That, in turn, caused the auto-throttle to reduce speed to a dangerously slow level so that the plane lost lift and stalled. Dutch investigators described the flight's three pilots' "automation surprise" when they discovered the plane was about to stall. They hadn't been closely monitoring the airspeed.
Last month, French investigators recommended that all pilots get mandatory training in manual flying and handling a high-altitude stall. The recommendations were in response to the 2009 crash of an Air France jet flying from Brazil to Paris. All 228 people aboard were killed.
An investigation found that airspeed sensors fed bad information to the Airbus A330's computers. That caused the autopilot to disengage suddenly and a stall warning to activate.
The co-pilot at the controls struggled to save the plane, but because he kept pointing the plane's nose up, he actually caused the stall instead of preventing it, experts said. Despite the bad airspeed information, which lasted for less than a minute, there was nothing to prevent the plane from continuing to fly if the pilot had followed the correct procedure for such circumstances, which is to continue to fly levelly in the same direction at the same speed while trying to determine the nature of the problem, they said.
In such cases, the pilots and the technology are failing together, said former US Airways Capt. Chesley "Sully" Sullenberger, whose precision flying is credited with saving all 155 people aboard an Airbus A320 after it lost power in a collision with Canada geese shortly after takeoff from New York's LaGuardia Airport two years ago.
"If we only look at the pilots - the human factor - then we are ignoring other important factors," he said. "We have to look at how they work together."
The ability of pilots to respond to the unexpected loss or malfunction of automated aircraft systems "is the big issue that we can no longer hide from in aviation," said Bill Voss, president of the Flight Safety Foundation in Alexandria, Va. "We've been very slow to recognize the consequence of it and deal with it."
The foundation, which is industry-supported, promotes aviation safety around the world.
Airlines are also seeing smaller incidents in which pilots waste precious time repeatedly trying to restart the autopilot or fix other automated systems when what they should be doing is "grasping the controls and flying the airplane," said Bob Coffman, another member of the FAA pilot training committee and an airline captain.
Paul Railsback, operations director at the Air Transport Association, which represents airlines, said: "We think the best way to handle this is through the policies and training of the airlines to ensure they stipulate that the pilots devote a fair amount of time to manually flying. We want to encourage pilots to do that and not rely 100 percent on the automation. I think many airlines are moving in that direction."
In May, the FAA proposed requiring airlines to train pilots on how to recover from a stall, as well as expose them to more realistic problem scenarios.
But other new regulations are going in the opposite direction. Today, pilots are required to use their autopilot when flying at altitudes above 24,000 feet, which is where airliners spend much of their time cruising. The required minimum vertical safety buffer between planes has been reduced from 2,000 feet to 1,000 feet. That means more planes flying closer together, necessitating the kind of precision flying more reliably produced by automation than human beings.
The same situation is increasingly common closer to the ground.
The FAA is moving from an air traffic control system based on radar technology to more precise GPS navigation. Instead of time-consuming, fuel-burning stair-step descents, planes will be able to glide in more steeply for landings with their engines idling. Aircraft will be able to land and take off closer together and more frequently, even in poor weather, because pilots will know the precise location of other aircraft and obstacles on the ground. Fewer planes will be diverted.
The board also found fault with the FAA for failing to update certification requirements for flying in icy conditions.
SFO Asiana crash spotlights automation addiction, experts testify
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