https://www.ntsb.gov/investigations/AccidentReports/Reports/ASR1901.pdf
P.12
Recommendations
To the Federal Aviation Administration
Require that Boeing (1) ensure that system safety assessments for the 737 MAX
in which it assumed immediate and appropriate pilot corrective actions in
response to uncommanded flight control inputs, from systems such as the
Maneuvering Characteristics Augmentation System, consider the effect of all
possible flight deck alerts and indications on pilot recognition and response;
and (2) incorporate design enhancements (including flight deck alerts and
indications), pilot procedures,and/or training requirements, where needed, to
minimize the potential for and safety impact of pilot actions that are
inconsistent with manufacturer assumptions.(A-19-10)
Require that for all other US type-certificated transport-category airplanes,
manufacturers (1) ensure that system safety assessments for which they assumed
immediate and appropriate pilot corrective actions in response to uncommanded
flight control inputs consider the effect of all possible flight deck alerts
and indications on pilot recognition and response; and (2) incorporate design
enhancements (including flight deck alerts and indications), pilot procedures,
and/or training requirements, where needed, to minimize the potential for and
safety impact of pilot actions that are inconsistent with manufacturer
assumptions.(A-19-11)
Notify other international regulators that certify transport-category
airplane type designs (for example, the European Union Aviation Safety Agency,
Transport Canada, the National Civil Aviation Agency-Brazil, the Civil
Aviation Administration of China, and the Russian Federal Air Transport Agency)
of Recommendation A-19-11 and encourage them to evaluate its relevance to
their processes and address any changes, if applicable. (A-19-12)
Develop robust tools and methods, with the input of industry and human factors
experts, for use in validating assumptions about pilot recognition and response
to safety-significant failure conditions as part of the design certification
process.(A-19-13)
Once the tools and methods have been developed as recommended in
Recommendation A-19-13, revise existing Federal Aviation Administration (FAA)
regulations and guidance to incorporate their use and documentation as part
of the design certification process, including re-examining the validity of
pilot recognition and response assumptions permitted in existing FAA guidance.
(A-19-14)
Develop design standards, with the input of industry and human factors experts,
for aircraft system diagnostic tools that improve the prioritization and
clarity of failure indications (direct and indirect) presented to pilots to
improve the timeliness and effectiveness of their response. (A-19-15)
Once the design standards have been developed as recommended in
Recommendation A-19-15, require implementation of system diagnostic tools on
transport-category aircraft to improve the timeliness and effectiveness of
pilots’response when multiple flight deck alerts and indications are present.
(A-19-16)
1.要求波音改進設計，在737 MAX系統安全評估中，確保飛行員在出現非指令性輸入
（例如機動特性增強系統，即MCAS）時，提供一切有效的駕駛艙警告，讓駕駛員可以當即
做出適當的判斷和操作。（A-19-10）
2.要求對其他美國認證的運輸飛機，在系統安全評估中，確保飛機的設計可以提供一切有
效的駕駛艙警告，讓飛行員可以當即作出適當的判斷及操作處理系統失控問題。另外，改
進飛行員程序或必要的訓練要求，減低因飛行員作出與製造商評估不一致的操作而構成的
安全風險。（A-19-11）
3.通知多國負責飛機認證的航空安全當局（例如中國民用航空總局CAAC，歐洲航空安全局
EASA等）有關A-19-11建議（即上述第二項），同時鼓勵當局作出參考和改進。（
A-19-12）
4.與業界和人為因素專家合作，研究可靠工具和方法，以供設計認證過程中對嚴重影響安
全的失效情況下飛行員的認知作出準確假設。（A-19-13）
5.在A-19-13建議的工具和方法推出後，FAA需現有對飛行員認知及反應的指導文件和相關
法規有效性作出重新檢討。（A-19-14）
6.與發展中國家和人為因素專家合作，制定設計標準，提高相關飛機系統診斷工具的優先
等級，以及更加清晰的提示，使飛行員做出更合時和有效的反應。（A-19-15）
7.在A-19-15建議的設計標準推出後，對有關運輸飛機約會系統診斷工具，讓飛行員在駕
駛艙出現各種警告時做出更合時和有效的反應。（A-19-16）
以上內容以原文為準