An analysis of more than 50 accidents involving automated commercial transp
ort aircraft showed that most of them attributed to pilot error involved re
programming of automated systems. An examination of current aircraft automa
tion and automation-related training and operations strongly suggests that
a major factor in this situation is the lack of adequate systems engineerin
g in the automation development process. An examination of contemporary com
mercial aircraft systems under guidelines developed in the systems engineer
ing process for an early military terrain-following system reveals weakness
es in the design of the commercial systems. Commercial aviation could benef
it substantially from more extensive use of proven systems engineering prac
tices.