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of aircraft position relative to the terrain.
 Exercise good radio communication discipline.
 Know the height of the highest terrain or obstacle in the
operating area.
 Know your aircraft’s position in relation to the surrounding
high terrain.
ATC
Approach &
Landing
Accident
Reduction
 Monitor the autoflight system for desired operation.
 Use the best available mode for current flight conditions.
 Follow procedures.
 Monitor navigation performance.
Autoflight
System
Approach &
Landing
Accident
Reduction
Amalberti 7
CRM, SOPs and Training
Factors Involved in ALAs
 74% - Inadequate crew decision making
 72% - Inadvertent non adherence to procedures
 63% - Failure in CRM (cross-check/coordination)
 46% - Failures in company management
 40% - Deliberate non adherence to procedures
 37% - Inadequate training
CRM = Crew resource management
SOPs = Standard operating procedures
Approach &
Landing
Accident
Reduction
Amalberti 8
 Training time costs money, and tends to
remain as short as possible
 Consistent plan for integrated human
factors training, conceptually and practically
hard to design
 Persistent false believes on cognition,
 human behaviour, and human error
 Training evaluation for human factors
related aspects hard to accept
The reality gap
Amalberti 9
Feedback from the FAA/JAA report on The Interfaces Between Flight crews and Modern
Flight Deck Systems, June 1996
0
1
2
3
4
5
6
Widebody
1stTCGlass'90
1st TC Glass'00
Conversion Glass
Training time (weeks)
 Reduction time
 Strong belief (evidence?)
that learning cognitive
skills needs a shorter
time compared to
learning motor skills
 Back to the minimum
 Ambiguities for decision
making
Reduction time in training courses
Amalberti 10
Persistent false belief on Human
behaviour and human error
 Training priorities not necessary the ones
identified
– False belief regarding « back to manual »
– Remaining language problems aggravating situation
awareness
– Effects of complexity on pilots’ expertise
Amalberti 11
Poor situation awareness and false
expectation on crew behaviour
Speed corruption
Mach corruption
Altitude corruption
Altitude preset
ineffective
Automatic reversion
of descent mode
between Heading-
Vertical Speed (Hdg-
Vs) and Track-Flightpath
angle (TK-FPA)
and versus.
INSTRUCTEUR
Emulation
ATC
J.P. Mesure
micro Cam閞a
micro
Tel閜hone
Jeuen pilote
Etudiante
Enregistrement
Liaison fonctionnelle
Salle d閜ort閑
Simul A320 •10 crews experiencing rare software failures
•Modification of Flight Simulator Capacities
•LOFT scenario: LYON - MADRID
Amalberti 12
 All crews landed safely
 Only four crews went back to manual
 All crews showed a tendency to cycle the failing system several
times to test the failure before trying to reset the system in order
to recover it (resetting fuse, proceeding the global function reset,
e.g. resetting FMGS)
 A thorough analysis of crews’ mental representation and situation
awareness via verbal protocols analysis show a series of
unexpected ‘magic’ thinking on sub-systems organisation and
inter-relations.
 Crews gave priority to the situation management, not to optimal
error or failure management. HE rate increases to 50%, error
detection rate going down to 30%, only 10% of HE properly
recovered.
 No causal reasoning, search for comprehension collectively
refrained
 First priorities for safe situation management : control the very
short term, and search for solutions compliant with the goal.
Experimental crew training to deal
with automation surprises (Results 1)
Amalberti 13
Exploration phase
Cognition in the wild
Glass-cockpit a/c, Amalberti, 1996, 2000
Retraction phase
Core of routines
Complexity, and Expertise
Virtual space of total system knowledge
Knowledge at the end of A/C type-rated
Initial phase
Routines
Amalberti 14
New Technologies and Associated Cultural
　
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