCP + CONF. FMA not usually read after initial reading Many Automation Reversion modes not fully detected Excessive focus on some items during GA : precursor of channelized attention? Downwind information on ND raise concern 35
36 Recommendations ASAGA Final report under review ATM : procedure / time vs performance / communication / training Procedure : classification, Pitch/Thrust oriented, validation trough visual circuit analysis Training : N vs N-1, MCC, Type Rating, flight check, PM monitoring hability, selection and training Automation: GA activation error mitigation, TRIM, Thrust limitation, FMA Simulation : improvement Video Recording : A/C and Simulators Study to be launched: CRM, tunnelling, 36
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