In this research paper, I go over research related to the dangers in automation in the aviation domain and how it compares to the two most recent Boeing 737 Max accidents. (This article was written before the final NTSB report was released).

1. The Dangers ofAutomation in theAviation Domain
In this research paper, I go over research related to the dangers in automation in the
aviation domain and how it compares to the two most recent Boeing 737 Max
accidents. (This article waswritten before the final NTSB report wasreleased).
The Dangers of Automation in the Aviation Domain
Technology has had an enormous impact on the development of aviation. Whether it be through
efficiency, cost, comfort or safety, the advancements that have been made since we first took
flight 116 years ago is substantial. Despite this, technology has also become aviation’s biggest

2. threat to the security and safety of those who use it. A prime example of this is the 346 lives lost
in October 2018 and March 2019, seemingly due to a software glitch in two relatively new
aircraft, the Boeing 737 Max. Because of these recent crashes and numerous ones before them, it
is imperative to stop relying so heavily on automated aircraft in order to prevent more automation-
related accidents from happening.
737 Max Accidents
On October 29, 2018, Lion Air Flight 610 crashed minutes after taking off from Jakarta,
Indonesia. It was the first fatal accident involving a 737 Max, killing all 189 people on board.
Five months later, on March 10, Ethiopian Airlines Flight 302, also a 737 Max, crashed minutes
after takeoff, killing all 157 people on board. According to the New York Times article by Zach
Wichter, early black box data suggested similarities between the two accidents. There were
similar struggles between the crew members and aircraft which eventually led investigators to cite
the automated system designed to help the aircraft avoid stalling the cause of the crashes.
There are two versions of the Max; the 8 and the 9 with two more versions on the way. The
Maneuvering Characteristics Augmentation System (MCAS) is an automated system specifically
used on the newest type of the 737 aircraft, the Max. This system prevents the aircraft from
stalling (or losing lift) and essentially from falling out of the sky. The aircraft’s engineers
designed the MCAS system in order to balance out the negative effects from the planes new
engine design. The new engines are supposed to increase fuel efficiency, which would allow the
plane to travel further without using as much fuel, ultimately saving money for the airlines. But
because of the increased size of the engines, engineers had to reposition the bigger engines in a

3. higher and more forward position than the original models of the 737. This new position stalls the
aircraft at a quicker rate than older versions of the 737, so it was important to add the MCAS
system in order to avert a perilous stall.
The way the MCAS system works is that it automatically pushes the nose of the aircraft down
whenever it senses it is reaching a stalling state. This system is supposed to be able to be turned
off in the case of any malfunction and allowed to be hand-flown. Investigators in Ethiopia said,
however, that the pilots on that flight repeatedly used procedures outlined by Boeing to disengage
the system when they noticed the systems was not responding the way it should, but the aircraft
still wound up in an unrecoverable nose-dive from the MCAS system reacting to false inputs,
resulting in the death of all passengers on board.
Since the Ethiopian crash, 737 Max aircraft were grounded all around the world. That equated to
around 8,600 flight being grounded within days, but since it is a relatively new plane, disruptions
remained minimal. Pilots are now required to get new training from their airline while new
software updates are installed on each aircraft. The Max will not be allowed to be “un-grounded”
until this update and new training is complete.
Immediately after both crashes there were early talks of what might have been the cause for these
accidents: Early allegations were fixated on the pilots and the lack of training that foreign airlines
provide. Such criticisms of this included hiring minimum hours captains with little experience to
fly these brand-new jet aircraft and therefore the pilots supposedly not knowing how to turn the
MCAS system off. Some even blamed the FAA for writing off on this system without having a
full understanding of it. Now, however, new information from preliminary reports are leading

4. investigators to believe that the two aircraft actually had software malfunctions that were
preventing the MCAS system to be disengaged, meaning that the crew had no chance to recover
the aircraft from their fatal nose-dives.
Summary of Main Points
Technology has significantly impacted every aspect of our lives whether we realize it or not.
Within the aviation domain specifically, the technology that we rely on to safely operate aircraft
can be unpredictable at times. If there are not backup systems put into place, malfunctions can be
unavoidable and even deadly. Our over-reliance on automated systems have been proven deadly
to the aviation domain long before the 737 Max crashes. According to a study by Curtis Taylor, a
master’s student in aviation technology at Purdue University, from January 2007 to December
2018, there were 161 total incidents that involved automation. In 73 of the incidents, the pilots
reported autopilot dependency as the cause of the incident. 34 were reported as an autopilot
malfunction, and 12 were a lack of familiarity with the system (Sreeharikesan). Each one of those
incidents is a threat to aviation safety and could have been prevented.
It has been shown time and time again that when pilots fully rely on automation, they lose the
ability to fully understand how to fly the aircraft. It has also been proven that our society has been
lagging with the fast-paced technological changes, to the point that it has been difficult for
lawmakers and federal organizations to keep up with such an advancement in technology.
Furthermore, because of the quick-paced nature of these advancements, the aviation domain will
never fully understand the scope of the danger’s technology brings. Whether it be through terrorist

5. threats or cyber-attacks, officials who are in charge of the safety of the aviation domain will never
be able to fully predict the next big crash.
Topic 1: With technology comes errors we as humans cannot control
In order to understand why we use automation, it is important to understand what automation is
and why we use it. The author of Commercial Aviation Safety, Alexander Wells, explains:
Automation, or assigning physical or mental tasks previously performed by the crew to machines
or computers is a frequently cited means of reducing human error. Although totally eliminating
humans from the operational loop is not yet feasible nor necessarily desirable, partial replacement
is becoming increasingly common (Wells).
Automation is widely used in aviation in order to have a more efficient and precise flight
operation. In turn, this helps airlines, airports and ultimately customers to save money and time.
With an already full workload, pilots are able to fall back on automation in order to lessen the
stressors of their jobs. This comes at a price though: Because these technologies are being
replaced by what is usually done by a human, it is now the human’s job to monitor the system and
ensure proper settings. So really, it does not truly lessen the workload of the pilot at all. Now they
are stuck with “babysitting” the system and make sure nothing goes wrong. An example of this
automated use is that of a glass cockpit, which is essentially a system that controls the aircraft
flight path through an electronic interface. This allows it to be flown through a pilot’s fingertips
through buttons, dials and knobs and not the actual aircraft controlling itself.

6. Automation was originally invented in order to help supplement the jobs of the people who use
the system, but it is also possible for it to get to the point that it is hurting more than helping. The
book Commercial Aviation Safety relates the Airline Deregulation Act with the safety of the
industry (or the lack thereof). The Airline Deregulation Act of 1978 increased competition
between the airlines, which removed much of the economic regulations that were imposed by the
Civil Aeronautics Board. It affected airlines in many ways, including through mergers and
acquisitions, flight schedules and fares, but this also brought safety concerns. Alexander Wells
explained that “…the merging of maintenance operations and procedures [created] a lack of
standardization of cockpit design and operating procedures across carriers” (Wells).
Consequently, with a system as potentially dangerous as this, you would think it would be a
heavily regulated one, but according to the author of Commercial Aviation Safety, Alexandar
Wells, it is not. He states that there are no FARs relating to cockpit automation and human
performance and that human error hazard analyses are not required in the design, test, or
certification stages. This can be threatening as we will not be able to regulate how far automation
in the cockpit will go.
Flight 148DA is a textbook example of how deadly an automated system mistake in a glass
cockpit can be. The captain of the Airbus A320 went to program the flight control unit to -3.3
degree descent but did so in the wrong mode: the aircraft was in Heading/Vertical Speed Mode
instead of the correct Track/Flight Path Angle Mode, which ultimately commanded the aircraft to
fly a vertical speed four times the rate of descent they needed and crashed just before the runway.
The crash killed 87 of the 96 people on board. Investigators believe that multiple factors such as
high workload, turbulence and unfamiliarity of the aircraft system caused the crash (Lutat). When

7. an aircraft is dependent on computers in order to fly, it loses the mechanics that are supposed to
physically be controlled by. The captain from flight 148DA was not necessarily incapable of
flying the aircraft, but because of the mistake made on inputting the data, many lives were lost.
The author of the book, Cockpit Automation for General Aviators and Future Airline Pilots wrote,
“The problems that arise do not necessarily represent a flaw in the design of the automation or a
defect in our piloting skills. Rather, they seem to be a phenomenon that occurs naturally when
humans work with computers.” (Casner). By saying this, he means that it is inevitable for humans
to work technology perfectly, without flaws. The use of technology produces inaccuracies we
cannot control as humans. Through the use and over-reliance of automation in glass cockpits, we
further increase our chances of dangerous errors that could cost many lives. Airline Deregulation
in 1978, unfortunately, created this culture of fierce competition and lessened economic
regulations between airlines that ultimately always puts safety in second place. The Indonesian
and Lion Air accidents, along with Flight 148DA are perfect examples of this.
Topic 2: Too much reliance on automation
When Captain Sully landed in the Hudson, it was not because pilots receive training to land in a
narrow strip of a river in a heavily populated city after losing an engine to a heavy bird strike. He
was able to recall back to his basic piloting skills and land safely, saving 155 people’s lives. If
Captain Sully had been totally reliant on the automated systems of the aircraft, the outcome of the
bird strike would have been very different. Quick thinking, years of experience and intuition
saved everyone on that flight. Regrettably though, not every automation related accident is lucky
enough to have a pilot as skilled as Sully on their flight.

8. When you begin to rely on a system to the point you forget how it originally is supposed to be
operated, it becomes dangerous. In the book, Stick and Rudder by Wolfgang Langewiesche, he
describes one of the “best” ways of flying; by the seat of your pants:
“…this is perhaps the most hard-to-get-at skill in the whole art of flying-the sense of ‘lift’, the
gauging of the firmness of one’s sustentation, the ‘feel’ a pilot must have for his ship’s Angle of
Attack, the ability to know how close the ship is to the stalled condition: this is what pilots used to
call the flying instinct.”
Flying by using this method is oftentimes described as the best way to fly. This way, a pilot is
able to decide their course of action as they go along, using their own intuition and perceptions
rather than a predetermined plan or mechanical aids.
Topic 3: Difficulties of keeping up with technology
Aviation and its related technologies grew at such a fast pace that those who use it and implement
it on aircraft are struggling to keep up with the ever-changing technologies. It can almost be said
that there can be no expert in any specific type of system nowadays since it is constantly
changing. This clearly becomes a hazardous situation to anyone who operates the system.
In a letter from Senate Commerce Committee chairman Sen. Roger Wicker to the Federal
Aviation Administration, he points out the fact that industry whistleblowers brought to light the
issue of “insufficient training and improper certification” of FAA Aviation Safety Inspectors in

9. regards to the 737 Max crashes. In this letter, he describes a lack of training of these inspectors
may have led to improper evaluation of the MCAS system that brought down the airplanes.
In an NPR transcribed interview, it explains the view from a pilot, David Schaper, who also
claims that there were reports of oversight from the FAA and the Being 737 Max certification.
They discuss The Seattle Times report finding crucial flaws in Boeing’s safety analysis of the new
MCAS system and that Boeing and the FAA were downplaying the risks.
These not being able to keep up with technology and the downplay of risks are just more factors
that add to the hazards of automation. Without a full understanding of the technologies that are
used in the aviation domain on a day to day basis, we are putting thousands of lives at risk and
could potentially cause another tragedy similar to those of the 737 Max’s.
Topic 4: Not fully understanding threats to the aviation domain
Because we are not able to fully understand this ever-changing environment, we lose the ability to
be proactive in safety, which is a big reason as to why the aviation industry is so proactive in its
regulations — you cannot prevent something you do not fully comprehend. In the Security and
Policy class, we discussed what the next aviation attack would look like since they have greatly
transformed throughout the years. In the article by Aerospace America, it discusses the possibility
of one of these possibilities: An aviation cyber-attack. The author talks about the possibility of
unauthorized interference with aviation communications through the use of ACARS. ACARS is a
two-way messaging system that was designed in the 1970s to improve data integrity and reduce
crew and air traffic controller workloads. Flight plans or weather updates from the airline’s

10. operations centers can be routed to a central computer and then transmitted via VHF radio ground
stations to the airplane. A threat using the ACARS system could be anything from corrupt data or
even unauthorized communications that impacts air traffic (Aerospace America).
It is important for us in the industry to become proactive in the search for new dangers rather than
wait for them to happen. This way, the aviation domain can be more successfully prepared for
dealing with terrorist attacks against it.
Possible Solutions:
Automation has proved to be a contributor to a safer more efficient operation of airliners, but it
has not reached a point yet where it can handle every incident. In an article by Aviation Week, the
author says that “crews must be trained to remain mentally engaged and, at low altitudes, tactilely
connected to the controls — even when automation is being employed”. It goes on to say that
aviation agencies need to update standards for certifying air carriers, a new performance-based
model that requires flight crews to log a minimum number if hand-flown takeoffs and departures
without autothrottles, and a general increase of homing in on basic pilot skills. This type of
approach could possibly prove to be advantageous to decreasing automation-related accidents.
According to a PowerPoint presentation from ICAO by Richard Batt, another set of solutions they
found to be helpful with controlling automation related incidents is centering the design of the
automated system and around humans — reduce the number and complexity of auto flight modes
— improve the feedback to pilots on mode transitions — ensure that mode logic assists pilots’
intuitive interpretation of failures and reversions.

11. Conclusion:
The Boeing 737 Max crashes proved that technology is very dangerous when it fails. By focusing
to improve the four topics discussed in this paper, aviation safety will surely benefit. As we rely
less on technology, we will be free from the errors we cannot control, pilots will become better
skilled at handling special situations, regulations will be developed and improved regarding
automation in the cockpit, which will all lead to a better understanding of the technologies we use
on a daily basis. The book The Future of Flight summarizes it perfectly, “The present has
problems. The future holds threats and promises.”
References
Batt, R. (n.d.). Automation Related Incidents — PowerPoint. Retrieved from
https://www.icao.int/
APAC/Meetings/2015 APACAIG3/14.AUS — automation related serious incidents
v2.pdf#search=automation accidents
Billings, Charles E. Aviation Automation: the Search for a Human-Centered Approach.
CRC Pr., 2009.
Casner, Stephen M., and Douglas A. Dupuie. Cockpit Automation for General Aviators and
Future Airline Pilots. Iowa State University Press, 2010.

12. Chang, A. (2019, March 18). Investigators Find More Evidence Of Connections Between
Crashes Of Boeing 737 Max Jets. Retrieved from https://www.npr.org/templates/
transcript/transcript.php?storyId=704562402?storyId=704562402
Don’t wait for disaster. (2019, October). Retrieved from https://aerospaceamerica.aiaa.org
/departments/dont-wait-for-disaster/
Editorial: How To End Automation Dependency. (2013, July 19). Retrieved from
https://aviationweek.com/commercial-aviation/editorial-how-end-automation-
dependency
Elwell, D. (2019, April 2). Committee Launches Investigation of FAA Aviation Safety Inspectors.
Retrieved from https://www.commerce.senate.gov/public/index.cfm/
pressreleases?ID=9A07ED55–194F-4A45-BFB9-E03E0BF5D641
Langewiesche, Wolfgang. Stick & Rudder. TAB/McGraw-Hill, 1994.
Lutat, Christopher J.., and S. Ryan. Swah. Automation Airmanship: Nine Principles for Operating
Glass Cockpit Aircraft. McGraw-Hill Education., 2013.

13. Myrabo, Leik, and Dean Ing. The Future of Flight. Baen Enterprises, 1985.
Risukhin, Vladimir. Controlling Pilot Error: Automation. McGraw-Hill, 2001.
Sreeharikesan, L. (2019, April 04). Purdue aviation technology learns from past accidents.
Retrieved from https://www.purdueexponent.org/campus/article_
d67ada28–9e9b-532b-a80b-c6481c040bbd.html
Thomas, Andrew R. Aviation Insecurity: The New Challenges of Air Travel.
Prometheus Books, 2003.
Wells, Alexander T. Commercial Aviation Safety. Tab Books, 1991.
Wichter, Z. (2019, March 22). Boeing 737 Max: What’s Happened After the Ethiopian Airlines
and Lion Air Crashes. Retrieved from https://www.nytimes.com/interactive/2019/
business/boeing-737-crashes.html