Human Factors Observations in Flightcrew Response to System Failure Events in Transport Category Aircraft from 2000 to 2024

Abstract

Understanding the effects of changes in aircraft technology on pilot response to system failure is crucial in the context of recent aviation safety events. This thesis makes human factors observations on pilot response to system malfunction in transport category aircraft through an analysis of final investigation reports produced by investigative authorities worldwide from 2000-2024. In the collected reports, system failure events in aircraft of newer generations correlated with higher percentages of appropriate response. Pilot response appropriateness was found to vary between systems, with particularly low appropriate response to failure of instruments and navigation, fuel, and autoflight systems (in decreasing order). When comparing the findings from the 2000-2024 data collection to those from a 1990-2000 study, pilot appropriate response was found to have increased for failures of the hydraulic and electrical systems. Pilot response to instruments and navigation, and autoflight failures was found to be low in both studies. Crew Alerting System (CAS) messages as initial stimuli for failure awareness were found to support increased levels of appropriate response percentages for failure of the electrical and hydraulic systems. CAS messages did not lead to a substantial improvement in appropriate response to failure of instruments and navigation, fuel, or the autoflight system. Finally, Endsley’s Situation Awareness theory was used as a framework to derive observations in the formulation of pilot responses to system failure across cases. CAS messages and system synoptic displays were observed to contribute to appropriate pilot perception, comprehension, and projection of failure of simple systems. Significant underlying complexity in the function of the autoflight and instruments and navigation systems, and the increased use of sensing, correlated with difficulty in comprehension and projection of system behavior following multiple failure events in 2000-2024 reports. Additionally, examples of failures across systems which displayed delayed or subtle stimuli, and unexpected system dependencies, were observed to lead to difficulties in flightcrew achievement of Level 2 and Level 3 Situation Awareness. Changes in aircraft technology were deemed to have had a varying effect on pilot situation awareness during failure of different airplane systems. Improvements in pilot response were observed in relatively simple systems, and gaps were identified given increased vulnerabilities in failure of systems with high functional complexity.