Crew Monitoring - ESASIConfidential and proprietary document. Study case 2 – A310 LOC mode reversion • A310 ILS approach, while approaching the Glide Slope with AP2 engaged (LAND

Crew Monitoring ESASI MILAN 2014

Airbus Product Safety Frédéric COMBES

Head of Accident / Incident Investigation

© AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

ESASI MILAN 2014

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• Setting the scene

• Study cases

• What is monitoring? • What are the challenges to effective monitoring?

• Strategies to enhance monitoring

Content


Setting the scene - Monitoring

• It is not natural even if it seems easy and intuitive • Humans are not good at it! • Monitoring is not a stand alone mechanism • It is not specifically trained

• Training focuses on “actions” rather than monitoring • Slowly changing parameters are not as attention getting as

an alarm or a big failure • Delaying some tasks may be needed

• It is not natural to stop doing something in the middle

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Setting the scene - Monitoring

Several studies have demonstrated

• Monitoring is an under estimated task

• When both pilots are involved in non-monitoring tasks, the risks increase

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• Study cases



Content

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Study Cases - Content

• Study case 1 – A321 alpha protection activation in approach • Study case 2 – A310 LOC mode reversion • Study case 3 – A330 Rejected Take Off

• Summary

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Study case 1 - A321 alpha protection activation in approach

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Initial conditions • AP1, A/THR and FD engaged , Open Des • Conf Clean • Speed 250kts • On descent from FL 90 to FL 60, ATC requested the crew to descend to 4000 ft, to be level

between 18 and 20 nm

• Crew decision to accelerate the descent : • Speed brakes not usable due to SEC1 being unserviceable • Thrust Levers : To IDLE, leading to A/THR disengagement

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Mixed flying situation : AP ON, A/THR OFF • Time Zero (T0) -Speed selected to 220 kts (following ATC request) • Reaching 4,000ft , ALT mode engaged IDLE thrust not enough to maintain speed in level flight Gradual increase of angle of attack

T0 + 32 sec • Actual speed below selected speed • Altitude maintained at 4,000ft • ATC announced Traffic “12 o’clock, 7NM, opposing route” Crew focused on looking outside simultaneously

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T0 + 1m 05s – High Angle of Attack protection triggered • AP disconnection • Speed at 177kts (VLS - 26kts) Crew inputs: Thrust Levers to CLB Pitch up inputs for about 10 seconds since the AC was in descent Priority to maintain the Altitude at 4,000ft

•Minimum speed reached : 172kts with descent rate at 1,000ft/mn

T0 +1m 15s • Thrust started to stabilise • Thrust levers set to FLEX/MCT • Pitch up inputs maintained • Minimum altitude reached : 3,840ft QNH

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T0 + 1m 20s • Maximum pitch reached : 11° Crew inputs: Pitch down inputs in order to counteract pitch up moments

•Deactivation of high angle of attack protection Not detected by the crew

End of the event • Pitch and AoA stabilised at 3° • Selected Speed and Altitude reached • Uneventful landing

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Content


• Summary

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Study case 2 – A310 LOC mode reversion

• A310 ILS approach, while approaching the Glide Slope with AP2 engaged (LAND Mode armed, LOC Track mode)

• Lateral mode reversion from LOC to HDG with GS mode engaged • Late detection of lateral mode reversion at 200ft • Go around performed • Final approach performed with both AP’s engaged

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Initial conditions • AP2 engaged, then AP1 engaged with

LAND mode armed • FD engaged • LOC engaged • At 3500ft aircraft stabilized

on the LOC and approaching the Glide Slope

FD1 CMD1

3500

3550

LOC GS* SPD

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T0 +3.5 sec • At Glide Slope capture, AP2 disconnected due to

second press on the LAND Pushbutton

• Lateral mode reversion from LOC to HDG hold mode

• Glide Track remained engaged with LOC mode disengaged • due to simultaneous engagement of Glide

capture mode with the loss of Land mode

FD1 CMD1

3500

3510

HDG GS SPD

LOC GS*

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Initial Approach • AP1 and FD engaged • In Glide Track and Heading hold modes , Manual Go Around at 200ft

Final Approach • Both AP’s engaged • Uneventful landing performed

FD1 CMD1

250

HDG GS SPD

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Content


• Summary

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Study case 3 – A330 Rejected Take Off

• A330 RTO performed by the crew at a speed of 112kts following RH engine surge • Day condition and dry runway • The right engine failed emitting a flash and smoke from the exhaust • FO PF, CAPT PM • Crew quickly established that there was a loss of power and aborted Take Off • Emergency stop on the runway and taxi clear using the unaffected left engine.

• Video from internet Page 17

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Time ASDA=2897m

T0 -135m Thrust levers FLEX

T0+26” 580m 100kt N1 84% stable

T0+27.1” 660m 107kt Actual N1% #2 sharp decrease Ny sharp variation up to -0.06g

T0+27.9” 700m 112kt=VMCG+4.5kts Rudder pedal input up to 33° (95% from maxi)

T0+28.1” 760m RTO: REV MAX in 1” 112kt=V1min-18kts GS extension / Autobrake activation

T0+35” 1065m 50kt Thrust levers selected to REV IDLE

T0+37” 1110m 40kt Thrust levers selected to IDLE GS deselection 1 sec after A/BRK OFF- Manual braking

T0+51” 1260m AC stopped

223T/29.1% (97% MTOW / MED CG) FLEX 40°C CONF2

T0+42” Engine Fire Handle selection

T0+30” 825m CAS max. 113kt Deviation lateral max. 3.7m

V1min no wind = 129.7kts V1max = VR = 144.5kts V2 = 150.8kts

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Summary of study cases

• Monitoring by PF/PM is key to the timely detection of issues and initiation of appropriate actions

• The first two examples demonstrate the importance of monitoring mode annunciations (Golden Rule No 1)

• The “normal” eye scan must also include basic flight parameters (pitch, thrust, speed…)

• In the third example other senses (sound, body accelerations) were also used to monitor and to trigger action

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• Study cases



Content

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What is monitoring?

• “Fly, navigate, communicate” requires the crew to be aware of evolving information of different natures and with different time spans

• Aircraft • Flight path • Environment & context • Crew members • In a dynamic environment • Evolving constraints

• You need “at the same time“ to focus on the • Big picture • Attention to specific details • Evolving information

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Monitoring is not a “stand alone” mechanism

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Monitoring To be aware of the state of something. But of what?

Monitoring against

expectations

When you monitor you compare the information against your expectations Expectations are based on your mental model which in turn is based on knowledge and experience

Objectives Accurate Situation awareness is essential to achieve YOUR GOAL

Expectations within Situation

awareness

Expectations form part of your situation awareness and attention mechanisms

• Knowing what is going on around you • Being able to continuously update

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• Study cases



Content

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The challenges of monitoring

• Organizing the information with priorities towards a shared goal and action plan

• Knowing and agreeing what is • Important versus Urgent • Seek information –using all your senses

• Know WHAT is important, • WHEN to seek it • WHERE to find it

• Check it • And share it

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The challenges of monitoring – the traps

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• Not enough importance on monitoring skills during training • Ex: call-out, cross-check, scanning…

• Routines accepted within a fleet or an airline • Focalisation

• your attention is caught and you forget the rest • Dispersion

• “you jump” from one information to another and you become overcome by the context

• Distractions / Interruptions • Fatigue • Complacency

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• Study cases



Content

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Strategies

• Review task in advance to anticipate potential problems and adjust monitoring

• Recognize multitask demands and decide how to divide attention between them • Share perception in vulnerable situations and increase vigilance

• Manage workload

• Active monitoring may be improved when you concentrate on “mentally flying the

aircraft” even when the AP is ON

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Strategies

• Adapt the monitoring of parameters / information to the speed of their evolution

• All information does not evolve at the same speed

• Make risk assessments • Ask “what if?”

• Assign monitoring tasks at least an equal or even higher priority than the other tasks

in the flightdeck

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Conclusion

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Situation awareness Procedures

Capture of aircraft information • flight parameters • FMA •…... Call out

Cross check Scanning

Teamwork and communication

Communication Call out Crosscheck Task-sharing

Task set • What? • When? • How? Briefing

and Preparation

Mental picture / plan • intentions • how to achieve • what to monitor • typical failures •...

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© Airbus S.A.S. All rights reserved. Confidential and proprietary document. This document and all information contained herein is the sole property of AIRBUS. No intellectual property rights are granted by the delivery of this document or the disclosure of its content. This document shall not be reproduced or disclosed to a third party without the express written consent of AIRBUS S.A.S. This document and its content shall not be used for any purpose other than that for which it is supplied. The statements made herein do not constitute an offer. They are based on the mentioned assumptions and are expressed in good faith. Where the supporting grounds for these statements are not shown, AIRBUS S.A.S. will be pleased to explain the basis thereof. AIRBUS, its logo, A300, A310, A318, A319, A320, A321, A330, A340, A350, A380, A400M are registered trademarks.

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Crew MonitoringContentSetting the scene - MonitoringSetting the scene - MonitoringContentStudy Cases - ContentStudy case 1 - A321 alpha protection activation in approachStudy case 1 - A321 alpha protection activation in approachStudy case 1 - A321 alpha protection activation in approachStudy case 1 - A321 alpha protection activation in approachContentStudy case 2 – A310 LOC mode reversionStudy case 2 – A310 LOC mode reversionStudy case 2 – A310 LOC mode reversionStudy case 2 – A310 LOC mode reversionContentStudy case 3 – A330 Rejected Take OffStudy case 3 – A330 Rejected Take OffStudy case 3 – A330 Rejected Take OffSummary of study casesContentWhat is monitoring?Monitoring is not a “stand alone” mechanismContentThe challenges of monitoringThe challenges of monitoring – the trapsContentStrategiesStrategiesConclusionSlide Number 31

Documents

Crew Monitoring - ESASIConfidential and proprietary document. Study case 2 – A310 LOC mode reversion • A310 ILS approach, while approaching the Glide Slope with AP2 engaged (LAND