1. Massachusetts Institute of Technology Sophie ADENOT Carl NEHME A320 Strasbourg 1992 Accident Analysis

2. Massachusetts Institute of Technology Accident Synopsis January 20, 1992 Airbus A320 Air Inter F-GGED Lyon -> Strasbourg The flight crew was prepared for an landing runway 23

3. Massachusetts Institute of Technology Why? Selected mode for automatic pilot 3300 3.3Major cause: selection of the descent rate of 3300 ft/min instead of descent rate of 800 ft/min (enabling a approach plan of 3.3 deg)… transcripts indicates that the crew is more worried about headingthan altitude & speed

4. Massachusetts Institute of Technology 3 Main Hypotheses The captain forgets to change the mode Vertical Speed (VS) in the Flight Control unit (FCU), and then dials 3.3 The captain wants to stay in VS mode, but dials 3.3 automatically, as he had determined in his approach briefing The captain changes the VS mode, but because of a problem in the FCU, this change is not taken into account

5. Massachusetts Institute of Technology FCU VS mode: 3,3 = 3300 feet per minute FPA mode: 3,3 = 3.3 degrees Bi-modal dials decide which mode

6. Massachusetts Institute of Technology Accident Analysis No mechanical failure No sense of panic No significant malpractice Automation surprise Entry to autopilot was central to events leading to disaster

7. Massachusetts Institute of Technology Task Procedural Structure Select Parameter Entry Mode Enter Parameter Select Autopilot Mode 4 second delay Execution Instruction Incomplete Instruction Complete Failure 1: Failure to perceive Parameter entry mode Enter Parameter Select Autopilot Mode 4 second delay Execution Failure 2: Failure to perceive Unsafe System State (Rapid Descent)

8. Massachusetts Institute of Technology Modal Errors Modal errors (failure 1) involve failure to perceive current system mode Modal errors falls under category of perceptual slips Solutions involve prevention of such slips

9. Massachusetts Institute of Technology Failure 2 explanation Mode error however does not explain failure 2 Could have noticed rapid descent from –Instrument panel –Raw physical sensation of rapid descent De Keyser [KJ] describes this as fixation error (confirmation bias) Confirmation bias: a tendency to confirm an existing world view in the face of contradictory evidence

10. Massachusetts Institute of Technology Knowledge-Based Errors More fundamental element exists that links the two failures Better explanation of surprise than mode error alone Modal errors better associated with knowledge-based errors than perceptual slips.

11. Massachusetts Institute of Technology New Model Knowledge Gap Selectivity Confirmation bias Modal Error

12. Massachusetts Institute of Technology Appendix A

13. Massachusetts Institute of Technology Experiment Houriziand Johnson (Univ. of Bath) conducted an experiment Looked at examples of coordination between pilot an co-pilot which has benefited from decades of research

14. Massachusetts Institute of Technology Pilot/Autopilot Task Model Recipient TRIGGERS instruction Instructor GIVES instruction Recipien REPEATS instruction Instructor CONFIRMS instruction Recipient CONSIDERS Recipient GIVES Acceptance Does NOT match Given Instruction Matches Given Instruction Instruction meets recipient’s internal rules Instruction does NOT meet recipient’s internal rules Recipient GIVES Feedback

15. Massachusetts Institute of Technology Comparison of the two task models shows: No full repetition of the desired instruction is provided No confirmation is required from the pilot (instruction automatically executed after 4 second delay) No internal rule check is performed by the recipient (autopilot) Feedback given back is both distributed and passive

16. Massachusetts Institute of Technology References [HJ] Hourizi, R & Johnson, P Human Computer Interaction Laboratory, Computing Science Group, University of Bath [KJ] De Keyser, V, Javaux, D, 1996. Human factors in aeronautics, design, specification & verification of interactive systems 1996 French accident analysis: http://www.bea-fr.org/docspa/1992/f-ed920120/htm/f- ed920120.html