Factors that Influenced Airplane State Awareness Accidents and Incidents: CAST SE-210 Output 2: Report 2 of 6

This report is part of a series of reports that address flight deck design and evaluation, written as a response to loss of control accidents. In particular, this activity is directed at failures in airplane state awareness in which the pilot loses awareness of the airplane’s energy state or attitude and enters an upset condition. The Commercial Aviation Safety Team (CAST) created a team to analyze a set of incidents and accidents associated with the flight crew’s loss of awareness of aircraft attitude or energy state. The CAST activity focused on a set of 18 loss of control (LOC) accidents and incidents. In those events, the pilot seemed to lose awareness of the state of the airplane, especially related to its energy state or its attitude. To understand the roots of that loss of awareness, we analyzed the events in relation to a set of factors that were present in many of them. We show how these factors contributed to lost awareness. Then, we use that understanding to identify potentially useful changes to the flight deck interface and how those flight deck changes could be evaluated.