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What Could Possibly Happen?

  • Published
  • By Mr. Mark Altenburg
  • HQ AMC CRM/TEM Program Director
Summer 2014 --  We've all been there ... It's been a long, routine mission. Good times were shared at a couple of the more decent crew rest locations, but now you're back in the air and more than a bit tired. You just want to kick back and relax. The other pilot is flying this leg and has a good head on his/her shoulders--as capable of flying as anyone in the squadron. You ask yourself, "Do I really need to be on my A-game? I just want to get home and back with my family. Seriously, what could possibly happen?" Seriously? PLENTY! And it happens most often when you are least prepared.

In addition to our six familiar but crucial CRM skills, the soon-to-be released AMC Supplement to AFI 11-290 now includes Threat and Error Management (TEM). It is a staple of the airline industry's safety arsenal, as featured in The Mobility Forum Winter 2013/2014 issue, available at www.amc.af.mil/shared/media/document/AFD-131120-017.pdf. To recap, TEM is an industry-proven safety method that addresses and mitigates threats to aircrews. TEM also encompasses the trapping of errors made by aircrew members.

Now hold on a second! Errors made by aircrews? You're kidding me! Well, sorry to burst your bubble, but even us "gods of the skies" can make a boatload of errors--on every flight. Errors are insidious. They can be insignificant or can result in a catastrophic event (or anywhere in between). When can they occur? Any time during your flight. The sneaky devils might even mask another error. However, that is why we have aircrews, though the pilot monitoring (PM) has the primary responsibility for trapping "piloting-related" errors.

Exemplifying international awareness for PM duties, the United Kingdom's Civil Aviation Authority (CAA) defines PM duties as "The observation and interpretation of the flight path data, configuration status, automation modes, and on-board systems appropriate to the phase of flight. It involves a cognitive comparison against the expected values, modes, and procedures. It also includes observation of the other crew member and timely intervention in the event of deviation."

Remember when PM was called PNF (pilot not flying)? It officially changed in 2003 after the FAA recognized that, "It makes better sense to characterize pilots by what they are doing rather than by what they are not doing. The term pilot not flying misses the point." Thus, the PM was born.

The PM's role is critical. So much so that representatives from 20 airlines and organizations are collaborating on behalf of The Flight Safety Foundation in an Active Pilot Monitoring (APM) workshop. APM's overall objective is to go beyond merely analyzing monitoring deficiencies by offering ways to improve PM skills. Helena Reidemar, the APM's co-lead and Air Line Pilots Association's (ALPA) Human Factors Director, insightfully states, "We've talked about monitoring in the past, but we've never taken as comprehensive a look as this group has."

Most aircrew members are smart enough to know a good PM when they see one, but do a reality check by asking yourself, "Was I a good PM on my last flight?" Better yet, "How was I a good PM?" or even, "What is effective monitoring?" Paraphrasing Aviation Week & Space Technology, effective monitoring means maintaining a big-picture view of what is happening in the cockpit, including the airplane's state (i.e., heading, airspeed, and altitude). It sounds easy, but good aircrew members know better. Captain Steve Dempsey, Delta Airline's Human Factors Working Group Chairman and APM co-lead, goes on to say that, "It turns out that effective monitoring is a tricky, error-prone task for pilots to consistently achieve."

You might snicker and say to yourself, "Yeah, but my MDS is really automated--I shouldn't have to monitor as much as on the old steam gauge airplanes." Let's dispel this myth. While it is true that modern planes are very reliable, their reliability is actually part of the problem! Key Dismukes, from the NASA Ames Research Center, enforces our rebuttal saying, "The human brain just isn't well designed to monitor for an event that very rarely happens." Thus, aircrews get lulled into a false sense of security. Bottom line: PM duties are extremely important in any aircraft, no matter the equipped technology.

"There I was at forty thousand feet when the autopilot jumped out with the only parachute on board and left me with nothing but a silk worm and a sewing kit!"
-Anonymous

Don't Overly Rely on Automation!

Experience has shown that certain times during an average flight are more prone to errors. The airline industry calls them Areas of Vulnerability. Ask yourself, "When do I find myself making more mistakes? When do those vulnerabilities occur? How does a good PM manage vulnerable periods during flights?"

"Establish the concept that there are certain, predictable areas during each flight where the risk of a flight path deviation is increased."
-Helena Reidemar, ALPA Human Factors Director

Obviously, most flyers likely make more errors during hectic periods because there is less time to deal with issues or threats. Thus, takeoffs, approaches, landings, and go-arounds are significant error-prone events. So how does one handle those times/events, in PM terms?

First, plan for the events. Remember, planning starts while you are still on the ground and does not end until you are back in the squadron after the flight. Talk with the other crewmembers--discuss those "what ifs" when time and conditions permit--and develop a workload strategy for dealing with the expected or potential situation.

Additionally, if you are a pilot, you can help yourself by treating error-prone periods the same way as when you hand-fly a well-flown approach--step up your cross-check! Leading airlines refer to this as "increasing the monitoring sampling rate." How fast do you sample? Only you can answer this because you know your situation best. But it must be a rate at which you can catch an error quickly, thereby preventing an undesirable aircraft state. If you find yourself in a series of "Oops, sorry--I missed that" situations, you probably need to step things up.

The appropriate sampling rate is also influenced by the division of workload between crewmembers. If the PM diverts his or her attention to another task, the monitoring sampling rate of another crewmember must increase. For example, while the PM is "heads-down" programming the FMC, the pilot flying must assume the PM's duties for active aircraft monitoring. If another crewmember is available and capable of doing so, he/she should assist. In fact, an argument can be made that all crewmembers (include ACMs) are unofficial PMs. Bear this in mind when you think about PM duties and skills.

Whether a pilot or not, official or unofficial, all aircrew members are PMs!

What about those times of relative calmness during flights? As mentioned, this is your time to plan with other crewmembers. Part of your planning might include assigning special duties, such as having the boom operator help clear the aircraft during especially tight taxi operations. An FAA-funded training study found that in approximately one-third of the Aviation Safety Reporting System reports, pilots failed to monitor errors, "often because they had planned their own workload poorly and were doing something else at a critical time."

PM Requirements Vary Depending on Phase of Flight Circumstances.
Develop a PM Strategy!

Though the official PM gets all the attention for trapping errors, every aircrew member on the plane must be active error monitors. Recall that the July 2013 Asiana KSFO flight mishap had three qualified pilots in the cockpit during the time of the incident. None of the pilots--the captain flying the approach, the check Airman (evaluator pilot) in the right seat, or the first officer in the jumpseat--recognized the undesired aircraft state (insufficient airspeed) until it was too late to recover.

Missions are rarely truly routine, and no two flights will be exactly alike. Monitoring rate requirements will fluctuate. By appropriately managing the aircrew's workload, pilot monitoring can be improved during error-prone times. Anticipate threats when possible, identify threats when they occur, detect crew errors, and avoid undesired aircraft states. In parting, remember what the CAA sagely stated in its 2013 article, Monitoring Matters: "Crew monitoring is frequently the last line of defense that stands between safe operations and an accident scenario."