These monitoring problems failed to catch primary errors>. 6.

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i |A Practical Guide for Improving Flight Path Monitoring Table of Contents Foreword ..viExecutive Summary ..vii1. Introduction ..11.1 Background .11.2 Defining Monitoring 31.3 Scope 41.4 Effective Monitoring Actions ..41.5 Working Group Makeup 51.6 Tasking of the Working Group .52. Monitoring Data and Research ..62.1 Aircraft Accident Reports ..62.2 Accident and Research Studies .72.3 LOSA Data ..82.4 ASRS Reports 92.5 ASAP Reports .103. Barriers to Effective Monitoring 123.1 Human Factors Limitations 123.2 Time Pressure .133.3 Lack of Feedback to Pilots When Monitoring Lapses .143.4 Design of Flight Deck Systems and SOPs .143.5 Pilots™ Inadequate Mental Models of Autoflight System Modes .143.6 Corporate Climate Does Not Support Emphasis on Monitoring ..144. Recommendations to Improve Monitoring Performance ..155. Concluding Remarks 43Appendix A Monitoring Link to Threat and Error Management Performance, The LOSA Collaborative .44Appendix B Effective Flight Path Monitoring, a Training Aid ..46Appendix C Selected Accidents in Which Inadequate Monitoring Was a Factor 47Appendix D What Skilled Monitors Do ..52

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ii |Figure 1. Observer Ratings of Monitor/Cross-Check Performance Across Phase of Flight .8Figure 2. Phase of Flight When a Monitoring Error Occurred 10Figure 3. What Set the Stage for the Monitoring Error? .11Figure 4. Consequences of Inadequate Monitoring .11Figure 5. Areas of Vulnerability (AOV) to Flight Path Deviation, Ground Profile Examples 19Figure 6. Areas of Vulnerability (AOV) to Flight Path Deviation, In-Flight Profile Examples ..19Figure 7. Example of an Auto˜ight fiMental Mapfl ..35Figure 8. Including Monitoring in Instructor Guides .40Figure 9. Elevation of Role of Pilot Monitoring During Debriefing ..41List of Tables Table 1. Monitor/Cross-Check Ratings During Preflight/Taxi, Correlated with Threat and Error Management Performanc e 9Table 2. Challenges and Barriers to Effective Flight Path Monitoring ..12Table 3. Task Allocation Between Pilot Flying and Pilot Monitoring for Heading Change with Autopilot ‚ON™ 17Table 4. Task Allocation Between Pilot Flying and Pilot Monitoring for Heading Change with Autopilot ‚OFF™ 17Table 5. Vulnerability During Flight Path Deviation 19Table 6. Example AOV Chart of Desired FPM Behaviors .22Table 7. General Threats to EFPM and Intervention Examples .24Table 8. Precursors to Task Overload and Intervention Examples ..25List of Figures

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iii |Acknowledgments The Active Pilot Monitoring Working Group (WG) thanks the many companies, organizations and individuals who made valuable contributions to the work described in this report. Without their cooperation and desire to improve avia- tion safety and operations, this report would not have been possible. Specifically, the WG would like to thank the manu- facturers, operators, pilots and other subject matter experts who met with us and provided us with data and information. In addition, the WG would like to acknowledge the significant contribution to the team from Delta Air Lines, Wright State University, the U.S. National Business Aviation Association and Flight Safety Foundation for hosting the meetings of the WG. Special thanks to Key Dismukes, Ph.D., whose comprehensive body of work on human factors provided the basis for many of the rec- ommendations in this report. Special thanks to U.S. National Transportation Safety Board Member Robert Sumwalt, whose decades-long passion for aviation safety was instrumental in initiating, completing and publishing this report. There are many more people who contributed to this work than can be listed, and all their inputs are greatly appreciated. Also, the co-chairs would like to commend their fellow WG members and thank their sponsoring organizations for their support of this work. Steven Dempsey Co-Chair (Delta Air Lines) Helena Reidemar Co-Chair (Air Line Pilots Association, International)

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iv |Working Group Members The WG membership consisted of representatives from industry, government and labor organizations. Name Organization Kathy AbbottU.S. Federal Aviation Administration Rich BollU.S. National Business Aviation Association Barbara BurianU.S. National Aeronautics and Space Administration (NASA) Ames Research Center Rudy Canto Airbus Doug CarrU.S. National Business Aviation Association Steve DempseyDelta Air Lines (Co-Chair) Key DismukesNASA Ames Research Center (Retired) Mark Draper American Airlines Mike Hayes Delta Air LinesScott Foose Regional Airline Association Jim GormanFedEx (Retired) Steve GuillianJetBlue Airways Osman IftikharDelta Air Lines Nat Iyengar U.S. National Business Aviation Association James KlinectThe LOSA Collaborative Bob LamondU.S. National Business Aviation Association Dave McKenneyInternational Federation of Air Line Pilots™ Associations Mark Millam Airlines for America Jay Pellicone American Airlines Rudy QuevedoFlight Safety Foundation Chris Reed JetBlue Airways Helena ReidemarAir Line Pilots Association, International (Co-Chair) Chris SharberUnited Airlines Robert SumwaltU.S. National Transportation Safety Board Steve SwaugerSouthwest Airlines Pilots™ Association Ron Thomas USAirways/American Airlines Brian Ward FedEx Donata ZiedinsUnited Airlines

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v |List of Abbreviations ACAdvisory circular ACARS Aircraft communications addressing and reporting system AQP Advanced qualification program AFCS Automatic flight control system ALPA Air Line Pilots Association, International AOV Areas/area of vulnerability APM Active pilot monitoring ALT Altitude ALT HOLD Altitude hold ASAP Aviation safety action program ASRS Aviation Safety Reporting System ATC Air traffic control A/T Auto throttles (Boeing) A/THR Auto thrust (Airbus) CACaptain CAMI Confirm, activate, monitor, intervene CAWS Caution and warning system CDUControl display unit CFIT Controlled flight into terrain CRM Crew resource management EFB Electronic flight bag EFPM Effective flight path monitoring FA Flight attendant FAA U.S. Federal Aviation Administration FCU Flight control unit FDM Flight data monitoring FGP Flight guidance panel FltDAWG Flight Deck Automation Working Group FMA Flight mode annunciator FMC Flight management computer (Boeing) FMGC Flight management guidance computer FMGS Flight management guidance system (Airbus) FMS 1Flight management system FOFirst officer FOQA Flight operational quality assurance FPM Flight path monitoring FSF Flight Safety Foundation GPGlareshield panel HFHuman factors ICAO International Civil Aviation Organization IFALPA International Federation of Air Line Pilots™ Associations IOEInitial operating experience LOSA Line operations safety audit MCP Mode control panel NASA U.S. National Aeronautics and Space Administration ND Navigation display NTSB U.S. National Transportation Safety Board PAPublic address PDIPower distance indicator PF Pilot flying PFD Primary flight display PM Pilot monitoring PNF Pilot not flying RNAV Area navigation RVSM Reduced vertical separation minima SASituational awareness SID Standard instrument departure SOP Standard operating procedure SPO Supporting proficiency objective STAR Standard terminal arrival route SWAPA Southwest Airlines Pilots™ Association TEM Threat and error management TOD Top of descent TPO Terminal proficiency objective VVM Verbalize, verify, monitor VNAV SPD Vertical navigation Œ speed WGActive Pilot Monitoring Working Group 1. In this report, ‚FMS™ refers to the Boeing FMC and the Airbus FMGC.

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vii |Executive Summary Contemporary aviation operators have access to information that their predecessors did not. Data streams such as those from the line operations safety audit (LOSA), aviation safety action program (ASAP), flight operational quality assurance (FOQA)/flight data monitoring (FDM), and U.S. National Aeronautics and Space Administration Aviation Safety Reporting System (ASRS) allow many errors in different phases of flight to be carefully scrutinized, categorized and analyzed. Many organizations have a data collection and analysis system to document these anomalies. A great deal of information on the various types of errors and where they occur is now well known and documented. One conclusion emerging from this wealth of information is the importance of effective flight path monitoring (EFPM) in a safe operation. Monitoring is something that flight crews must use to help them identify, prevent and mitigate events that may impact safety margins. Participants at the first Human Factors Aviation Industry Roundtable meeting in 2012 were con- cerned that while the aviation accident/incident rates are at their historically lowest levels, too many events (for example, the crash of Colgan Air Flight 3407 3) involved ineffective monitoring as a factor. The result of the meeting was the creation of the Active Pilot Monitoring Working Group (WG), tasked with studying the issue and creating practical guidelines intended for use by aviation managers to improve the effectiveness of monitoring. The result of this effort is this fiPractical Guide for Improving Flight Path Monitoring.fl fiMonitoringfl is a very broad term, and there are many tasks that involve monitoring. The first ac- tion of the WG was to examine the data, and the results were used to limit the scope of the effort to monitoring of the aircraft™s flight and taxi path, 4 because it is the errors that result in deviations from these intended paths that may lead to accidents. Once the scope was defined, the group identified the following barriers to EFPM: Ł Human factors limitations; Ł Time pressure; Ł Lack of feedback to pilots when monitoring lapses; Ł Design of flight deck systems and standard operating procedures (SOPs); 3. The final report said, fi– the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management.fl In Loss of Control on Approach, Colgan Air, Inc., Operating as Continental Connection Flight 3407, Bombardier DHC-8-400, N200WQ, Clarence Center, New York, February 12, 2009. NTSB/AAR-10/01. 4. For simplicity, the term fiflight pathfl will be used throughout this report to denote any time the aircraft is in mo- tion, including taxiing the aircraft on the ground. Flight path also includes both the trajectory and energy state of the aircraft.

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viii |Ł Pilots™ inadequate mental models of autoflight system modes; and, Ł A corporate climate that does not support emphasis on monitoring. The WG then set about identifying organizational philosophies, policies, procedures, practices and training that may mitigate these barriers to EFPM. This effort resulted in 20 recommendations orga- nized into the following categories: Ł Monitoring practices; Ł Procedures, policies and monitoring; Ł Monitoring autoflight systems; and, Ł Training and evaluating monitoring skills. The WG recognizes that organizations throughout the world are diverse in operational requirements, culture and areas of flight operations. Recommendations in this guide should be evaluated by each or- ganization against its current policies/practices, then adopted, adopted with modification as required to suit its operation, or rejected. When evaluating these recommendations, it is important to remem- ber the goal is to improve pilot monitoring in your operation. Regardless of any action taken by any operator, the WG feels strongly that elevating the monitoring role on the flight deck is a significant and worthwhile operational challenge. Successful improvement in monitoring will require a commitment of time and resources from managers, comprehensive train -ing and appropriate evaluation, and time for the operational culture to change. Many experts agree that implementation of any procedure as an SOP is most effective if the attitudes shown by managers, instructors, check airmen and pilots all reinforce the need for the procedure. 5Recommendations to Improve Monitoring Performance The WG™s analyses of safety data and research studies have made clear that monitoring skills of pilots are important to aviation safety. The following recommendations are based on policies, procedures and practices currently in use at some operators, and on the expertise and resources available to the WG. Recommended Monitoring Practices 1. Institute practices that support effective flight path monitoring. List 12 commonly accepted practices that promote effective flight path monitoring and ensure both pilots™ intentions are well understood. 2. Clearly define the monitoring role of each pilot. Explain that all crewmembers are responsible for monitoring as a primary task. 3. Instill the concept that there are predictable situations during each flight when the risk of a flight path deviation is increased, heightening the importance of proper task/workload management. Introduce the concept of areas of vulnerability (AOV) to flight path deviations and discuss the resul- tant need for improved task/workload management. 4. Practice interventions to maintain effective monitoring or to resume effective monitoring if degraded. Suggest interventions that protect situational awareness and flight path monitoring capability dur- ing high-workload situations. 5. FAA Advisory Circular 120-71A, fiStandard Operating Procedures for Flight Deck Crewmembers,fl Feb. 27, 2003.

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ix |5. Institute policies and practices that protect flight path management from distractions and interruptions. Refine the AOV concept into policies and practices. 6. Practice interventions to resume effective monitoring after distractions and interruptions. Highlight a method of regaining situational awareness after completing non-flying tasks that rou- tinely interrupt flight path monitoring (e.g., crew changes, referencing on-board publications, com- municating with cabin crew, using the aircraft communications addressing and reporting system (ACARS). 7. Promote policies, procedures and practices to improve monitoring of altitude changes. Suggest an SOP to address these, one of the most common errors in flight. 8. Emphasize the effect that emergency and non-normal situations have on monitoring. Discuss the challenges to effective monitoring during stressful situations. Procedures, Policies and Monitoring 9. Review current operating procedures for conflicts with operating policy. Explain how problematic design of procedures can inhibit EFPM. 10. Review specific, monitoring-related procedures that your standards pilots are not willing or able to enforce. Consider recategorizing as policies any procedures that frequently allow for pilot judgment in certain circumstances. Consider recategorizing as practices any procedures with routinely allowed pilot variations. Explain how procedures that are routinely not followed can promote normalization of deviance across all areas of operation. 11. Analyze corporate messages Š explicit and implicit Š that conflict with effective flight path monitoring. Describe how corporate messages to the pilot group (explicit and implicit) may be creating compet- ing goals (e.g., on-time performance vs. safety). 12. Institute policies/procedures/practices to ensure common understanding of air traffic con- trol (ATC) clearances between crewmembers. List SOPs that may help reduce flight management system (FMS) data entries. Monitoring Autoflight Systems 13. Explicitly address monitoring as part of a comprehensive flight path management policy that includes guidance on use of automated systems. Make sure the policy is compatible with the aircraft manufacturer™s recommendations. In this policy, the assignment of tasks (especially monitoring and cross-verification tasks related to managing the aircraft flight path) to each pilot should be clearly identified. Explain the importance of having a comprehensive flight path management policy. List some of the guiding principles that should be included when developing this policy. 14. Develop and refine training to improve the monitoring of automated systems as incorporated in the flight path management policy. Explain how pilots must have full technical knowledge of the automated systems and how pilots must interface with them to effectively manage the aircraft™s flight path. List five areas that should be consid – ered to develop and improve training for operational use of flight path management systems.

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x |Training and Evaluating Monitoring Skills 15. Train pilots about why they are vulnerable to errors and monitoring lapses. Explain how pilots, thinking that they themselves are unlikely to commit errors, may underestimate their vulnerability to monitoring lapses. 16. Reinforce the responsibility of monitoring pilots to challenge deviations. Explain why one pilot may not alert the other about an observed flight path error. Monitoring is inef- fective if pilots do not say anything about observed deviations. 17. Develop and publish clearly defined monitoring tasks, training objectives and proficiency standards. Ensure that instructors and evaluators are proficient at training and evaluating these standards. Explain how clearly defined monitoring tasks, standards, training objectives and instructor profi- ciency are all necessary to improve pilots™ monitoring performance. 18. Implement a comprehensive approach to training and evaluating use of autoflight systems and flight path monitoring. Recognize that pilots will place an emphasis on items they know are going to be evaluated. Monitoring should be trained and evaluated during initial training, recurrent training and opera- tional line checks. 19. Incorporate monitoring training into simulator sessions or other device training. Suggest methods of incorporating monitoring training into training modules and instructor guides. 20. Place greater emphasis on monitoring in operator flight standards programs. Explain how the failure of check pilots to critique monitoring during checking events will lessen the effect of, if not completely undermine, all monitoring training.

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