When 737MAX accidents happened, I have a book in the final stage, dealing precisely with some wrong automation related practices. This presentation intends to be an extremely short summary of the book. It was prepared for a professional meeting that, finally, I could not attend.

1. Pilots’ Training and
Automation
A deathly mix
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2. Why Pilots’ Training is not so
good as it should be?
• Because it’s a piece of the design:
• Good training is costly in time and money.
• A properly trained pilot is not easy to replace.
• A training going beyond procedural knowledge could reveal design secrets.
• And these problems are avoided in these ways:
• Providing the pilots with user knowledge about the systems that are
operated.
• Designing planes who hide the real difficulty to operate them (i.e. unstable
airframes with software help to handle them).
• Building very different planes with identical systems..
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3. Summarizing…
• In the modern planes, the pilot operates a system instead of a plane…
• The knowledge about the system can be defined as user knowledge…
• That can be shared by different planes…
• Allowing multi-rating…
• Shortening the time for transition and for initial training…
• And making the pilot easy to replace.
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4. However, sometimes accidents
happen…
• Saint Odile:
• An instrument, depending of the position of a switch, could mean angle or rate of descent.
• XL888T:
• The “minority report” approach failed: Two out of three sensors provided wrong information, triggering an automatic answer.
• AF447:
• A frozen sensor provokes a confusion state in a plane that, supposedly, could not stall and, hence, the crew did not practice its recovery.
• Wrong behavior of the pilot. Environment: A warning goes off when the plane starts to recover and remains silent when the spped of the
plane is out of valid values.
• EMIRATES 407:
• A mistake at setting take-off power produced and accident. This mistake has happened several times, especially, with crews used to fly varieties
of the same plane.
• ASIANA 214:
• The pilot does not feel comfortable at landing manually the plane.
• A difference in the design of Boeing and Airbus drives the pilot to miss a detail indicating that the engines are not supplying power (thrust lever
position).
• BOEING 737MAX CASES:
• A new system, addressed to get a similar behavior of the plane to former generations of the same plane, was hidden to the pilots. Supposedly,
it could help to avoid new training for those used to those former generations of the plane.
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5. Common answer to the accidents
• Pointing to “Human Error” in different ways:
• Lack of training.
• Complacency.
• Lack of Compliance.
• Most usual solutions:
• Introducing a new item in training, especifically addressed to deal with the
last discovered problem (we will deal with the next one when it happens).
• Emphasizing procedures that, supposedly, would have avoided the problem.
• In some cases, design changes are introduced and they are presented as
“improvement”, avoiding calling them “ corrections”.
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6. Problem with this approach:
• Risk calculation model similar to the used by an insurance company:
• If the number of accidents is below a threshold, the system is valid.
• Only minor adjustments are allowed.
• The existence of uncommon accidents is assumed.
• The profits of this model justify its use.
• Eliminates or limits the options of an alternative resource:
• Pilots appear more as supervisors than as actors (and people are more gifted for
action than for supervision).
• The wrong triggering of automatic processes can make harder the identification of
the original problem, preventing its solution.
• The system can show a fully developed emergency, without a previous warning that
could have helped to assess the situation.
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7. Reasons to change the model
• The insurance company approach is not valid for public and an
acceptability crisis could happen:
• People don’t accept in the same way an accident whose causes were unknown and
another accident whose causes were known and the accidents had been discounted
in the design.
• An “assumed accident” position can become a “trending topic”, unshackling a tide
that, in the present environment, would be uncontrollable:
• i.e. an ETOPS 370 related major event.
• New confusions related with automation.
• Planes loaded with lithium batteries…
• Technically, keeping the positive side of the present approach and
eliminate or limitate the negative side is possible:
• Training based in the real functionality of systems instead of metaphors about how
they work.
• “Ecological Interface Design” or similar approaches.
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8. Instead…
• Different actors are working to eliminate the first officer or, in some
cases, to use drones for cargo flights:
• Still more automation.
• Opening to “hacking” possibilities (see RQ-170 case).
• Introduction of Artificial Intelligence and Machine Learning:
• There is not a single system able to access the meaning of a situation nor to
question itself.
• No guarantees about the correctness of the learned lessons (if wrong, that
will become evident in critical situations, not in ordinary ones).
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9. To finish…
Edgar Morin said that “the machine-machine is always superior to the
man-machine”.
If we insist using people like machines, we will incur in the same
problems, corrected and increased.
If, instead, the potential of people is used, the environment should
allow it:
• More action than supervision.
• Functional knowledge, not metaphors nor “user transparent” systems.
• Automation must be designed keeping in mind the impact in situation
awareness, not only workload.
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10. Thank you very much
Any question or comment can be addressed to my Linkedin profile:
https://www.linkedin.com/in/sanchezalarcos/
This presentation is a kind of extremely short summary of the contents of my new book
https://www.crcpress.com/Aviation-and-Human-Factors-How-to-Incorporate-Human-
Factors-into-the-Field/Sanchez-Alarcos/p/book/9780367245733
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