Luca Bertuccelli and Seung Chung

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Presentation transcript:

Luca Bertuccelli and Seung Chung China Airline CI676 Nagoya Incident 26 April 1994 Luca Bertuccelli and Seung Chung

Outline I. Accident Background II. Investigation Results III. Airbus Automation Issues IV. Recommendations

China Airline CI676 (A300B4-622R B1816)

Accident Background Glideslope Stall 1730 ft Stall warning (11:15’25’’) Stall warning (11:15’21’’) Captain takes over, Go Around (11:15’03’’) Alpha floor at 570 ft (11:14’57’’) ILS approach AP disengage ATS engaged (11:11’35’’) AP engaged at 1040 ft (11:14’18’’) TOGA mode activated at 1070 ft (11:14’05’’) AP disengaged (11:14’49’’) Impact (11:15’45’’) Glideslope

Investigation Results TOGA mode by the First Officer Misunderstanding of the state of the aircraft (out-of-trim condition) • Autopilot activation in TOGA mode • Pilots opposing the aircaft’s motion Poor crew coordination— miscommunication and poor execution Earlier service bulletin not enforced

Go Lever Position (Image removed due to copyright considerations.)

A300-600 Out-of-Trim Condition Trimmable Horizontal Stabilizer (THS) Out-of-trim Condition • THS controlled by AP • Override elevator control by crew Accidents • March 1, 1985 • January 9, 1989 • February 11, 1991 Service Bulletin: SB A300-22-6021 • “Modifications to the AFS which disengages the AP when a force in excess of 15kgf is applied…”--June 24, 1993

Airbus Automation Issues Autopilot disconnect • Captain mental model mismatch between B747 and the Airbus Disengagement of TOGA mode Airbus automation philosophy • Who has the last word?

Recommendations Clearer Crew Operating Manual • AFS operational ambiguity • Recovery procedures More informative auditory warnings • “Click Click Click”—huh? Display information should be modified based on “human cognitive process in high-stress situation” • At time of accident, aircraft mode on FD • Display aircraft mode clearly

Quote from an Expert “There have been issues with the design of the Airbus autopilots having to do with the automation philosophy Airbus uses.” (CNN February 16, 1998)

Conclusion Human error was first mistake Automation misinterpretation contributed to escalation of accidental TOGA activation in a time-critical situation Service bulletin could have prevented the accident If crew had not opposed Go Around mode, could the crash have been avoided?