1. Pilot Monitoring Training
Capt. Juan Carlos Gonzalez Curzio
& Capt. Carlos Arroyo
FIRST PAN AMERICAN AVIATION SAFETY SUMMIT 2010

2. Enhancing Flight-crew Monitoring Skills Can Increase Flight Safety
Comentario inicial: La filosofía de Piloto Monitoreando lleva varios años en la industria, hay comprobados resultados en la seguridad operacional, es en algunas aerolíneas una habilidad CRM y elemento constante en el desarrollo de SOP´s. Boeing ha cambiado a PM, pero hay varios fabricantes (Airbus entre ellos) que aún consideran al PNF en sus SOP´s.

4. Improving Monitoring
“First, we must change our approach to monitoring …”
“Good monitoring skills are not inherent in a pilot as they progress in their careers. Therefore, effective monitoring techniques must be trained and rewarded”
Captain Frank J. Tullo
“Aviation Week & Space Technology” May 21, 2001
Captain Frank Tullo wrote in a recent Aviation Week and Space Technology editorial, “First, we must change our approach to monitoring. Instructors must insist that the non-flying crewmember monitors the flier effectively. A system that grades monitoring must be established… Good monitoring skills are not inherent in a pilot as they progress in their careers. Therefore, effective monitoring techniques must be trained and rewarded.”10 Tullo, Frank J. “Viewpoint: Responses to mistakes reveal more than perfect rides.” Aviation Week & Space Technology. May 21, 2001.

5. October 25, 2002 Eveleth, Minnesota
Narrar este evento con los slides siguientes, enfatizando en la perdida de control, y que, llevamos varios años con la misma amenaza, porque no hemos sido consistentes en la industria.
October 25, 2002 Eveleth, Minnesota

6. According to NTSB “During the later stages of the
approach, the flight crew failed to
monitor the airplane’s airspeed and
allowed it to decrease to a dangerously
low level (as low as about 50 knots
below the company’s recommended
approach airspeed) and to remain
below the recommended approach
airspeed for about 50 seconds.”
Source: NTSB/AAR-03/03.

7. “If the First Officer had monitored the
approach on the instruments...he would
have been better able to notice and
immediately call the Captain’s attention
to the altitude deviation below the
minimum descent altitude.”
Source: NTSB/AAR-96/05.

8. ….And the story continues
Colgan Air 3407 February 12, 2009
Recalcar que la iniciativa de PM “es actual”.

9. Introduction Each crewmember must carefully monitor the
aircraft’s flight path and systems, and actively
cross-check the actions of each other.
• Effective monitoring and cross-checking can
literally be the last line of defense
– When this layer of defense is absent the error may go undetected, leading to adverse safety consequences
Todas las iniciativas de Factor Humano bien implementadas dan resultados en corto plazo.

10. Good monitoring is important
• By better monitoring and cross- checking, a crewmember will be more likely to catch an error or unsafe act • This detection may break a chain of events leading to an accident scenario

11. Why improve monitoring? - Accident Data -
• Inadequate crew monitoring or challenging was a
factor in 84% of 37 crew-caused air carrier accidents reviewed in a NTSB safety study.
– 76% of the monitoring/challenging errors involved failure to catch something that was causal to the accident
– 17% of the monitoring/challenging errors were failure to catch something that contributed to the accident’s cause
Primero los datos más duros: ACCIDENTES

12. Why improve monitoring? - Accident Data -
• Poor monitoring was a factor in 63% of the ALA
accidents reviewed by the FSF ALAR working groups.
• 50% of the CFIT accidents reviewed by ICAO to
support the FSF CFIT efforts involved poor
monitoring.
Accidentes

13. Why improve monitoring? - Incident Data -
• Researchers examined 200 incident reports submitted to NASA ASRS
• They found evidence that
inadequate monitoring can
lead to adverse safety
consequences
– Altitude deviations
– CFIT
– Stall
– Loss of aircraft control
– Course/Heading deviations
Identifica los factores que contribuyen a los errores de monitoreo. Ofrece recomendaciones operacionalmente orientadas - Incrementar la conciencia en este tema,- Mejorar el monitoreo de la tripulación.
Los hallazgos: Trayectoria del avión reportes (93%)
- trayectoria de vuelo y rodaje
- manejo de la velocidad
Automatización reportes (32%)
- modo conciencia / estatus
- MCP ajustes / selecciones
- FMS ingreso de datos
Sistemas del avión reportes (17%)
- estado del combustible
- configuración del avión

14. Why improve monitoring? - LOSA Data -
Roughly 64% of “unintentional errors” in the
University of Texas LOSA archive were
undetected by flight crew.
• In a recent LOSA, 19% of errors could have
been eliminated by more effective crew
monitoring and cross-checking.
• In that same LOSA, 69% of “undesired states”
could have been eliminated by more effective
monitoring.
Breve explicación de que esta compuesto el archivo LOSA

15. Underlying factors associated with poor monitoring
1. Until now, the industry has not made
monitoring a primary task.
– When listing PNF duties, we often list duties such as handling radio communications, keeping flight logs and operating gear and flaps.
– Monitoring is not one of the duties primarily listed, but rather it seems to be treated as a secondary task, or not addressed at all.

16. Underlying factors associated with poor monitoring
2. Effective monitoring is not easy and
Intuitive
– requires a skill and discipline

17. Underlying factors associated with poor monitoring
3. There is somewhat of a monitoring
paradox that works against effective
Monitoring.
– Serious errors do not occur frequently which can lead to boredom and complacency
Detenerse en la complacencia vs. Fatiga. Tanto la fatiga como el monitoreo requieren de contramedidas, la combinación de ambas esta relacionadas y sería de alto riesgo.
“A low-probability, high-criticality error is exactly the one that must be caught and corrected.”

18. Underlying factors associated with poor monitoring
4. Although traditional CRM courses have generally improved the ability of crewmembers to challenge others when a situation appears unsafe or unwise…
• many of these courses provide little or no explicit guidance on how to improve monitoring.

19. Underlying factors associated with poor monitoring
5. We seem satisfied that we cannot improve monitoring, and simply explain it as, “Humans just are not good monitors.”
– While it may be true that humans are not naturally
good monitors, crew monitoring performance can be
significantly improved through policy changes and
crewmember training.

20. NASA ASRS Monitoring Study
• This study was a good resource for helping us get stared and providing data
• The objectives of the study were to identify factors that contribute to monitoring errors, and
• Offer operationally- oriented recommendations to
– increase awareness of this subject
– improve crew monitoring

21. ASRS Monitoring Study: Flight Phase where Monitoring Errors Occurred

22. ASRS Study: Number of tasks crew was doing when error occurred*

23. ASRS study significant findings
• 76 percent of monitoring errors occurred when aircraft was climbing, descending or on approach (“vertical flight phase”) • 30 percent of the reports indicated that pilots were programming the FMS shortly before or during the monitoring error

24. ASRS Study Cornerstones for Improving Monitoring
• Management and regulatory officials must provide crews with clearly thought-out procedures and guidelines to maximize monitoring. • Flight crews must constantly exercise monitoring discipline and use operational guidelines designed to improve monitoring.

25. Approach to Improving Monitoring
Developing well thought-out SOPs
Training monitoring skills
Practicing those skills

26. Approach to Improving Monitoring
Developing well thought-out SOPs
Training monitoring skills
Practicing those skills

27. Developing SOPs AC 120-71A “Standard Operating Procedures”
• Revised in February 2003, this AC contains template SOPs that can be adopted by operators to improve monitoring.

29. Developing SOPs
• Change title of “Pilot -Not-Flying” (PNF) to “Pilot Monitoring” (PM)
– Describes what the pilot should be doing
(monitoring) versus what he/she is not doing
(not flying)

30. Monitoring is a primary responsibility of each pilot.
Developing SOPs
Monitoring Responsibility
– The PF will monitor/control the aircraft, regardless of the level of automation employed.
– The PM will monitor the aircraft and actions of the PF.
Monitoring is a primary responsibility of each pilot.

31. Developing SOPs
• Both pilots will have taxi charts available, when necessary
• Both pilots will monitor taxi clearance
• Captain will verbalize to FO any hold short instructions
– FO will request confirmation from Captain if not received
SOP´s claros y de fácil aplicación. Consistencia en todos los procedimientos.

32. Developing SOPs
When approaching an entrance to an active runway, both pilots will ensure the hold short or crossing clearance is complied-with before continuing with non-monitoring tasks (FMS programming, ACARS, company radio calls, etc.)
Sentido común de “Piloto Seguro”. Decirle a todos lo que sabemos que requiere atención. Sop´s que incluyan estos conceptos son más que necesarios…. Relacionar con los hallazgos archivo LOSA.

33. Developing SOPs During high workload, FMS inputs will
be made by PM, upon the request of
PF.
High workload examples
– below 10,000 feet
– within 1000 feet of level off or Transition Altitude.

34. Evento en DFW, pistas paralelas, un avión despegando y otro en la carrera de aterrizaje que abandona la pista activa (rodaje de alta velocidad) y se le instruye a mantener en corto y por distracción en cabina no atienden el mantener en corto…. Una casi colisión.
Relacionar con Runway Safety.

35. Developing SOPs
• Perform non-essential duties/activities during lowest workload periods (e.g., cruise altitude or level flight) • When able, brief anticipated approach prior to top of descent • PF will brief PM where or when delayed climb or descent will begin • During the last 1000 feet of altitude change, both pilots will focus on making sure the aircraft levels at the assigned altitude • Airline eliminated “10,000 ft announcements” and specified that the pre-arrival announcement be conducted just after leaving cruise altitude.
Las siguientes conclusiones quedan muy Ad hoc después del video (moralejas)

36. Approach to Improving Monitoring
Developing well thought-out SOPs
Training monitoring skills
Practicing those skills

37. Training monitoring skills
• NTSB safety study states that simulator training provides a good opportunity to teach and practice monitoring and crosschecking.
– NTSB Safety Study of Crew-caused Accidents

38. Training monitoring skills
• Starting from day 1 of training, ensure all monitoring/ crosschecking SOPs are followed.
• Discuss how barriers are cut in half with one pilot out of the loop.
• Train workload management so at least one pilot is always monitoring during low workload and both pilots are monitoring as much as possible during high workload.
• Acknowledge good monitoring.
– Introduction of occasional subtle failures in simulator training,
such as failure of automation to level-off at proper altitude
Relacionar con todos los cambios en adiestramiento (aerolíneas), pero no como requerimientos de los reguladores de cómo se debe entrenar. Esta iniciativa de seguridad debería ser regulada por las agencias gubernamentales aéreas, especialmente en operadores regionales, cargueros y operadores no regulares. Las mejores practicas de entrenamiento se dan en las aerolíneas más importantes.
Relacionar con la carta de FAA (Randy Babbitt) “Call to Action” (documento adjunto)

39. Approach to Improving Monitoring
Developing well thought-out SOPs
Training monitoring skills
Practicing those skills

40. Practicing monitoring skills
• Know and comply with SOPs
• Pilots must “actively monitor” the aircraft.
• This means that they must mentally fly the aircraft, even when the autopilot or other pilot is flying.
– Monitor the flight instruments just as you would when hand flying.
– If the aircraft (or other pilot) is not doing what it is supposed to do, actions should be taken to rectify the situation.

41. Practicing monitoring skills
• In approximately one-third of the cases studied by researchers, pilots “failed to monitor errors, often because they had planned their own workload poorly and were doing something else
at a critical time.”
– Jentsch, Martin, Bowers (1997)
• Threat and Error Management with a focus on
monitoring and cross-checking is a good way to
teach pilots better workload prioritization skills.

42. Practicing monitoring skills
• Pilots should recognize those flight phases where poor monitoring can be most problematic.
• Strategically plan workload to maximize monitoring during those areas of vulnerability (AOV)
– Examples of non-monitoring tasks that should be conducted during lower AOV include stowing charts, programming the FMS, getting ATIS, accomplishing approach briefing, PA announcements, non-essential conversation, etc.

43. Practicing monitoring skills
Los sectores amarillos son los de mayor riesgo de errores de monitoreo.
We used those workload management findings to develop strategies to improve monitoring. Our program emphasizes that pilots should recognize those flight phases where poor monitoring can be most problematic. We ask our pilots to strategically plan workload to maximize monitoring during those areas of vulnerability (AOV). Examples of non-monitoring tasks that should be conducted during lower AOV include stowing charts, programming the FMS, getting ATIS, accomplishing approach briefing, PA announcements, etc. A chart that graphically depicts higher AOV is shown here. The orange (lighter) lines represent higher AOV.

44. Practicing monitoring skills
By pre-briefing the approach in low workload periods, greater attention can be devoted to monitoring/cross-checking during descent.
• In fact, LOSA data showed that crews who briefed the approach after Top-Of- Descent (TOD) committed 1.6 times more errors during the descent/ approach/land flight phase than crews who briefed prior to TOD.

45. Practicing monitoring skills
• One way of assessing your current monitoring ability is to ask: “How often do I miss making the 1,000’ to level –off altitude callout?”
– When this callout is missed, chances are that you are not actively monitoring the aircraft.

46. Practicing monitoring skills
Both Pilots Creates Barriers PV PM

47. Practicing monitoring skills
When one Pilot is out of the loop……………. PV PM

48. Practicing monitoring skills
…..Half of the barriers are lost PV PM

49. Practicing monitoring skills
If both Pilots are out of the loop…
¿Who is taking care of bussines? PV PM

50. MONITORING AND CHALLENGE
Pilot Monitoring
(PM)
Crosschecking
Steps
Take Action
Express your view
Error Resolved

51. MONITORING AND CHALLENGE (PM) Error Resolve Take Action Solution
Express your view
Problem
Express your view
Error Resolve

52. Practicing monitoring skills
We need a ACTIVE and PROACTIVE monitoring
……………...….…¡We don´t want this!

53. Practicing monitoring skills

54. Paradigm shift
• It must become accepted that monitoring is a “core skill,” just as it is currently accepted that a good pilot must posses good “stick and rudder” and effective communicational skills.

55. Summary
• Inadequate flight crew monitoring has been cited by a number of sources as a problem for aviation safety. • While it is true that humans are not naturally good monitors, crew monitoring performance can be significantly improved through policy changes, training and by pilots following an active monitoring concept.

56. (1992 a 2002) 67.0% 67% Flight Crew Airplane Weather 11% Maintenance
10%
20%
30%
40%
50%
60%
70%
80%
Flight Crew 91
67%
Airplane 15
Weather
11%
Maintenance 10 7%
Misc./Other 8 6%
Airport/ATC 6 4%
Total with known causes 5 4%
Unknown or awaiting reports
135
Las siguientes tres laminas (estadística), demuestran que las iniciativas de seguridad operacional enfocadas al Factor Humano es el camino a seguir. 65
Total
200
(1992 a 2002) 67.0%

57. (1993 a 2003) 62.0% 62% Flight Crew Airplane 14% Weather 12%
10%
20%
30%
40%
50%
60%
70%
80%
Flight Crew 84
62%
Airplane 19
14%
Weather 16
12%
Maintenance 7 5%
Misc./Other 5 4%
Airport/ATC 5 4%
Total with known causes
136
Unknown or awaiting reports 50
Total
186
(1993 a 2003) 62.0%

58. (1995 a 2005) 56.0% 56% Flight Crew Airplane 17% Weather 13%
10%
20%
30%
40%
50%
60%
70%
80%
Flight Crew 75
56%
Airplane 23
17%
Weather 17
13%
Maintenance 8 6%
Misc./Other 5 4%
Airport/ATC 5 4%
Total with known causes
133
Unknown or awaiting reports 44
Total
177
(1995 a 2005) 56.0%

59. The challenge
Take this concept home with you and implement a program to improve monitoring/cross-checking at your company.

60. FO after being involved in fatal loss of control accident
“If I had been watching the instruments, I could have prevented the accident."
FO after being involved in fatal loss of control accident