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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 effort Operational philosophies, policies, procedures and practices are designed to support effective monitoring Operational 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 presentation

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 presentation

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. This presentation highlights much of the information in Recommendations 1-9 and some of the information in Recommendation 15. [[WORDS CAPITALIZED]] Slide intended to be hidden during presentation

Improving Flight Path Monitoring A Training Aid

The Goal The goal of this training aid is to reduce errors in flight path management through improved monitoring performance.

Learning Objectives Industry concerns around monitoring
Fight path monitoring is a primary responsibility Need to control and monitor the aircraft’s flight path Dual responsibility for monitoring the flight path Predictable areas where flight-path risk is increased Effective crew-resource allocation Decoupling tasks that interfere with flight path monitoring Increased flight path monitoring feedback Recommended monitoring practices

Our Scope

Monitoring Definition
Monitoring is adequately watching, observing, keeping track of, or cross-checking. That’s certainly a very broad term, and the list of all that a pilot monitors on the flight deck is enormous: State of aircraft systems Flight path Aircraft configuration Aircraft energy level Actions of the other crewmember ATC, etc. Start a discussion with the audience about all that they monitor during flight.

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. The term monitoring is often used, regardless of what is being monitored: Flight path Aircraft systems Threats (for example: weather, workload, operational pressures, complex procedures, terrain hazards, etc.) Other pilot Or how it is monitored: Passively (example: alerted by master warning) Actively (example: as part of a learned scan pattern that is adjusted to fit current operational conditions) Deliberate checking (example: the deliberate, focused concentration used to verify checklist items or flight path guidance entries)

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.

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 monitoring

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.

Today’s Topic This 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.

The Central Fallacy

“Nowadays, these airplanes pretty much fly themselves.”

The airplane does not fly itself.
Flight path did not become less important when the aircraft became automated. Impact with terrain and loss of control are potential issues if we neglect flight path in both classic and modern aircraft.

Recent Accidents in Which Inadequate Monitoring Was Cited as a Factor
UPS 1354 2013 FedEx 1478 2002 Turkish Air 1951 2009 Colgan 3407 2009 Empire 8284 2009 Asiana 214 2013

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 accidents Flight Safety Foundation Study (1998) 63% of accidents involved inadequate monitoring and cross-checking Line Operations Safety Audit Data Query (2013) Observations 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 Add/discuss other data from report as necessary. Point is to get buy-in that monitoring issues are not new and that inadequate monitoring contributes to accidents.

Flight Path Monitoring
The need to address this issue has been highlighted as a major industry concern by several flight safety organizations.

Automated aircraft do not “fly themselves.”

Please participate in the following monitoring challenge …

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.

Watch the following video …
This “Selective Attention” video is widely available on the Internet and can be made into a professional training aid with minimal video editing. On average 65%-75% of students did not see the gorilla. Instruct students to count the number of passes made by the white team. 2. Bait the students by insinuating that the task of counting the correct number of passes is difficult. 3. Offer a prize, I usually offer $1, and tell them that if (by chance) more than one gets the right number, they can split the pot. 4. Tell them “Do not count out loud (and, for that matter, do not say anything out loud.”) [Say the part in parentheses with less emphasis. It lessens the effect if one of the students shouts out “gorilla.”] 5. Have fun with it. Click image to play video

How many passes did you count?
Line of reasoning – selective attention demonstration Say “How many passes did you count?” and “Did you see anything else?” Main Point: We do not see everything happening in front of us. We see what is relevant to the task we are doing. Background Science: It looks to us as if our eyes operate as a video recorder that sees nearly everything happening around us. This is a powerful illusion created by our “cognitive hardware.” The reality is that our eyes focus only on a small fraction of what is happening around us. Thinking we see nearly everything, when in fact we don’t, can lead us to make bad choices about how we prioritize our attention. Researchers noticed that the amount of data traveling along the optic nerve was actually too small to account for the size of the picture that we see in our mind. This prompted a lot of further research where it was discovered that our eyes move to the things we think are most important and then our brains “fill in” the background.

By show of hands, did you see anything unusual during the game?
Ask, “Did you see anything else?” Individually ask students what they saw that was unusual. Students often raise their hands to report minor anomalies, but do not see that gorilla. What is important about the exercise is not who saw the gorilla and who didn’t. What is important, is the fact that we all are prone to miss information that is in plain view. Main Point: We do not see everything happening in front of us. We see what is relevant to the task we are doing. Background explanation: It looks to us as if our eyes operate as a video recorder that sees nearly everything happening around us. This is a powerful illusion created by our “cognitive hardware.” The reality is that our eyes focus only on a small fraction of what is happening around us. Thinking we see nearly everything, when in fact we don’t, can lead us to make bad choices about how we prioritize our attention. Researchers noticed that the amount of data traveling along the optic nerve was actually too small to account for the size of the picture that we see in our mind. This prompted further research where it was discovered that our eyes move to the things we think are most important and then our brains “fill in” the background creating the illusion that we see “everything.”

Warning The main idea… (go to next slide)

Perception is highly selective.
Warning Perception is highly selective.

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. Main Point: We do not see everything happening in front of us. We see what is most relevant to the task we are doing. We were counting passes, not looking for gorillas. If you are putting away approach charts during climb, is it possible you wouldn’t see your airspeed decay? Does the fact that your airspeed indicator is right in front of you guarantee you will look at it in a meaningful way?

Thinking we see everything in front of us,
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. Main Point: Thinking we see everything in front of us, (when in fact we don’t) … … This is why it is crucial that we take a critical look at deliberately prioritizing flight path at specific points in our path.

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 There are a lot of barriers to effective monitoring. Here are a few. Use excerpts from A Practical Guide for Improving Flight Path Monitoring to expand on each of these topics. This is not meant to be a human factors lesson, but merely to educate crews that there are forces acting against their effective monitoring.

Both pilots are responsible for monitoring the flight path.

PF vs. PM Duties for a Heading Change
PF Duties PM Duties Monitor radio communications Acknowledge clearance (with other pilot) Rotate heading knob Monitor heading bug (verify correct heading set) Select heading lateral mode Monitor 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 To illustrate the previous point …

PF vs. PM Duties for a Heading Change
PF Duties PM Duties Monitor radio communications Acknowledge clearance (with other pilot) Rotate heading knob Monitor heading bug (verify correct heading set) Select heading lateral mode Monitor 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 Now all of the similar duties are in blue. Note that PF and PM duties are far more alike than different, and that both crewmembers are responsible for monitoring. This demonstrates how the labels PF and PM are misleading. It is imperative that crews recognize that both crewmembers are responsible for effectively monitoring the flight path.

Areas Where Flight Path Needs Elevated Prioritization

Improving Flight Path–Monitoring Performance
One 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.” Main Point The priority of flight path and the need for higher flight path sample rates varies situationally. This variation is highly context-dependent, but to a certain extent, the variation follows a predictable pattern. The fact that there is some element of predictability allows us to plan and manage our workload in a way that maximizes appropriate attention to flight path. 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.” The ability to maintain flight path as a higher order priority requires a combination of both strategic and fine-grained workload management.

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.

When is the flight path most vulnerable?
The flight path is most vulnerable when: Your trajectory or energy is changing, or Your available time to intervene is limited Let’s use a simple visual model to represent our flight path threat environment … Goal: Define when flight path matters most as a priority.

Areas of Vulnerability – In Flight
High Medium Low Areas of Vulnerability – In Flight Key to Red Dot Labels: L = Lateral Trajectory Change V = Vertical Trajectory Change S = Speed Change L,V L Vertical Profile (Side) View L,V V V 10,000 ft1 S S L,V V L Close to Ground2 V V,S 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.

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 Goal: Introduce AOV Diagram Main Points: 1. This picture is an intentionally over-oversimplified debrief tool. 2. The red zones are “cut and dry.” In these high vulnerability phases of flight, there is little debate . 3. The yellow zones require the pilots to judge the situation in context. These yellow areas really come in shades of yellow and must have some level of nuance to be realistic (in accordance with how complex is the climb/descent vs. how big/small is the competing task that you are managing). Examples: The PF loading a new approach on a complex descent is asking for trouble. The PF completing a very short simple task on a simple descent is probably OK.

On the ground: - We are most vulnerable approaching, crossing and entering active runways - We are fairly vulnerable whenever we are moving on the ground Even on nice days, ground movement is inherently hazardous. Ground red and yellow zones are cut and dry.

High Medium Low Departure Destination Drawn to scale, we see that many flights spend the majority of their time in a low flight path risk mode. Main Point: On flights longer than an hour, we spend most of the flight in an environment that is simple, stable and safe. Green zones are periods of low-sample-rate active flight path monitoring. Most of the flight, pilots are in the low-sample-rate active flight path monitoring state. Most higher-sample-rate active flight path monitoring occurs at the beginning and end of the flight.

Time is available to intervene if needed.
Low AOV High Medium Low E.g., Cruise Stable Simple Safe Time is available to intervene if needed. In Low AOV, lower sample rates are appropriate.

High Medium Low Main Points: 1. Have the students list the periods of the flight in which they think the flight path threat is highest, and where the probability of undesired aircraft state is highest or most critical. 2. Point out that the red lines and red dots are the high flight-path-threat spots. (Caution: Some students do not notice the red dots.) Point out that the red dots indicate trajectory and energy transitions.) 3. Point out that the red areas are pretty cut and dry. 4. Point out that the yellow is a little less rigid, and that it is up to flight crews to look at the situation and context and use judgment to decide if something is “more yellow” or “less yellow.” Let’s compress cruise flight and talk about where the flight path is most vulnerable to deviations.

Medium AOV E.g., All Climbs and Descents High Medium Low
Point out that most ASAP-reported occurrences occur on descent. Top two ASAP categories are: Crossing altitude constraints too high Leveling off below assigned altitude

Medium AOV High Medium Low E.g., All Flight Below 10,000 ft

High AOV E.g., All Changes of Trajectory and/or Energy
Medium Low E.g., All Changes of Trajectory and/or Energy Initiating climb or descent Leveling off Turning, changing routing Changing speed and/or configuration

High AOV E.g., The Last 1,000 ft of a Climb or Descent** 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. Note: Some operators will want to make the last 1,000 ft a red AOV. Others may wish to simply make the last 1,000 ft a sterile cockpit so as to avoid encumbering both pilots with a high sample rate flight path scan. Most operators, however, will want both pilots to monitor the actual level-off (flight path transition) with a high-sample-rate flight path scan.

High AOV E.g., All Low-Altitude Flight All flight below MSA
Medium Low All flight below MSA E.g., All Low-Altitude Flight Below approx. 1,500 ft AGL or Below surrounding terrain

Ground Path AOV E.g., All Ground Movement
High Medium Low E.g., All Ground Movement Approaching, crossing or entering a runway or tight space Note: The green dot represents “aircraft stopped with the parking brake set.”

The video suggested for this slide is produced by the Dutch Accident Investigation Board and is available on the Dutch AIB website. Click to play video

Turkish Air 1951 What 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? Remember the gorilla “Sample rate” is the frequency with which a pilot directs his or her gaze and mental attention to the various items or indicators. What monitoring threats were present? The crew mistakenly believed that the faulty RadAlt would only affect its “on-side autopilot” High-fast start of approach, precipitating to high workload at low altitude Necessary-large-energy change when transitioning from stall to recovery and go-around Was the airplane stable at 1,000 ft? No, the airplane was not configured and the crew was not able to initiate the landing checklist until just below 1,000 ft As airspeed decayed below target and throttles should have advanced, the crew was preoccupied with the landing checklist What was the impact of tolerating instability below 1,000 ft? Throttle idle and speed decreasing was an expected configuration recovering from the high-fast start and masked the underlying problem until the aircraft was below 1,000 ft Tolerating instability passing 1,000 ft had the result of carrying the insidious anomaly into the low-altitude regime Allowing the anomaly to manifest below 1,000 ft left very little time for proper reaction. Nearing the stall, was anyone flying the aircraft? In this case, there was: Failure to get the aircraft stable by 1,000 ft (required by Turkish Air SOP) Continuation of the approach below 1,000 ft in an unstable condition Result was an unanticipated stall at critically low altitude The decision to be busy below 1,000 ft invited the unhappy coincidence of: Missing the deceleration to stall, and, Critically low altitude What needs to be the main priority during a high-energy event, like a stall recovery or go-around? Pitch and power

Allocate adequate crew resources to managing the flight path.
The ability to maintain flight path as a higher-order priority requires a combination of strategic and tactical (fine-grained) workload management.

The types of things a crew does:
Flight Path Related Tasks Non-Flight Path Related Tasks The flight deck is full of competing demands. Major Planning and Decision making Non- Essential Tasks

Flight Path Related Tasks
Non- Flight Path Related Tasks Typical ineffective/default task distribution in highly automated aircraft. We tend to relegate flight path monitoring to a more-or-less secondary role! Major Planning and Decision making Automation can lead pilots to stop thinking of flying the airplane as a task. This, combined with our false belief “that we see everything happening in front of us,” can easily lead us to relegate flying the aircraft to a more or less secondary role! Aircraft computers do not have intent, they can not fit facts into context, they can not command aircraft. Automation is only an aid to assist an engaged and proficient pilot. Non- Essential Tasks

Effective Crew Resource Division (Who does what in moderate AOV)
Non-Flight Path Related Tasks Monitoring the aircraft is such a critical task that it needs to be decoupled from other tasks Non- Essential Tasks PM PF Flight Path Related Tasks Main Point: Not only is managing the flight path a task, it is such an important task that it needs to be decoupled from other tasks. When the aircraft is climbing or descending, the crew should divide duties so that the controlling pilot is not distracted from monitoring the flight path. The more complex the climb or arrival, the more total the controlling pilot’s focus on the flight path should be. Major Planning and Decision making

Effective Crew Resource Division (Who does what in high AOV)
Flight Path Related Tasks PM PF Flight Path Related Tasks Main Point: When the aircraft is engaged in a trajectory change, or is at very low altitude, both pilots should engage in a high-sample-rate flight instrument/flight path scan. There are three benefits: To guarantee the trajectory of the aircraft is the intended one, To minimize the potential for distraction at potential critical moments, and To frequently and regularly exercise the pilot’s instrument scan, increasing the prominence of flight path in the pilot’s pattern of attention and as an aid to maintaining a high-performance instrument scan. During brief periods of high AOV, it should be the only task being done (by either pilot!) on the flight deck.

Prioritize Flight Path
Anytime the AOV is medium, at least one pilot needs to prioritize flight path scan. - Climbing - Descending - Below 10,000 ft? High Medium Low In medium AOV, the controlling pilot should not engage in tasks other than controlling the aircraft. If a task presents itself, it should be delegated to the assisting pilot or control should be transferred. FMS-related activities should be delegated to the pilot-assisting proportional to the complexity of the task/complexity of the arrival or departure. Example: Direct XYZ might be OK in a simple open descent, but maybe not on a complex descent via below terrain. Allowing the controlling pilot to change an entire approach or arrival is not a good idea in any vertical phase of flight.

Prioritize Flight Path
For the brief periods when AOV is high, both pilots need to prioritize flight path scan. Flight path is changing Very low altitude High Medium Low During those relatively brief instances when the flight path is changing, both pilots should actively focus their attention on, and monitor, flight path-related items.

Decouple Tasks From Flight Path
Note On this slide: Tasks means non-flight path–related tasks Flight Path means flight path–related tasks Instructor should say out loud: “Decouple non-flight path–related tasks from flight path–related tasks.”

Plan Your Workload Do these tasks during low
Many tasks can be done when you choose: Talking on the PA Talking to dispatch Running W&B calculations Reviewing ABG, manuals Stowing charts Do these tasks during low flight path vulnerability. Main Point Tasks can be performed proactively or reactively. Tasks are far more likely to cause distraction errors when done reactively, so it makes sense to schedule tasks proactively to the greatest extent possible. For example, if it is a very short flight and you anticipate a minimal cruise segment, and there is time before departure, there may be an opportunity to plan the arrival a little bit while you are still at your departure gate.

Medium AOV Make 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 fly Note: Tasks means non-flight path–related tasks and Flight Path means flight path-related tasks. Below 10,000 ft, the operator should consider prohibiting the PF from engaging in distracting tasks. (Some operators use FL180 for this demarcation.) But even above 10,000 ft, when the aircraft is climbing or descending and particularly during complex descents, while not prohibited, it may be a bad idea to take on big tasks and fly the plane. Ask the PM to do the task or Ask the PM to fly

Medium AOV Or, 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 scan Note: Tasks means non-flight path–related tasks and Flight Path means flight-path–related tasks. Say, “Or, as a last line of defense: If you are the PM and the PF begins doing a task, make sure you monitor.”

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 AOV Note: Tasks means non-flight path–related tasks and Flight Path means flight path–related tasks. Say, “Do not ‘task’ when you should be ‘flying.’” Delay the task until you are out of the red. For example, the ATIS can wait until you are not in a turn.”

WARNING Do not work problems on approach Put the aircraft in a state that is simple, stable and safe red AOV Note: Tasks means non-flight-path–related tasks and Flight Path means flight path–related tasks. Say, “Do NOT work problems on approach.” If a problem arises on approach, go around. Both pilots should focus primarily on flight path scan until the aircraft has reached a safe location and crew duties (i.e., who is flying the aircraft) have been assigned by the captain.

FPM Attention and Sampling Rate Workload Management Strategy
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 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 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 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 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 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 Flight path is primary, but division of attention to complete other tasks is permitted

Empire 8284 Think about prioritizing flight path as we watch the following NTSB video that recreates the accident of Empire Flight 8284. Video animation is available at <ntsb.gov>. Some operators find that the training value of the videos is increased by using video editing to add voiceover to the animation.

Empire 8284 Click to play video
The first officer … noticed that the airplane did not decelerate as expected (and briefly accelerated); however, … [the first officer] did not say anything to the captain about this observation. The airplane’s failure to decelerate is consistent with a flap asymmetry because the abnormal condition provided less lift and drag than the desired 15-degree approach flap configuration. … However, the FDR showed that … about 30 seconds after the asymmetry occurred, the first officer reduced engine power to about 3 percent torque, which was likely an effort to reduce the airspeed; as the airplane continued its descent on autopilot, only a minimal increase in engine power was commanded. About 40 seconds after the asymmetry occurred, the captain observed a problem with the flaps; at this time, the airplane was just outside the LOM/FAF at an altitude of about 1,400 ft AGL. In response, the captain began a nonstandard procedure to troubleshoot the flap problem [that involved inspecting the CB panel behind the cockpit seats.] He did not verbalize his plan of action with the first officer, who continued flying the approach. The airplane’s airspeed decreased throughout the approach, resulting in an increasing AOA, and the stick shaker activated when the airplane was about 900 ft AGL at an airspeed of 125 kt. … The stick shaker disconnected the autopilot …, and the first officer began to manually fly the approach, increasing engine power to about 70 percent torque. Control force estimates showed that the first officer was applying about 35 to 40 lb of rudder pedal pressure and about 13 lb of control wheel force to manually counter the flap asymmetry. However, under manual control, the airplane deviated high and to the right of the Runway 17R ILS glide path, indicating that the first officer may not have immediately recognized the extent of the airplane’s right banking tendency induced by the flap asymmetry. As the deviation increased…, the first officer asked the captain, “should I go around?” The captain replied, “no” and instructed the first officer to “keep descending.” About 4 seconds later, when with a strained voice the first officer stated, “we’re getting close here,” the captain asked the first officer if she wanted him to take the controls, and she replied that she did. Click to play video

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? Once you make a decision, in this case the decision to continue, it is very hard to reverse your decision.**For this reason: It is critical to avoid making an initial bad decision to continue an approach with a problem. It is also critical to attempt to gain the psychological maturity to be able to say, “I made a bad decision, let’s go around (or words to this effect).” **This point was in the NTSB findings for this accident. Remember the gorilla

Increase Your Sensitivity to Monitoring Feedback
Main Point The ability to maintain flight path as a higher-order priority requires a combination of strategic and tactical (fine-grained) workload management.

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? Noticing when you are not doing something is hard. So, how do you notice when you (or your partner) are not flying the aircraft? Since the cockpit is a high feedback environment, there are subtle but dependable clues.

Fortunately, there are some clues that can alert us that we are not engaged in EFPM. When we lose situational awareness (SA), it is a reliable phenomenon that there are cues in the environment that something isn’t right.** **We call those clues SA Flags.

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 monitoring

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” The first clue is: Missed (or late) flight path callouts

If a change in pitch, roll or power occurs … and you were not actively looking for it Another clue is: If a change in pitch, roll or power occurs … and you were not actively looking for it

If a mode change occurs … and you were not actively looking for it

If you are late to recognize terrain, traffic or weather Or: If you are late to recognize terrain, traffic or weather

If you notice yourself performing concurrent (non-flight path–related) tasks during flight path transitions Last and very important: If you catch yourself or the other pilot performing concurrent tasks during flight path transitions

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 transitions If you discipline yourself to interpret all of these things to mean, “I am not focusing enough on monitoring at the moment,” you will increase your ability to notice when your monitoring is lapsing. ((SG – worded important point more clearly/ strongly))

React to these indicators by increasing the priority of your flight-path scan

Recommended Practices

Recommended FPM Practices
Exhibit good monitoring practices In 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 situation In the following slides, we will talk about the tools that are tried and true: Tools are not SOPs, but they are agreed-upon best practices that you apply in the way that best fits your current situation.

First and foremost, adhere to SOPs: SOPs are not optional tools SOPs are items that are agreed to be so important that they are mandatory unless superseded by emergency authority Some monitoring habits are so easy to define, and so important, that they are mandatory SOPs. Use this placeholder to discuss SOPs at your airline that are specifically designed to support EFPM. Examples might be: Restrictions on activities during climbs/descents Approach or altitude callouts Mandatory briefings (to set expectations, so PM knows what to monitor) Sterile cockpit

Several SOPs are in place to help you monitor. Example: SOPs require sterile cockpit below 10,000 ft To help you avoid distraction during medium and high AOVs Because perception is a scarce resource Main Point: Sterile cockpit is a sound policy. 2. We can allocate our attention resources between what we are looking at, listening to and thinking about. We need to be careful because our attention resources all come out of the same finite, limited “pot.” Nonessential activities and conversation misallocate our scarce perception resources, degrade our pattern of attention, and decrease the probability that our attention will be on the right thing at the right time. 3. From a threat-and-error management (TEM) perspective, avoiding conversation in any red zone would be a prudent personal decision (i.e., the last 1,000 ft, trajectory energy changes, etc.) Remember the gorilla

Practices That Enhance the Awareness Necessary for EFPM

Mentally Fly the Airplane Scan the flight instruments and anticipate control inputs exactly as you would when hand-flying — even when the autopilot (or the other pilot) is flying. When you monitor, periodically: Scan the flight instruments and anticipate control inputs exactly as you would when hand flying. High AOV – always a good idea Medium AOV – often a good idea

Stay ahead of the aircraft Predictive awareness comes from thinking ahead. Staying ahead of the aircraft is the key driver of our pattern of attention. Staying ahead of the aircraft leads us to be looking in the right place at the right time. Thinking about the right thing at the right time is a byproduct of stimulating our attention effectively. The way it works is: The act of anticipating what is going to happen next or what might happen … • Automatically ”cues up” relevant experience, which … • Automatically signals to your brain “what is important” and “what to look for” and … • Influences you to look in the right place at the right time. So what we think of as vigilance (seeing everything that is important) is really a subtle (and automatic) form of anticipating where to look. To make this powerful, human-survival instinct work for you, you need to: • Stay ahead of the aircraft.

Hand-Fly Hand-flying requires a sound instrument cross-check and is a good way to hone your monitoring skills Many operators require pilots to maintain proficiency with manual flight skills: - Use good judgment about when to hand-fly One reason we hand-fly is to maintain proficiency at hand-flying, which is a good idea and something we are required to do. Another reason to hand-fly is to help maintain proficiency at high levels of automation. We still need to move in and out of the same rapid and effective scan even in managed modes. Hand-flying is a good way to maintain a strong scan. If we are really engaged when we monitor the aircraft, we activate the same neural paths when we are mentally flying that we do when we are actually hand-flying. Hand-flying literally strengthens the same neural paths we use to mentally fly the aircraft.** ** Additional background: This effect is due to a type of nerve cells known as “mirror neurons” that fire in the same pattern whether we move the thrust levers or whether we are so highly engaged that we experience subtle sensations similar to actually manipulating the controls.

Set/Check Targets Examples include intermediate altitude targets during descents to crossing restrictions, and altitude targets/DME targets on approach Main Points Set altitude targets prior to constraints and cross-check them, e.g., 20 nm (37 km) prior to a crossing fix, you should be 6,000 ft above the restriction. Set configuration targets on approach, e.g., “Since we will be above the glide slope, we will be fully configured not later than ____.” Set altitude targets from runway end and cross-check them. We cross-check our instruments when we have miscompare flags to determine which are valid. In Class 2 Nav, we cross-check our fuel burn with a calculation on our flight plan. We cross-check the aircraft-generated top-of-descent (ToD) calculations to verify their accuracy. We sometimes check our progress on descent or approach using a mental calculation. We do not rely solely on the automation.

Plan your workload to protect AOVs Anticipate foreseeable task loading and get work done early The more proactive our workload management, the better our monitoring. When we find our workload is getting high, we do a good job of adding time. This is a good thing. An even better thing, when task loading is foreseeable, is to begin/complete tasks early. In other words, to add time on the front end instead of the back end.

Practices That Maintain and/or Reestablish Critical Flight Path Targets in Working Memory

Restate constraints/restrictions periodically Thinking 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 attention Thinking out loud is a good way to stay “on the same page” with the other pilot. But there is another benefit: Periodically restate your intention to comply with restrictions to help you keep your focus on priority items. Audibly refreshing restrictions/constraints helps you keep important intentions from dropping out of your pattern of attention.

Restate constraints/restrictions periodically When does it make sense to do this? When there is a long time between the clearance and the constraint When 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 events Announce status/intention as often as this makes sense given the situation. When a there is a long time between the clearance and the constraint, e.g.: Dep 13R JFK “Taxi Fox, Bravo, hold short of November” When the environment is very busy or distracting, e.g.: Any taxi restriction on the ground in Chicago At the beginning and end of a large “pop-up” task, e.g.: Programming runway change to 31L at KE and remembering to hold short of Juliet After unusual or distracting events, e.g.: After an ECAM/EICAS message that occurs while descending for a restriction

State clearances in a loud, clear voice This practice: Helps encode the clearance in your memory Helps 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 clearances Main Point Stating clearances: Helps encode the clearance in your memory. Helps the other pilot remember it, too.

Verbally acknowledge when distraction events occur Saying something triggers both pilots to deliberately review last steps: “Hey, we just got sidetracked (or similar words). … We were just about to start down to make Providence at 11.” Drawing attention to the distraction forms a retrieval cue for your memory that helps you remember to go back to the item that you were originally attending to. This retrieval-cue function becomes especially effective if you make a habit out of it.

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.” There have been a number of ASAP reports stating: “I made a mental note.” Do not use mental notes. Use an external memory jogger.

Practices to Intervene Effectively

Deviation Callouts Make specific deviation callouts Encourage deviation callouts Call your own deviations if the other pilot is reluctant Thank the other pilot for deviation callouts

Refuse problematic clearances Pilots have the authority to tell ATC “unable” if a clearance will jeopardize the ability to manage the flight path

Participation Request
Identify the effective monitoring practices used by the flight crew in the following story …

Erroneous “on glideslope" indication
The Story of NZ 60 The NZ 60 incident occurred on an ILS approach Due to multiple failures to the ILS system, the ILS was broadcasting an erroneous “on glideslope” signal regardless of aircraft trajectory Erroneous “on glideslope" indication Information about this event is available in written form through Flight Safety Foundation, or in a movie that may be available by special permission from Air New Zealand.

The Story of NZ 60 This case study may utilize flight safety articles on the NZ 60 event. As you watch this video, pay particular attention to the SA flags, notice which ones are noticed by the crew and how the crew reacts to them. SA Flags: The crew notices several anomalies (unexpected high energy, unexpected visual picture) The crew is aware that they feel uncomfortable, that they have doubts (bad “gut feeling”) The crew notices the aircraft is not making energy targets (despite missing the SOP FAF check) Notice that getting the aircraft stable by 1,000 ft allows this crew time to react to anomalies before they get dangerously low. (Contrast this to the Turkish Air event.)

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? Facilitate discussion. Possible answers are below: Threats Unknown: Insidious failure of ILS glideslope Known: Unexpected high workload at low altitude SA Flags Violated expectations/anomalies (multiple) Failure to meet targets (descent path and energy) High workload Demonstrated best practices The crew was mentally “ahead of the aircraft.” The crew got the aircraft stable by 1,000 ft, which had the effect of giving them time to notice things before they were dangerously low. They reacted to SA flags (noticed that they were rushing, reacted to perceived anomalies, associated doubts and confusion, etc.). They cross-checked the approach path. They got their energy under control immediately. Given the discipline this crew exhibited, it seems like there is a good chance they would have gone around had they been unable to stabilize the aircraft at 1,000 ft. They reacted to SA flags. (Note: They never knew exactly what the problem was, they just knew they weren’t sure about what was going on!) Differences between NZ 60 and TKY 1951? The flight crew got the airplane stable by 1,000 ft, allowing them time to focus on the aircraft, to consider the flags they were experiencing, and to run “3-to-1” cross-checks on the approach profile.

If you remember one thing …
Flight Path Management …means… Always ensure someone is really flying the aircraft REMEMBER THE WARNING Attention Is Highly Selective

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