Senior Human Performance Investigator

Human Performance Issues

Asiana Flight 214, B777
San Francisco, CA
J uly 6, 2013
Human Performance Issues
Flightpath management
Understanding of automation
Communication and coordination
Monitoring
Go-around decision-making





2
Human Performance Issues
Context-dependent, low energy
alerting systems
Expanded low speed protection





3
Flightpath Management
Airplane high at 5 nautical miles
Delayed deceleration and configuration
Increased flight crew workload
Degraded monitoring
Increased opportunity for error
Reduced likelihood of error detection
4
Understanding of Automation
Complex autoflight system logic, inadequate
documentation and training
PF had an inaccurate understanding
of the system
Did not correctly anticipate the effect of
his actions on airspeed control
Did not understand the A/T automatic
engagement feature
5
Communication and Coordination
Asiana SOPs specified that when the A/P
was ON:
The PF operated the MCP, called out
selections
The PM verified, called out mode
changes
The flight crew did not consistently follow
these SOPs throughout the approach


6
Communication and Coordination
7
The PF did not call out his selection
of FLCH
The PM and observer did not notice:
The PFs selection
Subsequent, related mode changes



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Calibrated Airspeed (Knots) Radar Altitude (Feet)
Monitoring

8
Low Speed Alert
Thrust Levers
Move Forward
Shaker
200 Feet
PM 17 Seconds
PF >24 Seconds
Airspeed
Monitoring Lapses
Monitoring

The flight crew did not effectively monitor
airspeed below 500 feet
Expectancy
Automation reliance
Increased workload
Fatigue
9
Go-Around Decision-Making
10
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Calibrated Airspeed (Knots) Radar Altitude (Feet)
PM: Its Low
PM Low Speed Awareness
Low Speed Alert
Aware
Aware
PF Low Speed Awareness
PM and PF RRRR PAPI Awareness
200 Feet
Aware
Throttle Levers
Advanced
----11 Seconds-----
Go-Around Decision-Making

Delayed go-around
Surprise
Nonstandard communication
Role confusion



11
Low Airspeed / Low-Energy Alerting





12
777 low airspeed alert
Provided visual and aural indication
of low speed condition
Occurred too late to change the
outcome of this accident
Presented as a less urgent caution
instead of warning alert


Low Airspeed / Low-Energy Alerting





13
Context-dependent, low-energy alert could:
J ointly consider
Speed
Altitude
Flight crew response time
Engine spool-up time
Determine most appropriate activation
threshold and method of presentation



Expanded Low Speed Protection
14
777 autothrottle system characteristics
Maintained the selected speed when A/T
was ON and in SPD mode
Provided low speed protection in some pitch
modes when A/T was disengaged and
ARMED
Did not maintain selected speed or provide
low speed protection when the A/T was ON
and in HOLD mode


Expanded Low Speed Protection
15
If automatic low speed protection had
been available in HOLD mode, it likely
would have increased power 20 seconds
before impact