The Active Pilot Monitoring Working Group WG feels strongly that changing how pilots think about monitoring is a comprehensive endeavor that cannot rely on any singular module of instruction Effective monitoring can be improved in any aviation operation only to the extent that ID: 285682
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Slide1
Notes to the User
The Active Pilot Monitoring Working Group (WG) feels strongly that changing how pilots think about monitoring is a comprehensive endeavor that cannot rely on any singular module of instruction. Effective monitoring can be improved in any aviation operation only to the extent that:Management buys in and supports the effortOperational philosophies, policies, procedures and practices are designed to support effective monitoringOperational philosophies, policies, procedures and practices involving monitoring are trained in context, throughout a pilot’s career as part of a pilot’s basic flying skills
Slide intended to be hidden during presentationSlide2
Notes to the User
This module only represents the beginning of the training noted in the third bullet in the preceding slide. It is an introductory module intended to bring an awareness to the pilot of the importance of monitoring in flight path management. This awareness is brought about by educating pilots as to the data that clearly show that poor monitoring puts flight safety at risk, that there are barriers working against them to become consistently effective monitors and that there are ways to improve their monitoring.Slide intended to be hidden during presentationSlide3
Notes to the User
There are 20 recommendations to improve monitoring performance in the Practical Guide to Effective Flight Path Monitoring. This training module highlights many, but not all, of these recommendations. Training managers should augment this training with subsequent modules highlighting other recommendations adopted from the Guide or other monitoring training deemed appropriate.
Slide intended to be hidden during presentationSlide4
Improving Flight Path MonitoringA Training AidSlide5
The Goal
The goal of this training aid is to reduce errors in flight path management through improved monitoring performance. Slide6
Learning Objectives
Industry concerns around monitoringFight path monitoring is a primary responsibilityNeed to control and monitor the aircraft’s flight pathDual responsibility for monitoring the flight pathPredictable areas where flight-path risk is increasedEffective crew-resource allocationDecoupling tasks that interfere with flight path monitoring
Increased flight path monitoring feedback
Recommended monitoring practicesSlide7
Our ScopeSlide8
Monitoring Definition
Monitoring is adequately watching, observing, keeping track of, or cross-checking.Slide9
Monitoring Definition
The word monitoring is a general term that has been applied to a large variety of specific activities that are very different in nature.Slide10
Spectrum of Monitoring Activities
The list of things pilots attend to in the course of a flight is large. They passively monitor systems that have internal monitoring and alerting.They deliberately check critical system configurations such as flaps.They actively monitor the changing status of their flight path.They time-share all of this with other activities.Slide11
Spectrum of Monitoring Activities
The list of things pilots attend to in the course of a flight is large. They passively monitor systems that have internal monitoring and alerting.They deliberately check critical system configurations such as flaps.They time-share all of this with other activities.
They actively monitor the changing status of their flight path.
This presentation focuses on issues related to flight path monitoringSlide12
Flight Path Management
Confusion arises because many pilots associate managing the flight path with simply controlling the flight path, either through manual control inputs or through automated flight guidance inputs. This view is dangerously incomplete, as it contains no provision to validate outputs. Validating that the aircraft is doing “what (you think) it was told it to do
”
is at least as important as control/guidance inputs.
Ensuring the aircraft is on the intended flight path is accomplished by effective flight path monitoring by
both
pilots.Slide13
Today
’s TopicThis module focuses on completing the flight management task cycle by improving pilot monitoring of the flight path so that crews are effective in discovering and correcting flight path management errors.Discovering and correcting flight path management errors is called Effective Flight Path Monitoring, or EFPM.Slide14
The Central FallacySlide15
“
Nowadays, these airplanes pretty much fly themselves.”Slide16
The airplane does
not fly itself.Slide17
Recent Accidents in Which Inadequate Monitoring Was Cited as a Factor
UPS 1354
2013
Asiana 214
2013
Colgan 3407
2009
Turkish Air 1951
2009
Empire 8284
2009
FedEx 1478
2002Slide18
Effective monitoring has been an identified safety-related topic for more than 20 years.
NTSB Safety Study (1994)Inadequate monitoring present in 31 of 37 (84%) of reviewed accidentsFlight Safety Foundation Study (1998)63% of accidents involved inadequate monitoring and cross-checkingLine Operations Safety Audit Data Query (2013)
O
bservations from more than 14,000 flights showed that flights with poor
or marginal monitoring had
2-3 times
more
mismanaged errors
and
2-3 times more undesired aircraft states
than flights with outstanding monitoring Slide19
Flight Path Monitoring
The need to address this issue has been highlighted as a major industry concern by several flight safety organizations.Slide20
Automated aircraft
do not “fly themselves.”Slide21
Please participate in the following monitoring challenge …Slide22
1. Silently, count the number of times the white team passes the basketball.
2. After the video, write the number of passes on a piece of paper large enough for the instructor to see.Slide23
Watch the following video …
Click image to play videoSlide24
How many passes did you count?Slide25
By show of hands, did you see anything unusual during the game?Slide26
WarningSlide27
Warning
Perception is highly selective.Slide28
Warning
We do not see everything happening in front of us.We see
what is most relevant
to the task we
choose
to focus on.Slide29
Warning
Thinking we see everything in front of us, when in fact we don’t, can lead us to make poor choices as to how we prioritize and allocate our attention.Slide30
Barriers to Effective Monitoring
Human factors limitations Time pressure Lack of feedback to pilots when monitoring lapses Design of flight deck systems Standard operating procedures Pilots’ inadequate mental models of autoflight modes Corporate culture does not emphasize monitoring Slide31
Both pilots
are responsible formonitoring the flight path.Slide32
PF vs. PM Duties for a Heading Change
Monitor radio communicationsAcknowledge clearance (with other pilot)Rotate heading knob Monitor heading bug (verify correct heading set)Select heading lateral modeMonitor FMA (verify lateral mode)Monitor flight instruments to confirm execution of turn Read back clearance
Acknowledge clearance (with other pilot)
Monitor heading bug (verify correct heading set)
Monitor FMA (verify lateral mode)
Monitor flight instruments to confirm execution of turn
PF Duties
PM Duties
Slide33
PF vs. PM Duties for a Heading Change
Monitor radio communicationsAcknowledge clearance (with other pilot)Rotate heading knob Monitor heading bug (verify correct heading set)Select heading lateral modeMonitor FMA (Verify lateral mode)Monitor flight instruments to confirm execution of turn Read back clearance
Acknowledge clearance (with other pilot)
Monitor heading bug (verify correct heading set)
Monitor FMA (Verify lateral mode)
Monitor flight instruments to confirm execution of turn
PF Duties
PM Duties
Slide34
Areas Where Flight Path Needs Elevated PrioritizationSlide35
Improving Flight Path–Monitoring
PerformanceOne strategy is to focus on crew workload management to schedule completion of non-flight path–related tasks to areas of flight when monitoring requirements are relaxed.An FAA-funded study of training needs for junior first officers found that in approximately one-third of the ASRS reports reviewed, pilots failed to monitor errors, “often because they had planned their own workload poorly and were doing something else at a critical time.
”Slide36
Areas of Vulnerability
If pilots could recognize those flight phases when they are most vulnerable to flight path deviations, they could strategically plan workload and manage distractions to maximize monitoring during those areas of vulnerability (AOV). Similarly, if pilots could recognize those flight phases where they are least vulnerable to flight path deviations, they could relax monitoring to some degree and complete non-flight–related tasks.Slide37
When is the flight path most vulnerable?
The flight path is most vulnerable when:Your trajectory or energy is changing, orYour available time to intervene is limitedLet’s use a simple visual model to represent our flight path threat environment …Slide38
Areas of Vulnerability – In Flight
High
Medium
Low
V
L,V
V
L,V
L,V
V
V
V,S
S
S
L
L
10,000 ft
1
Vertical
Profile
(Side) View
Close to Ground
2
Key to Red Dot Labels
:
L = Lateral Trajectory Change
V = Vertical Trajectory Change
S = Speed Change
Note 1
: 10,000 ft is used in the U.S. as the boundary altitude for sterile cockpit rules and for the 250 KIAS speed restriction (both required below 10,000 ft). For the purposes of the areas of vulnerability (AOV) model, an altitude other than 10,000 ft may be chosen, but it is suggested that this boundary match the use of sterile cockpit rules for your carrier (or nation/state) for ease of operational applicability by flight crews.
Note 2
:
“
Close to Ground
”
may be defined by the carrier, but it is suggested that this be an altitude no less than (a) 1,500 ft AGL or (b) the altitude of surrounding terrain (if terrain threats exist within 5 nm (9 km) of the flight path), whichever is higher.Slide39
In flight:
- We are most vulnerable at very low altitude- We are next-most vulnerable when the flight path of the aircraft is changing (decelerating, turning, leveling, etc.)- The next-most vulnerable time is during complex descents- We have some vulnerability any time the aircraft is climbing or descending
Areas of VulnerabilitySlide40
On the ground:
- We are most vulnerable approaching, crossing and entering active runways- We are fairly vulnerable whenever we are moving on the ground
Areas of VulnerabilitySlide41
Areas of Vulnerability
Departure DestinationDrawn to scale, we see that many flights spend the majority of their time in a low flight path risk mode.
High
Medium
LowSlide42
Low AOV
E.g., CruiseStableSimple SafeTime is available to intervene if needed.
High
Medium
LowSlide43
Areas of Vulnerability
High
Medium
Low
Let
’
s compress cruise flight and talk about where the flight path is most vulnerable to deviations.
Slide44
Medium AOV
High
Medium
Low
E.g., All Climbs and DescentsSlide45
Medium AOV
High
Medium
Low
E.g., All Flight Below 10,000
ftSlide46
High AOV
High
Medium
Low
E.g.,
All Changes of Trajectory and/or Energy
Initiating climb or descent
Leveling off
Turning, changing routing
Changing speed and/or configurationSlide47
High AOV
High
Medium
Low
E.g., The Last 1,000 ft of a Climb
or Descent**
** Operators
’
philosophies may vary. High sample rate is clearly
required for PF, but PM exclusive focus on FP might be too onerous for
some operations.
Slide48
High AOV
High
Medium
Low
All flight below MSA
E.g., All Low-Altitude Flight
Below approx. 1,500 ft AGL or
Below surrounding terrainSlide49
Ground Path AOV
High
Medium
Low
Approaching, crossing or entering a runway or tight space
E.g., All Ground MovementSlide50
Click to play videoSlide51
Turkish Air 1951
Remember the gorillaWhat monitoring threats were present?What was the impact of tolerating instability below 1,000 ft?
What can we infer about the sample rate of airspeed on this approach?
What can we conclude about high AOV?Slide52
Allocate adequate crew resources to managing the flight path.Slide53
The types of things a crew does:
Flight Path Related Tasks
Non-Flight Path
Related Tasks
Major Planning and Decision making
Non- Essential TasksSlide54
Typical ineffective/default task distribution in highly automated aircraft.
Non- Flight Path Related Tasks
Major Planning and Decision making
We tend to relegate flight path monitoring to a more-or-less secondary role!
Non- Essential Tasks
Flight Path Related TasksSlide55
Effective Crew Resource Division(Who does what in moderate AOV)
Flight Path Related Tasks
Non-Flight Path
Related Tasks
Non- Essential Tasks
Major Planning and Decision making
PM PF
Monitoring the aircraft is such a critical task that it needs to be decoupled from other tasksSlide56
Effective
Crew Resource Division(Who does what in high AOV)
Flight Path
Related Tasks
Flight Path
Related Tasks
PM PF
During brief periods of high AOV, it should be the only task being done (by either pilot!) on the flight deck.Slide57
Anytime the AOV is
medium, at least one pilot needs to prioritize flight path scan. - Climbing - Descending - Below 10,000 ft?Prioritize Flight Path
High
Medium
LowSlide58
For the brief periods when AOV is
high, both pilots need to prioritize flight path scan.Flight path is changingVery low altitude
Prioritize Flight Path
High
Medium
LowSlide59
Decouple Tasks From Flight PathSlide60
Plan Your Workload
Many tasks can be done when you choose:Talking on the PATalking to dispatchRunning W&B calculationsReviewing ABG, manualsStowing charts
Do these tasks during
low
flight path vulnerability
.Slide61
Decouple Tasks From Flight Path
Medium AOVMake flight path a higher priority than the task:Don’t task and fly at the same time
Ask the PM to do the task
or
Ask the PM to flySlide62
Decouple Tasks From Flight Path
Medium AOVOr, as a last line of defense: If you are the PM and the PF begins doing a task, then make sure that you activate a high-sample-rate flight path scanSlide63
Decouple Tasks From Flight Path
Make flight path a higher priority than the task.Do not "task" when you should be "flying“Delay the task until you are out of the red
Red AOVSlide64
Decouple
Tasks From Flight PathWARNINGDo not work problems on approachPut the aircraft in a state that is simple, stable and safe
red AOVSlide65
Level of Vulnerability
Definition
Desired FPM Behaviors
In Flight
On Ground
PF/PM
FPM Attention and Sampling Rate
Workload Management Strategy
High
(Red Areas)
All changes of:
Lateral trajectory
Vertical trajectory
Speed
Last 1,000
’
of climb or descent
All flight close to the ground
Approaching, crossing or entering a runway or tight space
Crew (general)
Both pilots maintain total focus on flight path scan, at a high sampling rate
Avoid any task not related to flight path
Unavoidable (especially pop-up) tasks must be delayed until exiting high AOV or, accomplished by PM
PF
Undivided attention to flight path
Avoid all tasks not related to flight path
PM
Undivided attention to flight path, if at all possible
Avoid all non-essential tasks
Avoid all tasks not related to flight path, if at all possible
Essential and time-critical tasks (not related to flight path) completed if both brief and unavoidable, but focus must be returned to flight path as soon as possible
Medium
(Yellow Areas)
Climbs and Descents
Flight below 10,000 ft
All other ground movement
Crew (general)
At least one pilot maintains focus on flight path scan, at an elevated sampling rate
Avoid any task that is non-essential
Essential tasks may be performed by PM; keep PF focused on flight path
PF
Undivided attention to flight path, if at all possible
Avoid all non-essential tasks
Avoid tasks not related to flight path, if at all possible
Essential, unavoidable tasks requiring PF involvement may only consume very brief moments of attention – return focus to flight path immediately
PM
Flight path is primary, but attention may be divided between flight path and essential tasks
Avoid non-essential tasks
Essential, non-time-critical tasks (not related to flight path) may be performed, but return focus to flight path at frequent intervals
Low
(Green Areas)
Straight-and-Level cruise flight above 10,000 ft
Stopped with parking brake set
Crew (general)
At least one pilot keeps flight path as top priority, but at a normal sampling rate
Manage tasks normally
Tasks not related to flight path preferentially done by PM; keep PF focused on flight path
PF
Flight path is primary, but
some
division of attention to complete other tasks is permitted
To the extent practical, use this time to accomplish all foreseeable tasks
Ensure frequent return of focus to flight path
PM
Flight path is primary, but division of attention to complete other tasks is permitted
To the extent practical, use this time to accomplish all foreseeable tasks
Ensure frequent return of focus to flight pathSlide66
Empire 8284
Think about prioritizing flight path as we watch the following NTSB video that recreates the accident of Empire Flight 8284.Slide67
Empire 8284
Click to play videoSlide68
Empire 8284
Describe the captain’s workload strategy for managing this event.What was the AOV? What should should the captain’s priority have been?
Remember the gorillaSlide69
Increase Your Sensitivity
to Monitoring FeedbackSlide70
Monitor Your Monitoring
Noticing when you are not doing something is hard.How do you know when you (or your partner) are not monitoring the flight path?Slide71
Monitor Your Monitoring
Fortunately, there are some clues that can alert us that we are not engaged in EFPM. Slide72
Monitor Your Monitoring
Is your flight instrument sample rate adequate? High sample rate ̶ Equivalent to hand flying Adequate sample rate ̶ Sample rate at or above which you do not encounter indications of inadequate monitoringSlide73
Indications of Inadequate Sample Rate
Missed (or late) flight path callouts:“3,000 for 2,000”“Glide slope intercept altitude 1,500, checked”“1,000 stable, cleared to land”Slide74
Indications of Inadequate Sample Rate
If a change in pitch, roll or power occurs … and you were not actively looking for it Slide75
Indications of Inadequate Sample Rate
If a mode change occurs … and you were not actively looking for itSlide76
Indications of Inadequate Sample Rate
If you are late to recognize terrain, traffic or weatherSlide77
Indications of Inadequate Sample Rate
If you notice yourself performing concurrent (non-flight path–related) tasks during flight path transitions Slide78
Feedback
that you are not effectively monitoring: You miss a flight path callout A pitch, power or roll change occurs that you were not actively looking for A mode change occurs that you were not actively looking for You are surprised by upcoming terrain, traffic or weather
You are performing non-flight path–related tasks during flight path transitionsSlide79
React to these indicators by increasing the priority of your flight-path scan Slide80
Recommended PracticesSlide81
Recommended FPM Practices
Exhibit good monitoring practicesIn the following slides, we will talk about the tools that are tried and true:Tools are not SOPs, but they are agreed-upon practices that you apply in the way that
best fits
your current situationSlide82
Recommended FPM Practices
First and foremost, adhere to SOPs:SOPs are not optional toolsSOPs are items that are agreed to be so important that they are mandatory unless superseded by emergency authoritySlide83
Recommended FPM Practices
Several SOPs are in place to help you monitor. Example:SOPs require sterile cockpit below 10,000 ftTo help you avoid distraction during medium and high AOVsBecause perception is a scarce resource
Remember the gorillaSlide84
Practices That Enhance the Awareness Necessary for EFPM Slide85
Recommended FPM Practices
Mentally Fly the AirplaneScan the flight instruments and anticipate control inputs exactly as you would when hand-flying — even when the autopilot (or the other pilot) is flying.
High AOV – always a good idea
Medium AOV – often a good ideaSlide86
Recommended FPM Practices
Stay ahead of the aircraftPredictive awareness comes from thinking ahead.Slide87
Recommended FPM Practices
Hand-FlyHand-flying requires a sound instrument cross-check and is a good way to hone your monitoring skillsMany operators require pilots to maintain proficiency with manual flight skills:- Use good judgment about when to hand-flySlide88
Recommended FPM Practices
Set/Check TargetsExamples include intermediate altitude targets during descents to crossing restrictions, and altitude targets/DME targets on approachSlide89
Recommended FPM Practices
Plan your workload to protect AOVsAnticipate foreseeable task loading and get work done earlySlide90
Practices That Maintain and/or Reestablish Critical Flight Path Targets in Working MemorySlide91
Recommended FPM Practices
Restate constraints/restrictions periodicallyThinking out loud is a good way to stay on the same page with the other pilot …But there is also another benefit:Audibly refreshing restrictions/constraints helps you keep important intentions from dropping out of your pattern of attentionSlide92
Recommended FPM Practices
Restate constraints/restrictions periodicallyWhen does it make sense to do this?When there is a long time between the clearance and the constraintWhen the environment is very busy or distracting
When you are tired
At the beginning and end of a large pop-up task
After completing a checklist while taxiing
After unusual or distracting eventsSlide93
Recommended FPM Practices
State clearances in a loud, clear voiceThis practice:Helps encode the clearance in your memoryHelps the other pilot remember it, too- Use this tool when the clearance is important and must be held in memory- Commonly used for approach and landing clearancesSlide94
Recommended FPM Practices
Verbally acknowledge when distraction events occurSaying something triggers both pilots to deliberately review last steps:“Hey, we just got sidetracked (or similar words). …
W
e were just about to start down to make Providence at 11.
”Slide95
Recommended FPM Practices
Use an external reminder (i.e., an actual written note)Do not use mental
notes
Write down any clearance that can not be immediately entered into the MCP (or MCDU)
There have been a number of ASAP reports stating:
“
I made a mental note.
”Slide96
Practices to Intervene Effectively Slide97
Recommended FPM Practices
Deviation CalloutsMake specific deviation calloutsEncourage deviation calloutsCall your own deviations if the other pilot is reluctantThank the other pilot for deviation calloutsSlide98
Recommended FPM Practices
Refuse problematic clearancesPilots have the authority to tell ATC “unable” if a clearance will jeopardize the ability to manage the flight pathSlide99
Identify the effective monitoring practices used by the flight crew in the following story …
Participation RequestSlide100
The Story of NZ 60
The NZ 60 incident occurred on an ILS approachDue to multiple failures to the ILS system, the ILS was broadcasting an erroneous “on glideslope” signal regardless of aircraft trajectory
Erroneous
“
on glideslope" indicationSlide101
The Story of NZ 60Slide102
NZ 60
What threats to EFPM were present?What recommended practices resulted in effective monitoring?What are some differences in practices between NZ 60 and TKY 1951?Slide103
If you remember one thing
…
Flight Path Management
Always ensure someone is
really
flying the aircraft
…means…
REMEMBER THE WARNING
Attention Is Highly SelectiveSlide104
Questions?