In enhancing aviation safety, what is the aviation community doing about the monitoring role of the pilot not flying the aircraft on a two-crew flightdeck? TIM ROBINSON reports from a major RAeS Flight Operations Group conference. [caption id="attachment_7942" align="alignnone" width="322"] From this crew-intensive flightdeck on a Vickers VC-10... (RAeS/NAL)[/caption] On 19-20 March the RAeS Flight Operations Group (FOG) hosted ‘Preparing the Aircraft Commander for the 21st Century’, a headline conference looking at how technology is changing the role of the airline pilot and captain. Let’s take a look at some of the highlights that emerged.

A false sense of security?

[caption id="attachment_7953" align="alignnone" width="384"] ...to this automated, information driven cockpit on a 787. (Boeing)[/caption] There is no doubt that aviation has changed massively in the past 60 years. The ‘baby boomer’ generation, according to FOG Chairman Pete Terry, grew up flying aircraft without computers, planning routes by hand and using mental arithmetic as a regular part of their jobs. Since then, steam gauges have been replaced by digital glass cockpit displays. Celestial and dead-reckoning navigation has been replaced by the ubiquitous GPS. And the four or five person cockpit with flight engineer and navigator has been streamlined down to two – Captain and First Officer. All these advances mean that air transport today is far, far safer than even 30 years ago. Yet, despite these improvements, aviation accidents stubbornly still continue to occur – many of them now with ‘human factors’ as a main cause, rather than mechanical failures in the past. Paradoxically, as airliners become ever more reliable, so new generations of pilots are becoming increasingly trusting of technology and, potentially, even complacent. For the vast majority of time this does not matter but, on the rare occasion that things do go wrong, even ‘experienced’ crews can find themselves surprised and unable to carry out even basic flying tasks. The tragedies of Colgan Air and AF447 bear this out. According to ICAO statistics, crew monitoring was a factor in 50% of CFIT (controlled flight into terrain) accidents. Ultra-reliable aircraft, with highly automated flight decks, threaten to lull today’s airline pilots into a false sense of security and the transition from normal to abnormal (emergency) can create a ‘startle’ effect that lowers the crew’s decision-making capabilities. Says Pete Terry: “In the old days there was usually something (minor) going wrong on the aircraft every flight - keeping alert wasn't a problem.” The problem is now becoming more critical as these older pilots, who experienced the step change from steam gauges to the glass cockpit age (and brought with them their experience of unreliable technology,) are now retiring. How then does the industry pass on this ‘naturally suspicious’ frame of mind to the next generation?   What is pilot monitoring? [caption id="attachment_7943" align="alignnone" width="376"] Pilots are becoming 'lazy, just watching' warned Captain Jacques Drappier.[/caption] Part of the safety net, to prevent accidents and to remain alert should be ‘pilot monitoring’ (PM). But what is it? Is it instrument scanning, cockpit resource management, (CRM), is it mentally ‘flying’ the aircraft and keeping ahead of the flight? “It is systematic and purposeful observation. It involves feedback and enables decision making.” said keynote speaker Captain Jacques Drappier, a senior aviation training consultant. “Moreover, he noted: “It is not just watching.” Indeed Drappier went further in highlighting the critical role of monitoring today. Thanks to autopilot and airline standard operating procedures (SOP)s, he said that: “95% of the time pilot flying is actually pilot monitoring.” He warned that the amount of information now available to pilots via glass cockpits means they are becoming “lazy and just watching.” The result, he argued, was events such as LOC-I (loss of control-incidents) which were really a “lack of airmanship, awareness and monitoring.” Drappier ended on this cautious note, saying that: “more automation in cockpit will mean monitoring will become more important but humans are not good in a passive role.” This was echoed by a later speaker, Linton Foat, a First Officer with Thomas Cook Airlines, who gave the line pilot’s thoughts on monitoring. He observed that automation brings its own expectation. “When I engage the autopilot, do I also disengage my brain?” Foat also recognised that: “Like fatigue, it is difficult for humans to self-measure or assess their own monitoring skills.” Finally, he also asked rhetorically whether instead of monitoring, ‘vigilance’ might be a better description of what we want pilots to do. Vigilance, he said, “implies an active, not a passive role.”   Outdated training? [caption id="attachment_7944" align="alignnone" width="376"] David Learmount argued that training is now massively outdated.[/caption] David Learmount, Operations and Safety  Editor at Flight Global and a former QFI and Hercules pilot also agreed: “The flying task hasn’t changed but aeroplanes have.” He added: “The tools have changed beyond recognition.” He noted that in LOC-I incidents now occupying the minds of the aviation community, there is no common aircraft type, or national culture involved. The finger points to pilots and human error. In particular, he blamed pilot training for not keeping pace.  The fact that recurrent training regulations had not changed since the days of the piston-engined Douglas DC-6 was: “inexcusable”, said Learmount. Training, in the form of multi-crew pilot licence (MPL) and Airbus’ drive to evidence-based training (EBT) (see below) is evolving but is it evolving fast enough?    Who’s monitoring who? [caption id="attachment_7954" align="alignnone" width="354"] Monitoring in some cases might be from outside the cockpit. (EC)[/caption] Another speaker noted that the perception of ‘monitoring’ differs whether it is the Captain or the junior officer doing the monitoring. For the Captain, common remarks heard were monitoring was ‘babysitting’ the first officer. Yet the conference also heard that it is not as simple as Captain = flying, co-pilot = monitoring. The divisions of Pilot Flying (PF) and Pilot Non Flying (PNF) or Pilot Monitoring (PM) may mean the roles are reversed. It was also noted at the conference that the PF should not stop monitoring themselves, simply because they are flying. Finally, as one speaker from Southwest Airlines pointed out, the monitoring function may in fact come from outside the cockpit. The warning may come from the ground crew, cabin crew, ATC or even passengers noticing the out-of-the-ordinary and informing the flight deck. Finally, many speakers and delegates agreed that, although monitoring is important, it is a skill that is rarely taught or assessed – being lumped in with airmanship or CRM.   How routine makes our brains trick us [caption id="attachment_7945" align="alignnone" width="333"] Our brains can work against us when we think we are monitoring things.[/caption] Monitoring the instruments or observing that checklists are followed correctly should be easy, shouldn’t it? Any deviation or mistakes should be easily rectified by concentrating extra hard? Not quite. As one speaker noted, humans face a major problem in concentrating on the routine. Our own brains start to sabotage us. In his presentation Dr Steve Jarvis, a human factors psychologist, warned, that even with the best will in the world, the brain starts to filter out information it regards as unchanging. This can include vital instruments or critical information. In simulator tests he conducted with an unnamed airline following a near miss, only 10% of 18 crews tested noticed a deliberately failed back-up instrument – despite insisting that they all monitored effectively. Says Jarvis: “Regularly you only find out when people are not monitoring when things go wrong.” The conference heard how, in non-normal conditions, pilots’ situational awareness can ‘tunnel’ into a narrow view, fixating on one instrument or aspect of the situation, while neglecting the others. One key question is when there is an abnormal situation on the flight deck, what tasks can be shed quickly by the crew to reduce the workload and focus on the immediate problem?   Not just monitoring but action [caption id="attachment_7952" align="alignnone" width="333"] Plenty of accidents have been 'monitored all the way to the crash' (NTSB)[/caption] Another theme to emerge from the conference is that monitoring by itself is not enough. As Captain Philip Adrian from Boeing pointed out, plenty of accidents are: “monitored all the way to the crash.” The solution then is linking monitoring with intervention and making monitoring ‘active’. This can be verbal or, in critical cases, a physical intervention and ‘taking over control’ of the stick or yoke. However, while the physical option has always been there, the modern CRM culture perhaps now leans towards a less assertive last-ditch approach – although, as we see below, one airline is attempting to buck the trend.   What is the aviation community doing about it? [caption id="attachment_7947" align="alignnone" width="376"] At the conference, the UK CAA revealed its work on monitoring with new guidance material.[/caption] However, there are grounds for optimism. Despite the nebulous aspect of monitoring and the way in which it is measured (or not), regulators, airlines, original equipment manufacturers (OEM)s and the aviation community are increasingly giving monitoring a higher priority. The conference heard from the European Aviation Safety Agency (EASA), in the form of Michel Masson, Safety Co-ordinator. He pointed out that 76% of monitoring errors were in climb, descent or approach – the busiest part of the flight. However, EASA is already incorporating safety lessons concerning monitoring into its work. For example, it has issued recommendations about A320 flight control reconfigurations in the wake of a 2008 incident and for better warnings (audio, visual and tactile) for loss of cabin pressure after the 2005 Helios 737 accident. However, Masson reiterated an earlier worry – that automation on the flightdeck brings a ‘Catch 22’ situation. “Manual skills are needed to manage automation breakdowns but high automation usage and reliability gives little opportunity to practice.” Meanwhile, the UK CAA has gone further in highlighting the issue of monitoring and revealed at the conference a major new human factors training guide and accompanying DVD and videos. The safety tool comes from work targeting seven safety factors, with loss of control (LOC) deemed most important. This study, led by Jo Davis - a human factors consultant - looked into the training and assessment of monitoring skills as part of the solution to LOC-I. The best practice (which included surveying airlines and other safety bodies, as well as, industries such as rail and road) was captured in a new set of guidelines ‘Monitoring Matters’ with accompanying training videos. These reconstructions show real incidents and near misses, with accompanying captions and explanation showing how monitoring mistakes and distraction can begin to line up the holes in the Swiss cheese that precedes an accident. You can watch one of the monitoring safety videos here.   The view from OEMs [caption id="attachment_7948" align="alignnone" width="346"] Airbus has been working on 'evidence based training' to update recurrent training for the past five years. (Airbus)[/caption] At the event the audience also heard from aircraft manufacturers in the form of Airbus and Boeing. How are they addressing the challenge of pilot monitoring? Airbus, for example, has already responded to worries about the younger generation of pilots lacking ‘airmanship and last year’ produced a simplified aide-memoir in the form of a card-sized Golden Rules for Pilots. These, on a handy small card are: 1)      Fly, navigate and communicate (in this order and with appropriate task-sharing) 2)      Use the appropriate level of automation at all times 3)      Understand the flight mode annunciator (FMA) at all times 4)      Take action if things do not go as expected In addition, Captain Michael Varney, Senior Director, Flight Crew Training, Airbus, explained that the company has been, for the past five years, working on evidence-based training (EBT) with the goal to substantiate a need for a change in assessment and training. This shakeup for training is based on deep study and research by Airbus on 9,000 flights, where it was found that “outstanding leadership and communication” could reduce ‘undesired aircraft states’ by up to four times. But how to train and assess these human factors skills? The solution, says Airbus, is in using realistic based scenarios instead of the proscribed (but now extremely rare) ‘Engine out on take-off’ recurrent tests.  EBT, where crews would have an hour of scripted ‘role-play’ in a non-jeopardy environment in the flight simulator would address the charge that training had not been updated ‘since the DC-6’. The aim, said Varney is “putting pilots in a learning environment, rather than a repetitive, testing environment.” Meanwhile, Captain Philip Adrian, 737/737 MAX Chief Technical Pilot/Chief Pilot Regulatory Affairs, outlined Boeing’s flightdeck philosophy. He asked whether we were making pilot monitoring ‘too complicated’, saying essentially: “The goal of the PM is to stop the pilot flying  from killing the crew and passengers and damaging the aircraft.” He argued that the PF/PM should not automatically be assumed to be Captain/co-pilot – the tasks are defined by the role, and “the role is more important than rank.” He also stressed that proper monitoring habits: “Should be created and maintained in normal flight,” not just in non-normal situations. Interestingly, he also had praise for Airbus’ EBT initiative: “We need to change the training paradigm.” However, he argued that some training need not be complex – randomly handing over control to the PM in a simulator could boost monitoring skills. He also cautioned against the MPL licence, asking if putting two pilots of similar experience in the same cockpit really is: ‘training as we fly’? The conference also heard from a cockpit display manufacturer, with a presentation from Joe Komer, Senior Systems Engineer, Garmin. He explained how Garmin is taking its cues from consumer technologies, including smartphones and tablet devices, to create a new generation of extremely easy-to-use cockpit instruments and displays. He said “the best way to improve pilot monitoring is to make the interface easy to understand.” In comparison with legacy FMS systems with a MS-DOS style interface, the modern touchscreen displays from Garmin feature picture icons, ‘back’ and ‘home’ buttons, shallow menus and are context sensitive.   Airlines take action [caption id="attachment_7951" align="alignnone" width="375"] Short, repetitive flights and a 'hybrid' flightdeck present a challenge to Flybe pilots. (Flybe)[/caption] Meanwhile, airlines themselves are already adapting their training and thinking to incorporate elements of pilot monitoring and the conference heard from a number of representatives. Lex Rock Heemstra, a Human Factors Specialist from Emirates Airline, for example, noted that: “Monitoring and vigilance increase in high-threat situations” but questioned: “does routine operations trigger this?” He warned that multi-tasking is a ‘myth’ – instead pilots should train for “task switching”. It was noteworthy, too, that he believed that even well- defined tasks and SOPs do not catch every single error.  He also pointed out that pilots do not report everything – even if they do spot it. Some errors (especially in training or the simulator) are assessed as “inconsequential” -  ‘I saw it but I obviously would say something if this were a real flight’. The solution, he said, was to assess monitoring as a crew. Meanwhile, Captain Chris Coney-Jones, Q400 Fleet General Manager, Flybe, gave the viewpoint from a regional airline. Coney-Jones explained that short-haul flights, with lots of destinations meant lots of repetition for Q400 pilots.  In particular, a study by Flybe on pilot monitoring errors had found 76% were attributable to the First Officer. The hybrid cockpit of the Q400, said Coney-Jones, made it a complex monitoring environment for Captains. The airline, he explained, has already carried out joint research with the University of Essex on interruptions on the flightdeck in a simulator which showed how distractions degrade performance. Flybe will also be working with NATS on a pilot monitoring study. Another perspective was provided from giant low-cost Southwest Airlines by Captain Tom Gasparolo, Training Committee Chairman, Southwest Pilot Association. He revealed that Southwest pilots use a verbal code “I’m in the yellow" to indicate when they are troubled or overloaded and extra vigilance is needed (as do United Airlines who use ‘I’m uncomfortable’ to communicate this).  Southwest, says Gasparolo, also uses an ABCD mnemonic - Assess, (situational awareness) Balance (workload) Communicate (task & intentions) Debrief (continuous improvement). He also stressed that enroute briefing and going over, say diversion airports, also help “set the tone of the flight.” Finally, he said that there must be a safety culture in place that allows a PM to take over or do a go around without penalty. This was echoed in a later presentation by Captain Peter Troup, TRE & Standards Captain at Thomson Airways, who spoke on the subject of intervention. There were three levels, he said, facilitation, instruction and physical (taking over control). He observed that physical intervention should be a valid tool for line training Captains and shouldn’t be a last resort 500ft off the runway. Instead he said it should be decided “over a cup of tea in the cruise” who would make he landing. Capt Troup admitted that in today’s CRM culture, physical intervention is perhaps seen as a ‘bit rude’ but he argued that “its much easier to fix the feelings of a pilot than to fix a jet.” Another airline view came from Captain Sandy Bayne, Chief Standards Pilot, South African Airways, explained how, because of unique cultural conditions, the Captain in any complex non-normal situation will immediately become the PNF or PM, with the junior co-pilot becoming pilot flying. This allows the crew to cut across any cockpit gradient/cultural issues – with the Captain giving instructions and, additionally, frees up mental capacity for the Captain. Finally, another airline view came from Donata Ziedins, Manager Human Factors, United Airlines. She observed that pilot monitoring challenges are increasing due to mergers between airlines. Merging two company cultures, pay scales, seniority and SOPs means there are a ready-made set of distractions to impinge on the flightdeck. Ziedins said that, because United and Continental had been a 'merger of equals' with the new carrier adopting best practice, this had guaranteed disruption for 100% of the pilots. Nor would these distractions cease with a new logo – company cultural issues could take years, if not decades, to disappear. To that end United uses verbalisation techniques and has CRM briefing cards (carried on ID lanyards) to address monitoring issues.   Lessons from other industries [caption id="attachment_7950" align="alignnone" width="333"] Astute submarine. Nuclear reactor operations are never taken lightly. (Royal Navy)[/caption] The conference also heard from other industries facing similar issues of critical tasks requiring close monitoring. In medicine, for example, Dr Allan Goldman from the children’s Great Ormond Street Hospital (GOSH) noted how surgeons have adapted and now use airline style checklists. Pre-operation briefings are now standard and the medical teams are now seeking to add long-term trends to their ‘glass cockpit’ display, instead of the past 20 seconds. The hospital even has learned lessons from Formula 1 motorsport in the way in which pit-teams prepare and hand over responsibilities. Another fascinating monitoring viewpoint came from the Royal Navy who described the challenge of monitoring another piece of high technology - a nuclear reactor in a submarine. Monitoring this atomic powerplant requires extreme vigilance and it was noteworthy from the speaker the safety culture and professionalism of the Silent Service. However, it was interesting to note that the reactor, although it has automatic systems, is controlled manually. Furthermore, submariners are indoctrinated to be naturally suspicious at all times - cultivating a ‘healthy unease’ has been second nature.   Eye tracking, brain wave monitoring and more [caption id="attachment_7955" align="alignnone" width="307"] Eye tracking technology is becoming a valuable research and training tool to assess monitoring skills.[/caption] But, as well as posing problems in the first place, the conference heard that technology may also assist the pilot monitoring task. One interesting technology to be raised more than once to aid pilot monitoring training and assessment was eye-tracking technology. This technology (now being used by consumer and marketing experts to discover our unconscious desires) could have valuable training and assessment uses, though the idea of eye-movements being recorded to a black-box similar to the cockpit voice recorder, was perhaps seen as a 'Big Brother' step too far. However, this technology already has been used in one post-incident study with revealing results as to what was actually happening on the flightdeck and at the conference a speaker from Cathay Pacific revealed it is now looking into utilising eye tracking. Indeed, another presentation from Dr Graham Edgar, a Reader in Psychology at the University of Gloucestershire, hinted that, in future, it may be the aircraft monitoring the pilots, who monitor the aircraft. Brain scanning or brainwave research, he showed, could already distinguish between test subjects who are able to process new information quickly and recover from a ‘startle’ incident to regain situational awareness and those whose situational awareness, once lost, does not recover. Finally, Donata Ziedins, from United Airlines posed other ‘out-of-box’ solutions to monitoring. Could, for example, pilots use their own personal electronic devices (PED/or iPads) to run mental alertness exercises or ‘games’ on long-haul flights? She also proposed that breathing and relaxation techniques from special forces and SWAT teams to sharpen mental focus might also have a place in a pilot’s toolbox. Finally, she also noted that, paradoxically, one solution to emergencies on the flightdeck might actually be to slow down to observe more, adding that, if the Airbus AF447 crew had just done nothing for two minutes, the situation would have resolved itself safely.   Summary [caption id="attachment_7949" align="alignnone" width="403"] Garmin G5000 flightdeck. Despite its ease of use, and reliability, pilots will have to avoid complacency. (Garmin)[/caption] In short, this is a challenging human factors issue. The life experience of tomorrow’s ‘digital natives’ who will grow up in a world where information is on tap and where smart phones very rarely go wrong, means that they will inevitably trust technology to work. Those entering the pilot profession will invariably carry this on, especially when aircraft are ultra-reliable and highly automated. The high reliability and safety built-in to modern airliners thus means today the role of the pilot is akin to a quote attributed to an Aerolineas pilot: "Most of the match the goalkeeper just watches the match then, suddenly, it’s all about him." However, as this conference demonstrated, it can be possible to cultivate a ‘healthy unease’ where pilots not only question the aircraft, their co-pilot but, most importantly, themselves. While it might not be possible (or desirable) to undo this innate trust in technology, simply recognising how bad humans are at monitoring everyday routine may, in fact, be the first step on the road to developing a questioning scepticism that one day may save lives. This conference, which brought together a wide range of viewpoints and speakers (said one presenter: “I’m simply staggered by the quality of the speakers”) was  a key event in raising the profile of this increasingly important issue.  

Join the debate on the RAeS Future Aircraft Commander discussion group to share your thoughts and experiences.

Tim Robinson
28 March 2013