An informal industry working group is producing a data-rich study to convince airlines that deficient pilot-monitoring skills are a widespread safety threat, and it will provide straightforward recommendations for carriers to help remedy the problem.

The Active Pilot Monitoring workshop (APM) grew out of a November 2012 human factors meeting. Robert Sumwalt, an NTSB member and former airline pilot, challenged fellow attendees to do what regulators have not: devise a focused method to help pilots become better monitors.

Representatives from 20 organizations, notably airlines, labor groups and regulators, have outlined an ambitious agenda. The objective: go beyond studies that analyze monitoring deficiencies and offer—peer to peer, not regulator to regulated—simple, effective tactics to improve pilot-monitoring skills.

“We structured this as a grassroots effort emanating from the airlines,” says Steve Dempsey, a Delta Air Lines Boeing 737 captain and the APM's co-lead. “We are reaching out to government and to labor for resources to solve an industry problem.”

The group, embracing a perfect-is-the-enemy-of-the-good approach, gave itself until the end of 2013 to break new ground in a maturing area. “We've talked about monitoring in the past, but we've never taken as comprehensive a look as this group has,” says Helena Reidemar, the APM's co-lead as well as a Delta 757/767 pilot and the Air Line Pilots Association's (ALPA) human factors director.

Effective monitoring means maintaining a big-picture view of what is happening on the flight deck and with an airplane's state, including heading, airspeed and altitude. It sounds easy, but pilots know better. “It turns out that effective monitoring is a tricky, error-prone task for pilots to consistently achieve,” says Dempsey, who also chairs Delta's Human Factors Working Group. “Solutions will require airlines to review their operating cultures, policies, procedures and practices.”

Qualitative evidence of pilot-monitoring deficiencies goes back at least two decades. A 1994 NTSB study on 37 “flight crew-involved” U.S. airline accident sequences found monitoring errors in 31 of them, or 84%. That prompted NTSB to issue its first monitoring-related recommendation to FAA. “The bad news is, all those accidents occurred,” Sumwalt said during a monitoring panel at the recent ALPA Safety Forum. “The good news is, if we're looking to improve safety, when you've got a bar on a bar chart saying 84 percent of something [needs improvement], that gives you a great opportunity to target in that area.”

NTSB's study examined accidents from 1978-90, which encompassed the dawn of crew resource management (CRM) programs. Among CRM's key tenets: respectfully questioning colleagues is part of a solid safety culture.

Before CRM, monitoring deficiencies were easily masked by an industry culture that did not promote questioning one's superiors. Investigators probing crew-related fatal accidents often did not know if a crewmember did not notice the captain's mistake, or simply did not challenge a more seasoned colleague.

Operators began embracing CRM training in the 1980s. The FAA mandated it for scheduled airlines in 1995, while non-scheduled commercial operators faced a March 2013 deadline to implement it.

Effective CRM practices make deficient monitoring easier to spot. As CRM programs took hold, it became clear that, despite numerous benefits, monitoring was not adequately addressed.

The FAA responded by updating CRM guidance (but not the rules), adding emphasis on monitoring. But in 2003, the agency, taking a cue from several carriers, replaced the term “pilot not flying” with “pilot monitoring” in guidance on developing flight-deck standard operating procedures. “It is increasingly acknowledged that it makes better sense to characterize pilots by what they are doing rather than by what they are not doing,” the agency reasoned. “[T]he term 'pilot not flying' misses the point.”

As regulators moved forward, human performance specialists examined the issue in the context of flying a modern aircraft. Among the findings: Reliable automation makes monitoring more challenging. “The human brain just isn't well designed to monitor for an event that very rarely happens,” explains Key Dismukes, the former chief scientist for aerospace human factors at NASA Ames Research Center.

Humans also struggle to detect minor changes in their environments, Dismukes says. While master caution lights present enough contrast to be noticed quickly, for instance, subtle changes on instrument panels do not grab a pilot's attention. “We're not well designed to monitor a little alphanumeric [indicator] on the panel, even though when that alphanumeric changes, it is telling us something important.”

While industry has learned much about monitoring, operators are struggling to translate that knowledge into effective procedures. In February 2007, the NTSB concluded that the flight-crew's failure to monitor airspeed was a causal factor in the 2005 crash of a Cessna Citation in Pueblo, Colo., that killed eight. The board, going beyond its 1994 recommendation, said the FAA should require monitoring in pilot-training programs. The FAA responded that CRM guidance adequately addressed the subject.

Over the next three years, inadequate monitoring would play a key role in one fatal accident and one high-profile incident. In February 2009, Colgan Air Flight 3407 went down near Buffalo, N.Y., killing 50. The NTSB determined that the crew's failure to notice a low-speed warning contributed to the stall that caused the Bombardier Q400 to crash. In February 2010, the overrun of an American Airlines 757 at Jackson Hole, Wyo., was set up in part by “a lack of pilot training emphasizing monitoring skills.”

Then came Asiana Flight 214, which is developing as a rich case study in monitoring deficiencies. Facts released by NTSB Chairman Deborah Hersman just after the July 6 accident revealed that the Boeing 777-200ER's final approach airspeed was too slow, falling below the crew's targeted landing speed at least 30 sec. before impact. Three pilots on the flight deck—a captain flying the approach, a check airman in the right seat serving as the pilot-in-command (PIC), and a first officer in the jumpseat—did not see the deviation until it was too late to recover.

The PIC told investigators he had expected the aircraft's autothrottle to maintain a safe speed. Even if the 777 malfunctioned—and nothing released suggests this is the case—it would not explain why the pilots took so long to detect the problem.

“The crew is required to maintain a safe aircraft,” Hersman said three days after the accident, which killed three passengers. “That means they need to monitor.”

The NTSB's initial Asiana briefings were enough to make the human factors community, and some airline training managers, lean forward. “Was [inadequate monitoring] a factor in Asiana Flight 214? We'll have to wait for the final accident report to know for sure,” Dempsey says. “Nevertheless, initial reports . . . have increased the level of interest and, I think, a sense of urgency for the APM report.”

Completed probes of recent monitoring-related incidents found at least one common factor. While inadequate monitoring alone did not cause any of them, proficient monitoring might have prevented each one. The FAA's CRM guidance updates suggest that monitoring initiatives were headed in the right direction, but the NTSB's breakdowns of the Pueblo, Buffalo and Jackson Hole accidents—and early word from San Francisco—paint a different picture.

“We felt like, OK, good, we're on the right path,” says Sumwalt. “But we are now reminded that this is a problem that never really went away.”

Part of the challenge is that human behavior is not the only obstacle for effective monitoring. Environment is another huge factor.

An oft-referenced example is the 1972 crash of Eastern Airlines Flight 401, caused by an undetected change in altitude when the pilot accidentally disengaged the altitude-hold function by bumping his control column. The crew, believing the aircraft was in a holding pattern, was fixated on a landing gear warning light. The NTSB determined they were not monitoring their instruments and failed to detect the deviation until just before the aircraft crashed into the Florida Everglades. A system design quirk allowed the Lockheed L-1011's altitude-hold mode to switch off without prompting a “disconnect” warning light, adding to the crew's monitoring challenges.

Changing factors such as cockpit layouts takes years. In its 1996 study, “The Interfaces Between Flightcrews and Modern Flight Deck Systems,” the FAA's Human Factors Team made 51 recommendations, including evaluating flight-deck design and systems from a human performance perspective.

In May, the FAA issued new certification standards based in part on the recommendation. “Until now, little or no guidance has existed to show the applicant how they may address potential flight-crew limitations and design-related errors,” the agency explained. The new standards require manufacturers to factor human abilities and limitations into their designs.

FAA's standards and a nearly identical set adopted by the European Aviation Safety Agency in 2006 are the clearest example of regulators mandating human factors elements into certification requirements. While the changes are big steps, it will be years before they make a dent in the 20,000-plus global airliner fleet. Sumwalt is advocating for bigger changes, sooner.

CRM taught industry that a pilot's core competencies can't be limited to hand flying, Sumwalt explains. In his mind, monitoring's importance means it too should rank as a core piloting skill. “Yes, pilots have to have good stick-and-rudder skills, and yes, they have to have good CRM skills, but they also have to have good monitoring skills,” he says. “That's the paradigm shift we're looking for.”

The APM group will present qualitative data to establish inadequate monitoring as a widespread problem. Its report will break new ground by presenting results derived from nearly two decades' worth of real-world observations from Line Operations Safety Audits (LOSA).

The audits, used by nearly 50 carriers, place an observer in the jumpseat to record specific pilot performance aspects on routine flights. LOSA's widespread use means trends gleaned from the data are more likely to garner attention than examples from a small set of accidents.

APM's conclusion is head-turning. LOSA data reveals pilots with poor monitoring skills are at least twice as likely to make a mistake as are pilots that monitor effectively.

“Most airline managers use data to drive operational changes,” says Dempsey. “In simplistic terms, we'd like to get each airline manager to admit, 'I have a problem at my airline and if I choose to ignore this problem, at some point, I'm two to three times more likely than my competitor to make an error.' I'm confident the data in this report will get us there.”

The report's deliverables are recommendations and ready-made training aids. The recommendations are not about ideology; they are about saying, “do this,” Dempsey says. The aim is to make them “very specific” and easy to implement.

One example: a sterile cockpit policy for the last 1,000 ft. of any altitude change. Altitude deviations are the most common flight-crew errors observed. Encouraging pilots to set aside non-essential tasks and focus on leveling off could help to eliminate the problem.

“We are hoping that if we have motivated airline managers to act and have provided them with enough practical solutions, we can move the industry monitoring needle in a positive direction,” Dempsey says. “No single report will contain all the answers to such a multifaceted problem, but I'm hopeful we're going to take a big bite of the apple.”

Tap the icon in the digital edition of AW&ST for 10 case studies of incidents and accidents presented in the U.K. Civil Aviation Authority's monitoring awareness guidance, or go to