As industry tackles areas like runway safety and inflight loss of control, which are seen as ripe for safety improvement, a working group is zeroing in on ways to minimize the most common contributor to airline accidents: inadequate flightpath monitoring.
In late 2012, the group was created with the goal of churning out a final report with recommendations and training aids within a year. The panel soon realized that its original focus—pilot monitoring—was too broad, explains Steve Dempsey, the co-leader and a737 captain and human factors working group chair.
“Monitoring in general is well beyond the scope of any singular project,” Dempsey says. “We determined the highest threat to safety—the one thing all accidents have in common—is deviation from the intended flightpath.”
While recent accidents and general trends have triggered actions on upset recovery (see page 36) and runway safety (see article below), monitoring has lagged as an action item. Theissued its first monitoring-related recommendations in 1994, and followed up with more after several investigations—notably of the 2009 crash near Buffalo, N.Y. But aside from a few changes to advisory material, regulators have done little to address the long-running challenge.
Frustrated by the lack of progress, NTSB board member Robert Sumwalt in 2012 challenged industry to tackle the problem itself.
“We have hit these things in a couple of different iterations, yet we are still seeing accidents, even as recently as last year—two major air carrier accidents in the U.S. where inadequate monitoring is a focus of the investigation,” Sumwalt said.
The ongoing investigations into July 2013'sFlight 214 crash, followed by the Flight 1354 accident five weeks later, have identified inadequate monitoring as a contributor. This underscores why Sumwalt has given the issue its own unofficial tagline: “The problem that never went away.”
The working group does not expect its findings will eliminate all monitoring flaws, but it does hope its recommendations—the final report is expected to contain about 20, covering philosophies and practices—will help operators mitigate the biggest risks.
Besides narrowing the monitoring scope to flightpath-related variables, the group made a subtle but important terminology change. It began with an unofficial moniker as the “active” pilot monitoring working group. Soon, members realized that emphasis should be placed on “effective” monitoring—doing it correctly, not just doing it. The group even created a loose definition, Dempsey says: Effective flightpath monitoring is recognizing issues before they lead to flightpath deviations.
The semantics may seem trivial, but Sumwalt—whose work on monitoring began when he was attwo decades ago—says they help drive the organization-level philosophical shift pilots need to be better monitors.
“People say 'we're doing pilot monitoring,' but when you scratch the surface, you find [they have only changed] the term 'pilot not flying' to 'pilot monitoring,' and that is it,” says Sumwalt, referring to a 2003 change in anguidance he helped write. “Name change alone does [nothing. There must be] a systemic, comprehensive change to the philosophy of managing the flight deck.”
The report also tackles what Dempsey describes as two “cultural misconceptions” that are hurdles to more effective monitoring.
The first is that managing the flightpath is synonymous with controlling it. But this leaves the crew's task cycle incomplete, because there is no feedback provision to confirm that the correct inputs have been made and the correct path is being followed, he explains.
The second misconception is that monitoring is done only by the pilot not flying the aircraft. Pilot duties are “far more alike than the titles “pilot flying” and “pilot monitoring” suggest; both pilots have a key responsibility to monitor the aircraft's path, Dempsey says.
The recommendations will be based in part on what the group believes is the most comprehensive monitoring dataset. Derived from thousands of Line Operations Safety Audit (LOSA) reports, the aggregated data will underscore how effective monitoring can cut down on undesired-aircraft states. The results confirm what Sumwalt discovered during LOSA audits at US Airways in the early 2000s, when data showed that, with better monitoring, about 20% of errors and 66% of undesired aircraft states would not have occurred.
The report is now slated to be released by mid-year. “We're on the one-yard line,” Dempsey says.