1. Learning from failure (to learn) Mahabubul Alam CS/SE 6361, Fall 2014  Final Term Paper Presentation  The University of Texas at Dallas Asiana Airlines #214

2. Recap On July 6, 2013 Asiana Airlines Flight 214, crashed short of runway 28L’s threshold while attempting to land at SFO. There were 3 Fatalities & 187 Injured. 1 NTSB Report: Confused Flight Crew over relied on Automation Flew too slow and too low, hit seawall

3. Through the eyes of the Reference Model 2 S, D ⊭ R but P, C ⊨ S Machine Performed per Specification Domain failed to collaborate Requirements were not met

4. Let’s look at the domain 3

5. Root Cause Analysis – P.I.G. 4

6. A Convergence of Circumstances 5 Inadequate Domain Assumptions lead to poor design Aircraft failed to maintain speed Did not provide adequate low speed warning Conflict of Design philosophy and Business Practice Over reliance on Automation without Training Nurturing Requirements Errors for Decades It has happened 4 times before! * Boeing is non-compliant with FAA SFO ILS Offline – Forced Visual Approach Lack of practice leads to confusion * 09/23/2007 – UK B737, 1/27/2009 – TX, ATR-42, 2/12/2009 – NY, DHC-8, 3/25/2009 – Netherlands – B737

7. Goal is to avoid crash 6

8. Recommendations 7 Comply with FAA AC 25.1329 & AC 25.1322-1 Low Speed Protection, Adequate Warning Improve Transition training, encourage manual flights Better mental model of automation, more prepared Human error cannot be prevented, so improve design Improved safety, saves lives Fill in the gaps in Requirements Inadequate requirements can spell disaster!

9. One probable solution 8 Introduce multiple channels in the flight system. In landing zones, it can take over before its too late. 58% of fatalities happen during descend to approach to landing Follow Pareto Principle. Minor changes in design philosophy can have Major impact on outcome

10. For Tacit knowledge apply Ethnomethodology 9

11. What did we learn? 10 The only way to have a perfect system is to have perfect humans design and operate the systems. That is not possible. So failures will happen. - Dr. Lawrence Chung. November 11, 2014 We need to keep asking questions, and the answers will help us design and build the system-to-be and the system-next and so on… But Boeing seems to claim their system is perfect…….

12. References Asiana Airlines Flight 214 http://en.wikipedia.org/wiki/Asiana_Airlines_Flight_214 Crash of Asiana Flight 214 Accident Report Summary http://www.ntsb.gov/news/events/2014/asiana214/abstract.html NTSB: Asiana crew 'over-relied' on automated systems http://www.usatoday.com/story/travel/news/2014/06/24/ntsb-asiana-fatal-crash-san-francisco/11302347/ Pilot in deadly plane crash had no experience landing 777 in San Francisco http://www.cnn.com/2013/07/07/us/plane-crash-main/ Asiana Flight 214 Investigation Focuses on Airspeed in Final Seconds http://www.wired.com/2013/07/ntsb-wraps-up-asiana-214/ Asiana cites crew failures and autothrottle design in flight 214 crash http://www.flightglobal.com/news/articles/asiana-cites-crew-failures-and-autothrottle-design-in-flight-214-397632/ Retired Senior Boeing Flight Instructor blames on the Auto-throttle System http://www.cockpitchatter.com/retired-senior-boeing-flight-instructor-blames-on-the-auto-throttle-system/ Statistical Summary of Commercial Jet Airplane Accidents http://www.boeing.com/news/techissues/pdf/statsum.pdf Descent Below Visual Glidepath and Impact With Seawall - Asiana Airlines Flight 214 http://www.ntsb.gov/doclib/reports/2014/AAR1401.pdf 11

13. Questions?