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Computer-Related Incidents with Commercial Aircraft

The Birgen Air B757 Accident near Puerto Plata, Dominican Republic

6 February 1996

Synopsis This is only the second fatal accident to the B757 since introduction into service. The aircraft crashed into the sea minutes after takeoff. The CVR and FDR were recovered on February 28, 1996, and yielded good quality recordings.

A draft of the final report (in German!) from the Dirección General de Aeronáutica Civil of the Dominican Republic, obtained from the Deutsche Luftfahrtbundesamt, was digitised from a copy sent by Karsten Munsky of EUCARE in Berlin, to whom we are very grateful. This draft includes only report body. I understand there are 100+pp of attachments also.

On February 7, the FAA issued a Press Release (Office of public affair Press Releases) clarifying the role played by the U.S. FAA (Federal Aviation Administration) and the NTSB (National Transportation Safety Board) in the investigation. On March 1, a short statement of Factual Information from a preliminary review of CVR and FDR data was made available by the NTSB on behalf of the Dominican Republic civil aviation authorities. On March 18, a longer Press Release, accompanied by the CVR transcript, explained further what the FDR and CVR data indicated. David Learmount in Flight International, 27 March - 2 April 1996, deduced from the CVR transcript four salient observations on the crew behavior and I provide a fifth from the B757 Operations Manual B757 Air Data System description and schematic diagram(JPEG, GIF). To paraphrase Learmount's points, although confusion about operation of computer-assisted systems (autopilot, warning annunciations) played a role, this confusion would not have arisen but for inappropriate pilot decisions and actions. However, a blocked pitot tube and inappropriate pilot behavior are not the only potential factors under study. The NTSB has identified a potential improvement in B757/767 operating manual as a result of further analysis (short note). note on the Puerto Plata and Cali accidents, highlighting the human-computer interface (HCI) issues, appeared in RISKS-18.10, was rebroadcast on Phil Agre's RRE mailing list (May 7th), and became the subject of the what's happening column of the British Computer Society HCI interest group magazine Interactions, July/August 1996, p13.