1. National Transportation Safety Board (NTSB) Safety Study Introduction of Glass Cockpit Avionics into Light Aircraft March 9, 2010 1NTSB Glass Cockpit Findings

2. Objective Address issues concerning transition of light aircraft to electronic primary flight displays (PFD) Determine how that change has affected safety of light aircraft. 2NTSB Glass Cockpit Findings

3. Background In only a few years, cockpits of light aircraft have undergone a transition from – conventional flight instruments to – computerized glass cockpits 3NTSB Glass Cockpit Findings

4. Change Has Occurred Rapidly By 2006, 90 + percent of new piston-powered, light airplanes were equipped with full glass cockpit displays Several manufacturers now produce STC displays to retrofit existing aircraft number of aircraft equipped with full glass cockpits will continue to grow Advanced technology has brought new safety concerns, – including equipment design and operation; – pilot performance and training; and – new accident investigation techniques. 4NTSB Glass Cockpit Findings

5. NTSB Study Designed to test the hypothesis that – The transition to glass cockpit would improve the safety of their operation. And to evaluate the adequacy of resources and requirements supporting transition to this new technology. 5NTSB Glass Cockpit Findings

6. To Accomplish These Goals Study included three separate analyses – An analysis of accidents and activity data of airplanes produced with and without electronic PFDs, to measure differences in activity, accident rates, and accident circumstances between glass cockpit and conventional aircraft. – A review of training resources and requirements related to glass cockpit displays conducted to characterize the training and identify areas for potential safety improvement. – A review of accident case studies conducted to identify emerging safety issues associated with the introduction of glass cockpit displays into this class of aircraft. 6NTSB Glass Cockpit Findings

7. Study Analyses Showed glass cockpit-equipped aircraft experienced fewer total accidents than aircraft with conventional round-dial instruments… but Glass cockpits had a significantly higher percentage of fatal accidents 7NTSB Glass Cockpit Findings

8. Data Confirmed That differences in activity and usage influenced the type and severity of accidents 8NTSB Glass Cockpit Findings

9. When considered as a whole, The study described two distinct aircraft operational profiles. – Aircraft with conventional cockpit displays were more likely to be used for flight instruction. – These aircraft flew more hours for shorter flights and flew less time in instrument conditions 9NTSB Glass Cockpit Findings

10. As a Result Conventional aircraft were involved in more accidents during takeoffs and landings, – less severe outcomes, – relatively low speeds – low impact forces. Glass cockpit aircraft involve fewer flight hours but longer trips – spent more time operating on instrument flight plans. – more likely to be fatal due to event profiles and impact forces associated with such accidents 10NTSB Glass Cockpit Findings

11. The Glass Cockpit Experienced higher fatal accident rates and higher accident rates in IMC than conventional aircraft – Despite pilots having higher levels of certification, – were more likely to be instrument rated, – had more total flight experience, and – had more experience in the aircraft type. 11NTSB Glass Cockpit Findings

12. Accident in Luna NM April 9, 2007 Cirrus SR22, 1 Uninjured Pilot climbing from 15,000 to 16,000 to avoid T-storms and snow Reported in IMC when ASI started to decrease and then ASI and ALT readouts, on PFD went to "hash marks." Pilot initiated a descent, and turned the pitot heat on Shortly ASI returned. Pilot sensed descent and "pulled back" to slow airplane and AI went "haywire." Terrain warning system activated —Pilot activated ballistic chute Airplane impacted trees and came to rest inverted. Pilot stated he might have turned icing protection system on instead of pitot heat. The switches are right next to each other. Exam of PFD/MFD revealed loss of air data, due to pitot icing. 12NTSB Glass Cockpit Findings

13. Observation Glass cockpit displays may function differently than conventional displays under certain conditions. Blocked pitot would normally affect only airspeed of conventional—cockpit glass cockpit resulted in loss of airspeed, altitude, and rate-of-climb information Info provided to pilot indicated only that air data computer failed—no indication why it failed or if situation could be safely corrected in flight NTSB—pilots not always provided all info necessary to adequately understand unique operational and functional details of PFDs 13NTSB Glass Cockpit Findings

14. The Study Noted A decrease in total accident rates but… An increase in fatal accident rates for the selected group of glass cockpit Overall, study analyses did not show a significant improvement in safety for the glass cockpit study group. 14NTSB Glass Cockpit Findings

15. NTSB Recommends FAA revise airman knowledge tests to include questions regarding electronic flight and navigation displays, including normal operations, limitations, and the interpretation of malfunctions and aircraft attitudes 15NTSB Glass Cockpit Findings

16. Changes to FAA Industry Training Standards (FITS) Recognize need for improved training for advanced aircraft systems. Implemented equipment-specific training requirements 16NTSB Glass Cockpit Findings

17. Provide Information About Display Operation and Limitations Several accidents highlighted the complexity and unique functionality of glass cockpit displays Pilots must be prepared to identify and safely respond to system malfunctions and failures 17NTSB Glass Cockpit Findings

18. NTSB Recommends FAA require all electronic PFDs to include information in POH regarding abnormal equipment op or malfunction due to subsystem and input malfunctions including: – pitot and/or static system blockages, – magnetic sensor malfunctions, and – attitude-heading reference system alignment failures 18NTSB Glass Cockpit Findings

19. Training Requirements As aircraft become more complex, demands placed on pilots to manage and monitor equipment op continue to increase. In contrast to generalized training required to operate the relatively simple systems in Part 23 aircraft—complexity and variation of Part 25 aircraft systems have been addressed by requiring pilots to hold a type rating to act as PIC However, with light aircraft incorporating glass cockpits that rival complexity of Part 25 aircraft, generalized systems training may not be sufficient for these aircraft. 19NTSB Glass Cockpit Findings

20. Different System Architectures Garmin vs Avidyne Require different operating techniques and responses to failure Knowledge of one type of glass cockpit are not likely to transfer to other systems 20NTSB Glass Cockpit Findings

21. NTSB Recommends FAA incorporate training on electronic PFDs into initial and recurrent flight proficiency requirements for pilots of aircraft equipped with those systems that address variations in equipment design and operation of such displays. 21NTSB Glass Cockpit Findings

22. Equipment Malfunction Training Pilots must be prepared to respond to flight instrument system malfunctions and failures, – pilots should be trained to identify and respond to all anticipated failure modes. – However, in many cases it is neither appropriate nor practical to train for all anticipated types of glass cockpit avionics failures and malfunctions in the aircraft. 22NTSB Glass Cockpit Findings

23. NTSB Observed Simulators or procedural trainers are the most practical alternative means of training to identify and respond to glass cockpit failures and malfunctions that cannot be easily or safely replicated in aircraft. Pilots who do not have access to approved flight simulators or training devices could benefit from equipment-specific training using software applications or procedural trainers that replicate glass cockpit displays. 23NTSB Glass Cockpit Findings

24. NTSB Noted Generalized guidance and training are no longer sufficient to prepare pilots to safely operate glass cockpit avionic Effective pilot instruction and evaluation must be tailored to specific equipment. 24NTSB Glass Cockpit Findings

25. Advanced Avionics and Electronic Displays Can increase safety potential of GA aircraft operations By providing more operational and safety-related information and functionality More effort is needed to ensure that pilots are prepared to realize that potential. 25NTSB Glass Cockpit Findings

26. Bottom Line… For the aircraft and time period studied, the introduction of glass cockpit PFDs has not yet resulted in the anticipated improvement in safety when compared to similar aircraft with conventional instruments. 26NTSB Glass Cockpit Findings

27. The End NTSB Glass Cockpit Findings27

28. NTSB Recommends : Revise airman knowledge tests to include questions regarding electronic flight and navigation displays, including normal operations, limitations, and the interpretation of malfunctions and aircraft attitudes. Require all manufacturers of primary flight displays to include info in their aircraft flight manual and POH supplements regarding abnormal equipment operation or malfunction due to subsystem and input malfunctions, including but not limited to pitot and/or static system blockages, magnetic sensor malfunctions, and attitude-heading reference system alignment failures. Incorporate training elements regarding electronic primary flight displays into training materials and aeronautical knowledge requirements for all pilots. Incorporate training elements regarding electronic primary flight displays into your initial and recurrent flight proficiency requirements for pilots of Part 23 certified aircraft Develop guidance for use of equipment-specific electronic avionics display simulators and procedural trainers to support equipment-specific pilot training requirements. Inform aircraft and avionics maintenance techs about critical role of voluntary service difficulty reporting system involving malfunctions or defects associated with electronic primary flight, navigation, and control systems. 28NTSB Glass Cockpit Findings

29. Tracking Service Difficulties and Equipment Malfunctions Investigations revealed instances of glass cockpit avionics malfunctions that were not required to be reported and that did not result in a service difficulty report (SDR). NTSB concluded that identification and tracking of service difficulties, equipment malfunctions or failures, abnormal operations, and other safety issues will be increasingly important as light aircraft avionics systems and equipment continue to increase in complexity and variation of design, and current reporting to the FAA’s SDR system does not adequately capture this information for 14 CFR Part 23 certified aircraft used in general aviation operations. 29NTSB Glass Cockpit Findings

30. Adoption of Uniform Training Elements to ensure pilots have adequate knowledge of aircraft equipment operation and malfunctions, as well as improved reporting of equipment malfunctions and service difficulties. 30NTSB Glass Cockpit Findings

31. Accident Involvement and Rates Study compared a defined group of glass cockpit aircraft and a cohort of the same makes/models of aircraft with conventional instruments to reduce the potential for confounds associated with comparing aircraft of different age and capability. 31NTSB Glass Cockpit Findings

32. The Term “cohort” Used in statistics to refer to a group of subjects (aircraft) that share similar characteristics. The aircraft cohorts in this study were all single-engine, piston-powered airplanes manufactured during the same 5-year period, with either glass or conventional cockpit instruments. 32NTSB Glass Cockpit Findings

33. A statistical confound A variable not accounted for in statistical comparisons but correlated to study variables in such a way that may result in misleading study findings 33NTSB Glass Cockpit Findings

34. The accident record is consistent with the way the aircraft were used – Glass cockpit aircraft experienced more accidents while on long trips and – in instrument meteorological conditions (IMC) 34NTSB Glass Cockpit Findings

35. Training Resources and Requirements Despite efforts on the part of the FAA to develop resources and update training materials to address the needs of pilots transitioning to glass cockpit aircraft, the study identified several safety issues and areas for improvement. 35NTSB Glass Cockpit Findings