Seattle and Toulouse, we have a serious problem with pilot training, skill levels, and automation.
That is the emerging message from the recent loss of two Boeing 737 MAX aircraft along with AF447, an A330 in 2009; Ethiopian ET409, a 737-800 in 2010, Asiana OZ214 a Boeing 777 in 2012, Indonesia AirAsia QZ8501, an A320 in 2014, and the Atlas Air 767F last month.
While the debate rages about the pilot automation interface, that may not be the direct issue.
Potentially more important is what happens when humans interact with that interface under intense pressure and the emerging problem of “automation paralysis”.
Although we are yet to find out what happened on ET302, it appears pilots under intense pressure may not have followed either basic airmanship fundamentals, core basic training or straightforward instructions from their fellow pilots (AF447 and QZ8501).
Professor Najmedin Meshkati*, a professor of engineering and aviation safety at the University of Southern California believes what Boeing and Airbus need to do is “first acknowledge and second to address individual differences in information processing and decision making both under routine and non-routine situations”.
He says they should also if possible, design “adaptive” automation to cater to the needs, limitations, and capabilities of different pilots regardless of their experience and varied training standards.
“I am talking about their cognitive styles which are totally different and independent from age, IQ, experiential knowledge or flying skills,” he says.
“I think it’s not simply making the aircraft “idiot proof” as many suggest. During the time of stress, some pilots are or may be “freezing up”.
Meshkati was commissioned to study the phenomenon, called “decision making under stress or overload” in the 1990s. He was given two grants from the US Nuclear Regulatory Commission (NRC) and designed and conducted experiments at a small nuclear reactor EBR II in Idaho Falls.
The study found that under extreme pressure, operators (pilots) dominant decision style shifts to their back up decision style during the overload stressful situation and instead of becoming more “Decisive”, uni-focus some of them may become more “Integrative”, multi-foci and may ask for more information which is a more elaborate and slower decision-making style.
“This is perfectly normal but the key is to understand and appreciate individual differences ahead of time and to address that in design and operation of our technological systems, such as the cockpit,’’ Meshkati says.
This is an enormous challenge for both manufactures when the skill levels — or lack thereof —- of some pilots going through training today is taken into account.
A senior captain with 35 years’ experience with a leading pilot training organization told AirlineRatings.com that of the pilots his company is training “only 10 percent are smart enough to understand every system on an aircraft.”
“Today’s aircraft – the A350, 787, A320neo and 737MAX are hugely complicated with multiple redundancies which is why flying is so safe. But when I instruct the pilots, I’ve got to be very careful about not telling them too many facts. Sure, if I’ve got a very, very clever pilot I will tell him or her more of the facts. But essentially, they don’t have to know all the complex background systems. The pilot just has to know how to react if a system fails,” said the training captain.
He adds: “For instance, the tutorials that we are given have the simplest little cartoon pictures on how this thing works. Really simple, and essentially that’s all the guys have to know and they don’t learn anything more than that. Both major manufacturers are buying into this philosophy. There are focused on making their planes as simple as possible to operate while increasing the complexity in the background to improve safety.”
In the Lion Air accident, a new background software system called Maneuvering Characteristics Augmentation System (MCAS), which was developed for the MAX to prevent stalls when the aircraft is in flaps-retracted, low-speed, nose-up flight configuration, activated because of a faulty Angle of Attack (AoA) sensor.
MCAS uses airspeed and other sensor data like AoA to compute a dangerous flight condition and trims the aircraft nose down. If the AoA continues to send the faulty data through the MCAS keeps trimming forward and a runaway stabilizer trim condition develops sending the aircraft into a dive. The solution is a memory item of switching off the runaway Stab Trim.
MCAS was developed to harmonize the flight characteristics of the MAX and the previous NG model as the new model has more powerful engines mounted higher and further forward on the wing.
A senior 737 check captain with an Australian airline backs up the background MCAS system saying “we don’t want to go too deep into background systems or pilots get overloaded at critical times. The runaway stabilizer trim procedure has been in Boeing aircraft since 1960.”
In the Lion Air tragedy on October 29, 2018, the training captain is critical of both pilots.
“If you have a stabilizer trim runaway, which they had, and it’s not your action, there are two cut-off switches right next to the throttles,’’ he says. “You uncap them and you switch it off. It’s just that simple.”
“The previous crew that had the same problem should have written that up properly so when the next pilot comes in, he looks in the tech log and he sees what happened. Even if he forgot the procedure he would have been reminded of the procedure.”
On the new much talked about MCAS system software, the training captain says “even if they had intimate knowledge of the system you still have to cut off the stabilizer trim regardless.”
He adds: It’s a bit like the cruise control on your car. If you get a surge of power for some reason you put your foot on the brake, you don’t troubleshoot the problem. Another great example is an engine fire – the pilot doesn’t need to know what part of the engine is on fire or why he just needs to kill the fire.”
The training captain highlights an earlier AoA issue on the A320 where it was icing up. “The 320’s were icing up and clever pilots knew exactly what to do with this thing when it happened. It was icing up at about 19,000ft and the airplane pitched down responding to the erroneous data.”
“Now in Boeing’s case if it does that [pitch down] you uncap the switches and switch the stabilizer trim off. On the Airbus what you do is to switch two computers off to stop the computer from taking control, so you go to a more manual phase.”
Former senior air safety investigator with the National Transportation Safety Board, Greg Feith, also questions the flying skills and training of the pilots in the Lion Air and Ethiopian crashes.
“United Airlines stated after the Lion Air accident that their training program for the 737MAX was robust and that their pilots were thoroughly trained,’’ he says.
“Over the past few days [after the Ethiopian crash], US carriers who stood behind the airplane also expressed confidence in their respective training programs for the MAX and the pilots who fly them.”
“So, the question that needs to be asked and investigated is how thorough and robust is the 737MAX pilot training program at Ethiopian Airlines [and Lion Air], what was the training history of the two accident pilots, how much time-in-type did they both have?
“Lastly what is the expectation and competence level of a 200-hour F/O in the Ethiopian crash and if the captain had very limited time in the MAX, his competence level as well,” Feith told AirlineRatings.com.
“I think the Lion Air accident is a good example – the pilots who flew the accident aircraft in the days before the crash were successful in recognizing the anomalous airspeed and stall warning indications and they took the appropriate corrective actions to successfully complete their respective flights – yet the accident flight crew failed to take the proper corrective actions.
“When that investigation is completed, I believe improper actions by maintenance personnel and the accident flight crew will be the prominent causal factors.”
Feith says that “in the coverage of both accidents virtually no one is talking about the pilots, nor the airlines involved, nor the training, nor the experience of the pilots”.
“It is well beyond time that these direct factors are understood, investigated and considered a possible contributor to the two distinct MAX accidents.”
Feith says the Ethiopian captain’s 8000 hours total time is one thing but “how much time in type is the real question.”
“Ethiopian does not have many of these model airplanes currently in service and the accident airplane was delivered in November.,’’ he says.
“Thus, one question is how many hours did both pilots have in the actual airplane since they completed training. A 200-hour F/O begs the questions about the training program and how much the F/O could really contribute with very limited experience.”
However, Representative Peter A. DeFazio, Democrat of Oregon and the chairman of the US House transportation committee, told the New York Times this past weekend that when he asked the FAA after the Lion Air crash why more substantial training was not required he was told that it based its rules for training around the typical experience of a pilot in the United States, explaining that “the average caliber, skill, and training of U.S. pilots is extensive, with countless hours of flight time and training both on the flight deck and in simulators.”
Mr DeFazio said that “overseas pilots, in some cases, have a tiny fraction of the training that our pilots have.”
Feith also highlights automation paralysis.
“In the Atlas Air 767 crash last month, the autopilot and auto-throttle were both engaged when it crashed. The issue that is becoming clear is that these ‘children of the magenta line’ don’t know when to disconnect automation and fly the plane,” says Feith.
“We are finding that when ‘an issue’ develops the pilots are waiting too long to intervene or not intervening at all and a benign situation quickly becomes catastrophic. In both MAX accidents it was daylight and clear skies. Put the nose on the horizon and fly the plane manually, what could be simpler?”
In the case of the Ethiopian accident the airline’s CEO, Tewolde Gebremariam told CNN’s Richard Quest that both pilots had gone through additional training related to MCAS software after the Lion Air accident.
Feith then asks: “So why didn’t they switch off the runaway stabilizer trim?”
Feith also highlights the amount of flying some low-cost airlines are forcing their pilots to perform. Some pilots are flying 110 hours a month. They are overworked and fatigue is a big issue,” he says.
Last year Frank Caron, who was brought in as Lion Air’s safety manager from 2009 to 2011 on orders from insurance ﬁrms, told the New York Times that the airline had an average of one major engineering issue every three days, even though most of its ﬂeet was new.
“Buying all the latest‑generation, state‑of‑the‑art engineering will be in vain if you don’t have systems in place that prioritize safety,” he told the NYT.
Caron said that pilot logbooks drastically understated the number of hours pilots actually worked.
“What I saw was a company, from the top down, that made saving money a motto — so spend the minimum on pilot training, salaries, management, everything,” he said.
Caron told Reuters that “safety is much more than running concepts and procedures, safety is a spirit, a state of mind, a way of thinking, an attitude in the daily aspects of operational life.
“And that is precisely what Lion never got. They would say, ‘the airline has 250 flights a day, it is not abnormal that you have accidents.’”
After the 2013 Bali crash, Lion Air co-founder Rusdi Kirana told media when asked about the airline’s poor safety record: “If we are seen to have many accidents, it’s because of our frequency of flights.”
Caron told Reuters that he left Lion Air after some of his safety recommendations were not implemented.
Lion Air rejected all of Caron’s claims.
Pondering these tragedies, Meshkati who has conducted extensive research on the role of safety culture in complex technological systems failures over the last 30 years, believes that “safety culture is analogous to human body’s “immune system” that protects it against pathogens and fends off diseases.”
And he quotes the renowned professor emeritus of Psychology at the University of Manchester, James Reason, who is considered a founding father of understanding of root-causes of human error and systems failures.
Reason noticed that because of the pervasive nature of safety culture and its widespread impact “it can affect all elements in a system for good or ill”.
Meshkati also reflects on Nobel laureate Richard Feynman’s famous observation ‘for a successful technology, reality must take precedence over public relations, for nature cannot be fooled’ saying it has relevance to the expectation by the aviation industry and general public that the new technology being incorporated into the latest generation of aircraft will by itself eliminate all airline accidents.
Meshkati warned in an interview with the author just before AF447 in 2009 that “all the gee-whiz technology may be masking a deterioration and ‘de-skilling’ in basic flying ability and that the lessons learned by generations of pilots “may be lost to the new breed of pilots.”
That view reflected a comprehensive NASA Research Center study based on Royal Air Force Institute of Aviation Medicine data by Dr. Marianne Rudisill in 1995 that surveyed more than 1,000 pilots from 20 airlines and aircraft manufacturers about pilots’ attitudes and experience with flight deck automation.
The strength of the study was that most respondents had flown aircraft from basic cockpit types like 727s through to Glass 2 types such as A320s and 747-400s.
It found the general consensus was that “safety is increased with automation but automation may lend a false sense of security, particularly with inexperienced pilots.”
Pilots reported that there was a higher sense of “insecurity” during an automation failure and a general temptation to ignore raw information and “follow the green/magenta line.”
The most worrying aspect was that pilots said their colleagues were “becoming complacent and relied too much on the automation but that was often because airline SoPs mandated reliance on automation.”
USAF Maj. Charles Spencer Jr., in a 2000 paper on cockpit automation and mode confusion that combined Rudisill’s findings, subsequent works and his own 20 years in civil flying in automated and nonautomated aircraft, found “mode confusion” to be a major issue and claimed that “ergonomic design has not kept up with cockpit design.”
He found that pilots misunderstand the behavior of cockpit automation and that; “usually the result is a benign inconvenience, but it has occasionally ended in tragedy.”
His paper called for a new approach to alerting pilots with a four-tiered aural system.
Airbus VP-Training Jacques Drappier, in a 2009 presentation on the subject of erosion of manual flying skills in highly automated aircraft, again just before AF447, said the jury is out on the subject.
“From a safety standpoint automation gives a maximum of safety. However, it must go alongside manual flying skills,’’ he said. “We must maintain these flying skills and the way is through training.” However, Asiana OZ214 was a wakeup call to the industry that cultural factors, when a pilot was under pressure, could not always be eliminated by training.
He also raised the issue of the speed with which copilots are reaching captain status, with some gaining the left seat in four years with fewer than 3,000 hr. as first officers.
“Can we really believe that these youngsters have mastered the skills necessary in this time?’ he asked.
He added: “In some respects, automated aircraft may require a higher standard of basic stick and rudder skills, if only because these skills are practiced less often and may be called upon in the most demanding emergency situations.”
But 10 years later, it would appear the opposite is the case with a significant deterioration of flying skills.
Not only do Boeing and Airbus have a problem but the entire industry has a problem if it is to double in size in the next 15 years. Do the aircraft manufacturers have to go back to the drawing board and design aircraft cockpits for a lower pilot skill and training level that we are now seeing?
On that issue, Meshkati again “urges safety regulators to take the lead in developing a more safety-focused culture to improve basic airmanship, as technology by itself cannot solve or remove all human factors from the safety equation.”
*Meshkati is also a fellow on the Project on Managing the Atom at the Belfer Center for Science and International Affairs at Kennedy School of Government at Harvard University.