Issue Number 219
September 1997
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

"Monitoring and Flying a Balancing Act" with Aircraft Balancing a Ball

On the back page of this CALLBACK issue, we summarize several ASRS research papers recently presented at the Ohio State University's Ninth International Aviation Psychology Symposium. One of these, a study of ASRS reports related to inadequate flight crew monitoring, showed that Flight Management System programming was the task most often being performed when a monitoring error occurred. A First Officer's report points out the difficulty that pilots of "glass cockpit" aircraft may have balancing monitoring and programming duties.

Another report from the ASRS study shows that pilots can still fall into monitoring "traps" in spite of extensive experience and thorough knowledge of the FMC.

Our reporter concludes, "This incident reinforces the requirement that someone must be flying the plane!"

CRM Strikes Again

Two reports address the more general topic of Crew Resource Management (CRM). An air carrier Captain describes how CRM skills came into play while the aircraft was still on the ground.

Another Captain, faced with what appeared to be an in-flight engine fire, applied CRM skills to make use of all on-board personnel to cope with the emergency.

"ASRS Research Snapshots" with Camera and Film

Editor's Note: In May 1997 ASRS presented several research papers at The Ohio State University's Ninth International Aviation Psychology Symposium. Brief summaries of two of the papers are presented below.

1. What ASRS Data Tell About Inadequate Flight Crew Monitoring

Inadequate flight crew monitoring has been recognized as a safety problem by a number of aviation organizations. In independent accident studies conducted in 1994, both the International Civil Aviation Organization (ICAO) and the National Transportation Safety Board (NTSB) found that monitoring failures contributed to a large number of the accidents under review. Monitoring is also a relatively neglected subject in Crew Resource Management (CRM) courses, which usually offer few procedures or guidelines to enhance flight crew monitoring.

This study analyzed 200 ASRS air carrier reports to identify factors that contribute to monitoring errors, and to offer operationally-oriented approaches aimed at improving crew monitoring. Several patterns emerged.

Three-fourths of the monitoring errors were initiated when the aircraft was in some "vertical" flight mode-climb, cruise-descent transition, descent, or approach. FMS programming was most frequently the task being performed when the monitoring error occurred. Flight crews and ATC were far more likely to detect the monitoring errors than were onboard alerting systems, such as altitude alerters and Ground Proximity Warning Systems (GPWS).

The paper translates research findings into operational approaches that may help prevent monitoring errors. The authors note that an air carrier's automation philosophy can either support, or conflict with, the monitoring function. As an example of the latter, some air carriers require that one pilot be exclusively dedicated to monitoring and controlling the aircraft, regardless of the level of automation. Several alternatives to this common practice are discussed, and suggestions are also offered for enhancing crews' monitoring effectiveness on long-range flights.

2. Communications-Related Incidents in General Aviation Dual Flight Training

A recent survey of the ASRS database revealed that one third of all incidents involving General Aviation (GA) aircraft

ASRS Request Formalso involved a reported communications-related difficulty, such as failure to comply with an ATC clearance or a communications equipment malfunction. Other research based on accident data and pilot interviews has raised the question of whether communications deficiencies contribute to incidents, accidents, and fatalities during dual instruction.

An analysis was undertaken of 200 ASRS reports that involved GA dual instruction and contained explicit evidence of verbal communications between the instructor and trainee. The main purposes of this research were to identify the operational context in which communications-related incidents occurred during GA dual instruction, as well as the types of problematic communications between instructors and trainees.

The authors found that half or more of the communications-related GA incidents occurred within the airport environs or airspace, within 10 nautical miles of the airport, at altitudes less than 1,000 feet AGL. Ongoing communications with control towers were a prominent element of both surface and airborne incidents. Analysis of instructor/trainee communications revealed that trainees delayed actions or acted inappropriately because instructors made confusing or misleading comments, misinterpreted trainees' comments, or delayed feedback. More than three-fourths of all the study incidents resulted in an ATC clearance violation or a related infraction, such as a runway incursion or ground conflict.

Drawing from study findings, the authors offer practical suggestions to enhance safety and prevent ATC clearance violations during dual flight instruction.

Readers may obtain free copies of papers by filling out the REQUEST FORM (click on "REQUEST FORM") and mailing it to:

ASRS Recently Issued Alerts On...
In-flight engine cowling separation on a PA-31
Communications blind spot at a North Carolina airport
B-757 EFIS failure attributed to a generator malfunction
Unclear "hold short" lines on a taxiway at an Ohio airport
Static electricity causing power outages at an ATC Tower
 July 1997 Report Intake
 Air Carrier Pilots
 General Aviation Pilots
 TOTAL 2,990