Pilot workload and touchscreen interface issues lead to altitude deviation

No fatalities • 32 km north-east of Adelaide Airport, South Australia

A pilot experienced a loss of situational awareness and descended below minimum sector altitude following difficulties with touchscreen data entry during turbulence.

What happened

While operating in instrument meteorological conditions and encountering turbulence, the pilot experienced significant difficulty interacting with the aircraft's touchscreen multi-function display. These interface challenges led to the accidental selection of an incorrect radio frequency. During the period when communication with air traffic control was interrupted, the aircraft descended below the assigned altitude, which was the minimum sector altitude. The descent continued until communication was eventually restored.

The investigation

The investigation focused on the pilot's workload and the impact of environmental conditions on cockpit interfaces. It was determined that the pilot was managing a high workload caused by the combination of turbulence, instrument meteorological conditions, and the pressure of feeling rushed. This high cognitive demand likely resulted in ineffective monitoring of flight instruments. The investigation also noted that the physical vibrations caused by turbulence can make touchscreen interfaces difficult to use, as the display moves independently of the pilot, often leading to increased input errors or the need to stabilize the hand against the screen edge, which risks accidental presses.

Findings

  • Turbulence caused data entry difficulties on the touchscreen multi-function display, leading to an incorrect radio frequency selection.
  • The pilot was likely experiencing high workload due to the demanding flight conditions, which contributed to a loss of situational awareness.
  • Ineffective monitoring of instruments occurred as a result of the pilot's cognitive resources being stretched by multiple simultaneous tasks.
  • An air traffic controller issued a terrain safety alert after communication was re-established, which likely prevented a controlled flight into terrain accident.

Probable cause

The aircraft descended below the minimum sector altitude due to the pilot's loss of situational awareness and ineffective instrument monitoring, driven by high workload and difficulties with touchscreen data entry during turbulence.

Frequently asked questions

What happened in the 2021-08-12 Aero Commander 500-S accident near 32 km north-east of Adelaide Airport, South Australia?

A pilot experienced a loss of situational awareness and descended below minimum sector altitude following difficulties with touchscreen data entry during turbulence.

Were there any fatalities in the 2021-08-12 Aero Commander 500-S accident?

No fatalities were recorded in this accident.

What aircraft was involved and where did it happen?

The accident on 2021-08-12 involved a Aero Commander 500-S, registration VH-LTP, operated by Australian Fishing Enterprises, at 32 km north-east of Adelaide Airport, South Australia.

What was the probable cause of the accident?

The aircraft descended below the minimum sector altitude due to the pilot's loss of situational awareness and ineffective instrument monitoring, driven by high workload and difficulties with touchscreen data entry during turbulence.

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