Dear Martin :
Please refer to D.A.Simmon's article in Flight Safety Digest(May-June 1998)
published by Flight Safety Foundation, in which the chain of many errors are
adressed and analysed by use of various human factors theories. I would,
however, recommend you to use in your SA training the more digested result of
the human factors analysis that specifies and stress significant human errors
involved. Let me present here my view on the Cali accident as follows.
(1) Most accidents occurs due to any human error followed by an omission error.
In the Cali case, the tragedy has started with an input error of FMS data("R"
instead of "ROZO"). The significant omission error was pilot's failure to
detect the undisired projected flight path appeared on the map display.
(2) The data input error is attributed to the mismatch between information
available from the approach chart and the FMS NAV data, both of which had been
provided with by the same organization( internal communication issue ?).
(3) The failure to detect the projected flight path may be closely related to
the moving map display which is widely used on current adv-tech aircrafts.
Generally speaking from the viewpoint of human factors, the moving map display
is not good for keeping situational awareness because so many things are
constantly moving on the map, which may discourage pilots from continuously
observing the map CRT. Stable map display is better for SA but not applicable
for technical reason. I personally think that this type of display have
negatively contributed to many past accidents of adv-tech aircrafts especially
associated with the lost position during turning maneuver around airpots with
higher workload. The famous tanker accident at Alaska is not the exception, in
which the seaman could not detect the approaching iceverg on the radar display.
The type of map display also have been a matter of discussion in the automobile
industry.
(4) I believe it would be helpful for your pilots to advise the above stated
feature in your SA training.
Hidetake Sakuma, JAL