EATS, Berlin, October 2019

Lex Rock Heemstra – Human Factors Specialist

PROBLEM STATEMENT

“The modern airplane is the product of a program of research, development and refinement in detail that no other structure or mechanism has ever matched. The results have been so remarkable that there is always danger of forgetting that these extraordinary craft still have to be operated by men, and that the most important test they have to meet is still that of being operable without imposing unreasonable demands or

unnecessary strains on the flight personnel.”Edward P. Warner , 1946

President ICAO : 1947-1957 “History repeats itself ….because nobody listens”

John Lennon

27 FATAL AIRLINE ACCIDENTS 2009-20192366 FATALITIES

Loss of Control 6

On Approach 10

Go Around (LOC) 6

LL Circuit (CFIT) 1

Engine Failure 1

Wrong Eng Shut 1

Ran out of Fuel 1

Unknown 1

Source: Boeing Statsum 2009-2018 & Civil Aviation Final & Preliminary Accident Reports

Total Flight Hours

Type of AccidentAircraft Designation Date Aircraft Type PIC FO

Air France 447 01-Jun-09A330-203 6547 2936 LOC

Ethiopean 409 25-Jan-10B737-800 10233 673 LOC

AeroUnion 302 13-Apr-10A300-203 16754 3114 Approach

Afriqiyah 771 12-May-10A330-202 17016 4216 Approach

Air India 812 22-May-10B737-800 10215 3620 Go Around

Air Blue 202 28-Jul-10A321-231 25497 1837 LL Circuit

Aires 8250 16-Aug-10B737NG 7643 1900 Go Around

Henan 8387 24-Aug-10EMB-190 ? ? Approach

UPS 6 03-Sep-10B747-400 11200 5549 Cargo Fire

Iran Air 277 09-Jan-11B727- 286 ? ? Go Around

Hewa Bora 08-Jul-11B727- 286 ? ? Approach

First Air 6560 20-Aug-11B737-200 12900 4848 Approach

Bhoja 213 20-Apr-12B737-236 10158 2832 Approach

Dana 992 03-Jun-12MD 83 18166 1143 Eng's Fail

Air Bagan 11 25-Dec-12Fokker 28 5937 849 Approach

Asiana 214 06-Jul-13B777-200 9793 12387 Approach

UPS 1354 14-Aug-13A300F 6406 4721 Approach

Tatarstan 363 17-Nov-13B737-500 2784 2093 Go Around

Malaysian 370 08-Mar-14B777-200ER 18365 2813 ?

Air Algiere 5017 20-Jul-14MD 83 12988 7016 LOC

AirAsia 8501 28-Dec-14A320-216 20537 2247 LOC

Transasia 235 04-Feb-15ATR 72-600 4914 6922 Shut down Wrong Engine

FlyDubai 981 19-Mar-16B737-800 5961 5767 Go Around

Emirates 521 03-Aug-16B777-31H 7457 7957 Go Around

LaMia 2933 28-Nov-16Avro RJ85 6692 6923 Fuel Starve

Turkish 6491 16-Jan-17B747-412F 10808 5894 Approach

Lion Air 610 29-Oct-18B737 Max 6028 5174 LOC

Ethiopean 302 10-Mar-19B737 Max 8122 361 LOC

Total Flight Hours

Captains < 8000 37%

FO’s < 4000 48%FO’s < 2000 22%

Monitoring &

Intervention

Resilience

Training

Startle EffectJet Upset

Recovery

REQUIRED CRM/HF TRAINING

▪ EXISTING

▪ Communication

▪ Leadership & Teamwork

▪ Situational Awareness

▪ Workload Management

▪ Problem Solving & Decision Making

▪ 5 of the 9 EBT Competencies

▪ ADDITIONAL

▪ Monitoring & Intervention

▪ Resilience Training

▪ Startle Effect & Management

▪ Jet Upset Recovery

Classroom

Theory

Simulators

Practise

During

Flight

Execution

RECURRENT CRM DELIVERY

On own, i.e.

Pilots only,

CC only,

ATC only

33%

First on own

and then

Combined

14%

Combined

Only

53%

WORLDEUROPE21 Operators

14 International Airlines

EASA - GM3 ORO.FC.115 (March 2019): (i) combined CRM training: 6 training hours over a period of 3 years;

On own,

i.e. Pilots

only, CC

only, ATC

only

33%

First on

own and

then

Combined

30%

Combined

Only

37%

SOURCE OF PROCEDURES

+

-

TOP 10% - MOVERS & SHAKERS

BOTTOM 10% - “TROUBLE MAKERS”

80% MAJORITY – GOOD, SOLID, RELIABLE

SOLUTION

“DELIBERATE MISTAKES”

HONEST MISTAKES

SPEND 80%

OF THEIR

TIME

FIXING

INDUSTRY CONCERN REGARDING MONITORING

▪ 2010 – NASA “Checklists and Monitoring in the Cockpit: Why Critical Defenses sometimes fail”. Dismukes, R.K. & Berman, B.

▪ 2013: RAeS Flight Operations Group – Aircraft Commander in the 21st

Century: “Pilot Monitoring – Cultivating a Healthy Unease”

▪ 2013: UKCAA Paper 2013/02: “Monitoring Matters - Guidance on the Development of Pilot Monitoring Skills”

▪ 2014: FSF: “A practical Guide for Improving Flight Path Monitoring”

▪ 2016: IATA: “Guidance material for improving Flight Crew Monitoring” 1st

edition

▪ 2017: FAA: AC 120-71B “Standard Operating Procedures and Pilot Monitoring Duties for Flight Deck Crewmembers”

PILOT MONITORING (PM)MAJORITY OF AIRLINES

The general PM phase of flight responsibilities are:

▪ Checklist reading

▪ Communications

▪ Tasks asked for by the PF

▪ Monitoring taxiing, flight path, airspeed, airplane configuration, and navigation.

▪ The general PF phase of flight responsibilities are:

▪ taxiing

▪ flight path and airspeed control

▪ airplane configuration

▪ navigation.

GORILLA VIDEO EXERCISES

• Count the number of passes by the white team

• Video over: • If Gorilla not spotted: 14 X passes

• If Gorilla spotted: 11-16 X passes

• Assign pairs – one PF and the other PM.

• The novelty of the situation draws in both PF and PM to the detail

• Who then monitors the big picture?

• When assigned PF – Detail & PM – Big Picture • Gorilla spotted and 14 passes as a team.

• Are we training monitoring correctly?

EFFECTIVE MONITORING

0

10

20

30

40

50

60

70

80

90

100

Never Hardly Ever Sometimes Often Very Often

"I have observed the other pilot make errors due to a lack of knowledge /understanding of the automation"

FO's Captains Instructors

Source: Multicultural Airline Automation Questionnaire 2010; N= 306 (Heemstra:2010)

FO’sCaptains

Instructors

Source: Automation & Monitoring Questionnaire, 2013; N = 326 Pilots (156 Captains & 170 FO’s)

0

10

20

30

40

50

60

70

80

90

100

0-2000 2000-4000 4000-6000 6000-8000 8000-10000 10000-12000 12000-14000 14000 Plus

“I have observed the other pilot make errors due to the lack of knowledge/understanding of the automation”

First Officer N=170 Based on Total Flight Hours

Never Hardly Ever Sometimes Often Very Often

EFFECTIVE MONITORING – FIRST OFFICERS

Beginning

of Effective

Monitoring

Source: Automation & Monitoring Questionnaire, 2013; N = 326 Pilots (156 Captains & 170 FO’s)

EFFECTIVE MONITORING – CAPTAINS

0

10

20

30

40

50

60

70

80

90

100

8000-10000 10000-12000 12000-14000 14000-16000 16000-18000 18000-20000 20000 Plus

“I have observed the other pilot make errors due to the lack of knowledge/understanding of the automation”Captains N = 156 Based on Total Flight Hours

Never Hardly Ever Sometimes Often Very Often

Source: Automation & Monitoring Questionnaire, 2013; N = 326 Pilots (156 Captains & 170 FO’s)

THE MONITORING COMPONENT – A HUMAN

▪Human Factors – Cognitive Limitations:

▪The human brain has difficulty with sustained vigilance

▪The human brain has quite limited ability to multitask ▪ (Task Switching – Yes, Multitasking – No)

▪Humans are vulnerable to interruptions and distractions

▪Humans are vulnerable to cognitive limitations that affect what they notice and do not notice

Flight Safety Foundation: Practical Guide to Flight Path Monitoring - November 2014

AUTOMATION CONFIDENCE

0

10

20

30

40

50

60

70

Not Confident With Difficulty Minor Deviations Fly it Accurately As accurately as

Automation

“I would be able to fly a SID out of Home base and meet all target speeds and altitudes without Autopilot, Auto-throttle and Flight

Director, i.e. totally manually”N= 306, FO:161; Capt:110; TRI/TRE:35

FO's Capts TRI

Source: Multicultural Airline Automation Questionnaire 2010; N= 306 (Heemstra; 2010)

Comfort

Zone

Automation

AUTOMATION INDUCED STARTLE

Inputs or Workload

Pe

rfo

rma

nce

Knowledge,

Skills & Experience

Automation Ability

Automation

Failure –Sudden

No Trend

Overall Research Feedback – Do nothing for up to 30 seconds it situation allows

PERCEPTION OF STRESS BY MULTINATIONAL PILOTS

0 10 20 30 40 50 60 70 80 90 100

Random drug/alcohol test

Holding pattern at destination

Departure delay after boarding

Shortage of meals, etc

Long wait for gate on arrival

Filing an ASR report

Encountering thunderstorms

Unpleasant exchange ground crew

Difficulty understanding ATC

Complex rerouting/flight plan change

Passenger requires medical care

Turbulence all levels

Wait for room at hotel

Unpleasant exchange Cabin Crew

Don’t get along with other pilot Flight crew becomes ill

Go around after unstable

Line check

Divert to alternate (weather)

Hard landing

Return due to mechanical failure

Unpleasant exchange Flight Crew

Security Emergency in flight

Emergency Landing

High speed rejected takeoff

Source: Multinational Airline Stress Questionnaire Jan/Feb 2011: N= 154, Captains = 81, FOs = 73

Stress Components

The amount of perceived

CONTROL over the

situation, and

The ability to PREDICT the

short term future.

PERCEPTION OF STRESS BY MULTINATIONAL PILOTS

0

20

40

60

80

100

120

140

160

180

200

Age

Perceived Stress by Age

Perceived Stress 10 per. Mov. Avg. (Perceived Stress)

Source: Multinational Airline Stress Questionnaire Jan/Feb 2011: N= 154, Captains = 81, FOs = 73

PERCEPTION OF STRESS BY MULTINATIONAL PILOTS

0

20

40

60

80

100

120

140

160

180

200

Flight Hours

Perceived Stress by Hours (Experience)

Perceived Stress 10 per. Mov. Avg. (Perceived Stress)

Source: Multinational Airline Stress Questionnaire Jan/Feb 2011: N= 154, Captains = 81, FOs = 73

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

Self Control Adaptibility Optimism Self Sufficiency Persistence

Le

ve

l o

f R

es

ilie

nc

e (

Pe

rce

nta

ge

)

Components of Resilience

Elements of ResiliencePersonal Situation vs Work Situation N=413

Personal Work

Source: Podzigun, I - Resilience Study based on “GRIT” – (A.L. Duckworth) - 2016

Acting or

Reacting

Improvise &

creative

Trust in own

talents &

solutions

Maintaining

a Positive

Outlook

Stick-to-it

attitude

5

8

11

14

17

20

1 2 3 4 5 6 7 8 9 10 11

Le

ve

l O

f R

esil

ien

ce

Years in Company

Resilience based on Years in CompanyPersonal Situation vs Work Situation N=413

Personal Work Linear (Personal) Linear (Work)

Source: Podzigun, I - Resilience Study based on “GRIT” – (A.L. Duckworth) - 2016

COGNITIVE PROCESSING – SYSTEM I & II THINKING

▪ System I : Fast, Automatic, Frequent, Emotional, Stereotypic & Subconscious

▪ Procedural Memory & Everyday thinking

▪ System II: Slow, Effortful, Infrequent, Logical, Calculating & Conscious

▪ Analytical & required for Problem Solving & Decision Making

SO WHAT NOW?

▪ Several monitoring functions automated

▪ Effective Monitoring grows with deliberate practise & qualitative experience

▪ Stress reaction does NOT improve with age or flight hours

▪ Resilience - fairly stable over a lifetime – you have got what you have got

▪ Startle – General consensus – do nothing for 30 seconds

▪ Overall the human is not designed to conduct sustained vigilance

▪ Complex automation failures require enhanced pattern recognition to rectify which increases with knowledge, skills & experience

▪ Existing PF & PM roles appear to create 1 + 1 = 1, especially during novel abnormal situations

▪ We need 1 + 1 =/ > 2

ABNORMAL/EMERGENCY EVENTS

▪Memory Item – conduct as trained.

▪All other: ▪ FO – Pilot Flying:

▪ max automation as available

▪ Intuitive (System I) – mainly procedural memory

▪ Detail Orientated

▪ Capt – Pilot Managing: (use of knowledge & experience)▪ Slide seat back – enhances big picture

▪ Engage System II – logical, calculating, conscious

▪ Big Picture Orientated

▪ Problem Solving & Decision Making

▪ Once new plan assessed and briefed – conduct flight/landing as per company procedure

CONSIDERATION▪Pilot Flying:

▪ Physically flies the aircraft – manual or automated

▪ Corrects as instructed by PM

▪ Responsible for correct & intended flight path

▪ Detail orientated – System I Thinking

▪Pilot Managing: ▪ Manages the flight path and operation of the aircraft

▪ Responsible for the safe and efficient operation of the aircraft

▪ When managing – it is his/her sector

▪ Takes ownership of responsibility – increased monitoring

▪ Big Picture Orientated – System II Thinking

BACK TO THE FUTURE CAPTAIN?

THANK YOU