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are essential during this phase and correction needed to be applied. for safety disclosures remain as or more
should be conducted very early in the important than ever.
investigation. The longer you wait, Considerations During the Analysis Emerging issues may include civilian
the fuzzier or biased the information Phase—It Goes Beyond What You See space flights with passengers, supersonic
becomes. • With factual information in hand, flights with new technologies, and avia-
what items and issues were factors tion law vs. space law.
Be Prepared to Consider… in the event integration or lack of My intention is to make you think
• Unexpected ways in which crews or integration with aircraft systems—for about the effects of technology, not only
individuals may miss or misunder- example, mounts. Lack of integra- in our personal lives but also during an
stand important operational informa- tion example: iPads mounts using accident investigation. Indeed, the world
tion. One sentence can be interpreted suction cups to hold them in place in has changed a lot over the last few
in many ways. As we know, when the cockpit side windows. Were they decades. With the arrival of mobile
you’re very familiar with the area, properly installed and in position be- technology, mobility is more present
you tend to take the route you always fore the event? On impact, was there than ever. We must readjust to the new
take and not the authorized one. An a potential to injure the crew? environment and the way we work. This
example of a clearance where pilots • Human factors readjustment isn’t a smooth one, but we
were told to cross 15 Right, Left, and º Ergonomics of data—how acces- have no choice but to think differently
Bravo to the gap at AK—is it left on sible—SHELL model. Software, and change the way we do things if we
Bravo or 15 Left? hardware, environment, liveware. want to succeed.
• Unexpected ways that crews or º Human Factors Analysis and Classi-
individuals use digital devices may be fication System (HFACS).
factors in the investigation.
º Crew resource management.
º A CRJ accident at Toronto Pearson º Human performance.
International Airport—crew film-
ing—A07O0124—Loss of situational • Did the digital information or activi-
awareness of a crewmember. When ties create distractions?
the captain began to engage in º Push notifications from the iPad.
nonpilot-related activities during º As you’re getting close to the
the final stage of the approach, he ground, if the iPad isn’t in airplane
left almost all decision-making and mode, you’ll have notifications pop-
control of the aircraft to the first of- ping on your screen, which can be
ficer. The captain didn’t notice that very distracting, especially at night.
the first officer left the autopilot en- • If recording was occurring—did this
gaged well below the recommended affect individual conduct and the “My intention is
minimum altitude. to make you think
event itself?
º A photo taken just before a fa- By using existing tools such as the about the effects
tal midair collision in May 2019 HFACS system, you’ll answer many of of technology,
between two passenger seaplanes these questions. But you still need to be
near Ketchikan, Alaska, has become familiar with the technology to under- not only in our
central to the NTSB investigation. stand the subtleties that it may entail. personal lives
º During the approach—a parasit- but also during
ic call to the cockpit late in the Summary an accident
approach. It could also be an alert The digital cockpit landscape is evolving.
from the ECAM/EICAS. This could From the B-747 to the A220, from the U.S. investigation.”
be very distracting while making an Space Shuttle to SpaceX’s Dragon capsule,
approach in bad weather, at night we’re operating in an extremely dynamic
especially. environment where technological change
is moving at a rapid pace. But we must
º Class 3 EFB—video surveillance of remember that the digital environment
the office—crew resource manage- will vary significantly from operator to
ment concern. The crewmembers operator and also from pilot to pilot.
might see movement in the galley To that end, self-disclosure and dis-
while conducting a briefing before closure remain essential under the just
the top of descent. When resuming culture principle. The importance of
the briefing, because they were having a safe and healthy environment to
distracted, they might have skipped encourage discussion is crucial. Crew in-
some really crucial information for terviews remain as important, if not more
the approach, e.g., a temperature so, than they were in the past. Protections

October-December 2021 ISASI Forum • 27