United States Department of Transportation
i
Flightcrew Response to Aircraft System Failures, Malfunctions, and Systems Not Functioning as Expected
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2023-10-01
[PDF-2.13 MB]
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Edition:Final Report
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Abstract:The primary goal of this research was to analyze operational data to study flightcrew response to system failures, malfunctions, and systems not functioning as expected. Data from normal flight operations show that pilots are exposed to such situations regularly. We reviewed 20 records from the Aviation Safety Reporting System (ASRS) public database and five public accident reports (Qantas 72, US Airways 1549, Qantas 32, Lion Air 610, and Ethiopian Airlines 302). Data from the accident reports are presented at three levels of detail. First, a short summary of basic facts introduces the reader to the malfunctions and pilot responses that occurred. Second, a bulleted summary focuses on the flightcrew perspective, what they experienced, and how they responded to the malfunction and overall situation. Finally, detailed quotes from the accident reports that support the summaries are provided in an appendix. We highlight key observations from both the ASRS analysis and the review of accidents. In addition to the data analysis, this report has a review of associated literature covering research on aircraft system problems, alerts and checklists, pilot training, and pilot response. The literature review illustrates the broad scope, variety, and depth of research connected to pilot response.
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