Background

This Briefing Note (BN) discusses on how to improve flight crew monitoring skills. It is important for every pilot to understand what is “monitoring” because it is an essential personal quality that can influence safety and because each of its elements is vital to safe and efficient aviation operations.

Unfortunately, there is an abundance of evidence showing that inadequate flight crew monitoring is a significant problem in the air transport industry.

Why the emphasis? First, the industry hadn't made monitoring a primary task. Second, we just assume that monitoring is easy, while, in truth, it's not.

Introduction

One of the most important aspects of a safe flight operation is the requirement for crewmembers to carefully monitor the aircraft's flight path and systems, as well as actively cross-check each other's actions.

"Good monitoring skills are not inherent in pilots as they progress in their careers. Effective monitoring techniques must be trained and rewarded..."(May 2001, Capt. Frank Tullo, leading the development of Crew Resource Management training at Continental Airlines).

Most humans aren't good at monitoring; it is a tedious activity and ripe for daydreaming. However, pilots can significantly improve monitoring skills through Standard Operating Procedures (SOPs), procedures, increased emphasis and practice. It is one of the purposes of this BN.

Data

An ICAO analysis of controlled-flight-into-terrain accidents found that poor crew monitoring was a factor in half of the 24 accidents reviewed. The FSF Approach-and-landing Accident Reduction (ALAR) Task Force found that "inadequate monitoring and cross-checking" were present in 63 percent of approach-and-landing accidents. Three-quarters of the monitoring errors failed to catch problems that the National Transportation Safety Board (USA) (NTSB) has identified as causal. A collaborative research effort by NASA-Ames, 21 worldwide airlines and the University of Texas Human Factors Research Program that observed more than 2,000 airline flights noted that roughly 62 percent of unintentional errors went undetected by flight crews. In other words, sometimes we aren't very good at catching our own errors. Researchers examining these data noted that more effective crew monitoring could have averted nearly one-fifth of errors and 69 percent of undesired aircraft states.

All too often, flight crews are doing too many concurrent things to adequately monitor the aircraft.

A particularly interesting statistic from this line operational safety audit data is that 30 percent of the crew errors observed in the 2,000-plus in-flight observations occurred when the flight crew was programming the Flight Management System.

Some 40 percent of the reports indicated air crews had been distracted by radio communications with ATC, the FBO or obtaining Automatic Terminal Information Service (ATIS), or by performing checklists, scanning for traffic and dealing with the FMS. Often several of these existed at the same time.

Observations during another Line Operational Safety Audit at several major airlines revealed over one-third of the monitoring errors occurred due to poor workload management. A significant number of pilots simply weren't planning ahead to accomplish as many tasks during low-workload periods as possible. The key periods in which pilots were committing the most errors due to poor workload management were during taxi-out, within 1,000 feet of level-off, while descending and making an approach or landing, and taxi-in.

Monitoring Defined

One major US airline changed the title of "Pilot Not Flying" (PNF) to "Pilot Monitoring" (PM) to describe what the pilot should be doing versus what he or she is not doing. Also, monitoring responsibilities are now clearly spelled out. The PF will monitor/control the aircraft, regardless of the level of automation used, while the PM will monitor the aircraft and actions of the PF. In an effort to reduce runway incursions, the same airline is now requiring both pilots to have taxi charts available, and both to monitor the taxi clearance. When ATC issues a taxi clearance, the captain will verbalize any hold-short instructions to the first officer. When the aircraft approaches an active runway, both pilots will ensure the aircraft holds short before continuing with non-monitoring tasks such as FMS, Aircraft Communications, Addressing and Reporting System, company radio calls and checklists. Since a high rate of altitude deviations can be tied to poor flight crew monitoring, several of the major airlines are now recommending that during the last 1,000 feet of altitude change, both pilots focus on making sure the aircraft levels off at the assigned altitude.

How to Monitor?

Carefully developed procedures and guidelines can make a significant contribution to enhancing flight-crew monitoring. Several major airlines have recently revised their procedures to maximize the monitoring of aircraft trajectory, automation and systems. They have tried to minimize or eliminate concurrent procedures that conflict with crew monitoring. Several of the major U.S. airlines actively helped the FAA revise "Standard Operating Procedures" (AC 120-71A) in February 2003 so that it promotes monitoring. The Advisory Circular contains an SOP template in Appendix 19 for operators that is specifically designed to improve monitoring.

One noteworthy observation was that crews were often distracted from aircraft monitoring during the descent phase while briefing the approach. In fact, one airline's Line Observational Safety Audit found that crews who briefed during the descent committed many more errors than crews who briefed prior to descent. Briefing during descent led to a significant "bump" in the number of level-off errors, missing ATC amended clearances, and altitude busts occurring during this time. Obviously briefing an approach is an attention-demanding task. US Airways now recommends briefing the anticipated approach prior to the top-of-descent, when the workload is low.

Now sometimes pilots can't pick up the ATIS to find out which approach will be in use before starting down from cruise. The US Airways experiment found that if crews would look at the weather forecast and make an informed guess on which approach would be in use based on the weather, they would be right more than 90 percent of the time. By having the approach already briefed before the descent, both crewmembers are able to be "heads up" and actively monitoring during the critical descent, approach and landing phases. This technique has significantly reduced the number of flight crew errors.

In addition to these procedures, it's helpful to impress upon pilots the importance of monitoring during training sessions. Instructors should insist that the pilot monitoring monitors the aircraft effectively, and then acknowledge those who demonstrate good monitoring skills. Pay more attention to workload management so that at least one pilot is always monitoring during low-workload periods and both pilots are monitoring as much as possible when things get busy. Starting from day one in the simulator, ensure all monitoring and cross-checking procedures are followed. Insist crews make the 1,000-foot level-off call prior to the alerter. If the crew misses, it's a clue that they are not actively monitoring the aircraft.

Key Points

• Flight Crew Monitoring Principles:
  • Be technically proficient
  • Keep your team workers informed
  • Insure the task is understood, supervised and accomplished
  • Train as a team
  • Make sound and timely decisions

Associated OGHFA material

Briefing Notes

• Discipline
• Decision Making
• Pilot judgment and expertise

Visuals

• Discipline
• Decide - Checklist

Situational Examples

• Loss of Control and In-Flight Upset After Loss of Engine Power

Additional Reading Material and Website References

• FSF Approach-and landing Accident Reduction (ALAR) Tool Kit
• AC 120-71A - Standard Operating Procedures for Fight Deck Crewmembers

Related industry publications

• NTSB Safety Study: A Review of Flight-Crew-Involved, Major Accidents of U.S. Air Carriers, 1978 through 1990. Report no. NTSB/SS-94/01.Washington, D.C., United States: NTSB, 1994.
• Enhancing Flight Crew Monitoring Skills Can Increase Flight Safety pp 1-8.