最新技術搭載航空機における致命的事故の検証

Abstract

Fatal Accidents In Advanced Technology Aircraft: A Critical Survey was prepared by Captain Livni Gideon who is a very experienced pilot and investigator, flying B-757, B-767 and B-777, mentor to the former Israeli Air Force Commander Gen (Ret) H. Bodinger.

The new study helps in identifying potential reasons for "Advanced Technology Aircraft" accidents and suggests acts to prevent them.

During an era when the outcome of one fatal accident often leads to the airline's bankruptcy, this study possesses a unique significance due to the general perception and to the irregular approach of the analysis concerning the phenomena common to the overall accidents.

In addition to the conclusions and recommendations, and to prevent the recurrence of similar accidents, the research outlines a strategy for future preparation to the replacement of future aircraft technology, in order to prevent accidents defined as "the childhood diseases of the new technology".

Computerizing the cockpit and using advance technologies brought a dramatic decrease of aircraft accidents during the last 20 years. However, the new Glass Cockpit created different kinds of safety problems and caused some fatal accidents in which thousands of people lost their lives and the damages were enormous.

This applied research tests, in great depth, the reasons why 27 fatal accidents occurred while involving advanced technology aircraft. The research analyzes the acute phenomena, which characterizes the human factor in Glass Cockpit aircraft:

• Misunderstanding the behavior of the aircraft, including its systems
• Canalizing events
• Spatial orientation failures
• Aircraft maneuvering envelopes exceedance
• The unique mental factors

The research analyzes the deterioration of acute technical failures, leading to loss of control of the aircraft, and to the contribution of the "organization" factors (manufacturer, airlines and the civil aviation authorities) to the chain of failures, which led to the occurrence of the accidents, relating to the aircrafts' design, maintenance, operation and the policy involving aircrew handling.

Table of Contents

Abstract

Preface

Abbreviations

I. Methodology

• Background
• Objectives
• Research Population

II. Analysis TOC

• Figure 1. Accident Rate in Advanced Technology Aircraft: General Trend
• 1. Introduction of Advanced Technology
• 2. Distribution by Manufacturer
• 3. Regional Distribution by Continent
• 4. Nature of Accidents
  • 4.1. CFIT-related Accidents
  • 4.2. Analysis of LOC-related Accidents
  • 4.3. On-Ground Collision
  • 4.4. In-Flight Collision (MIDAIR)
  • 4.5. Landing
• 5. The Human Factor
  • 5.1. Distribution of Causes
  • 5.2. Human-FDC
  • 5.3. Factors that Contribute to FDC
• 6. Technical Malfunction
• 7. G/C Related Accidents
  • 7.1. Phases of G/C Accidents
  • 7.2. The Nature of G/C Related Accidents
  • 7.3. Knowledge in G/C Related Accidents
  • 7.4. Mental Factors in G/C-Related Accidents
  • 7.5. G/C - MMI
• Table: Types of Error - G/C Switches
• Table: Types of Failure in G/C Flight-Mode Detection
• 8. The Organization
  • 8.1. The Organization as a Cause of Accidents
  • 8.2. Organization - Contributing Factors
  • 8.3. The Manufacturer
  • 8.4. The Airline
  • 8.5. Civil Aviation Authorities (CAA)

III Findings

• 1. Principal Findings
• 2. Detailed Findings
  • 2.1. Categorization of Causal Factors
  • 2.2. Risk Categories
  • 2.3. Human Factors -Summary of Findings
  • 2.4. MMI
  • 2.5. G/C related accidents

IV. Conclusions

• 1. General
• 2. The Manufacturer
• 3. The Airline
• 4. Civil Aviation Authorities (CAA)

V. Recommendations

• 1. Recommendations to CAA
• 2. Recommendations to the Airlines
• 3. Recommendations to the Manufacturer

Acknowledgements

References

Appendixes

App. 1 Description of the Accidents ( 92 pages)

App. 2 Tables - Data Distribution

• 1. General Data
• 2. Nature
• 3. Cause
• 4. Location of Accident - Continents
• 5. Contributing Factors - Flight Phase
• 6. Contributing Factors - Air Crew
• 7. Contributing Factors - ATC
• 8. Contributing Factors - Environment
• 9. Contributing Factors - Technical Failures
• 10. Organization Related Factors

FDC Related - Types of Errors

• 11. Noncompliance to SOP
• 12. Spatial Orientation Error (Perceptual Error)
• 13. Types of FDC Errors - ATC & Area
• 14. Aircraft Handling Errors (Skill Based Errors)
• 15. Disregarding the Alert Systems
• 16. Man-Machine Interface (MMI) Errors
• 17. Flight Condition Identification Errors
• 18. Casual Factors -Human- Machine - Environment: Summary Table
• 19. Types of Errors - Air Traffic Controllers

App. 3 Graphic representation of data