Recognizing the value of crew monitoring and cross checking skills, the industry is poised to roll out the first edition of a comprehensive training guide to teach pilot monitoring skills. At the Bombardier Safety Standdown, NTSB member Robert Sumwalt characterized “a lack of good cross checking and pilot monitoring skills” as one of the greatest threats we face today.” A former USAir pilot, Sumwalt said 20 percent of the errors his old airline experienced and some two thirds of the undesired aircraft states would never have occurred if the crews had been properly monitoring the aircraft. “Humans are not naturally good monitors, but their skills can be improved,” he said. “And we must get better at monitoring or it’s going to bite us.”
In 1994 the NTSB reviewed 37 airline accidents and found that poor crew monitoring was an element in 84 percent of them, and the board made it clear then that this was an area in need of attention. “Of the monitoring errors,” Sumwalt said, “seventy-six percent involved failing to catch something that caused the accident. In 15,000 airline line oriented safety audits [LOSA] that looked at how crews operate, at least 20 percent had substandard monitoring in at least one phase of flight. The crews with substandard monitoring skills were also responsible for more overall errors than crews with good monitoring skills.”
The industry changed the term years ago from pilot not flying to pilot monitoring to more clearly indicate what the non-flying pilot should be doing. But changing the term didn’t really change anything. “Poor pilot monitoring is a threat that has never really gone away,” he said. Effective monitoring is the last line of defense in the accident chain. “If the flying pilot misses an altitude on the approach and the monitoring pilot catches it, there’s not a safety problem. But if both pilots miss the altitude there will be some serious consequences.”
A number of business aviation accidents, notably the 2002 King Air crash in Minnesota and the 2005 Circuit City Citation crash at Pueblo, Colo., point to poor monitoring skills. In both cases the flight crews failed to monitor engine power levels and airspeed after a descent, which resulted in a stall and fatal crash. In a 2004 GIII accident near Houston, the crew failed to monitor the instruments and descended below minimums. The aircraft was destroyed when it hit the ground. All of these accidents and incidents tell you “there must be a relationship between poor monitoring skills and bad things happening to people,” Sumwalt said.
Good monitoring is “a real skill and we don’t train people how to monitor,” Sumwalt said, identifying an obstacle to successful monitoring: manufacturers have done a great job of building nearly failure-free equipment, and pilots get bored. CRM teaches crews to speak up when something doesn’t look right, but someone needs to notice something amiss through his or her monitoring efforts before anyone can speak up. “Sometimes we look but don’t see,” Sumwalt explained. “You can’t monitor an airplane, especially an automated one, when you don’t honestly know for sure what it should be doing. That’s memory flying even when the autopilot is on. Without that, you can’t anticipate the next steps.”
Poor workload planning also gets in the way of good monitoring. The aviation safety reporting system shows that 80 percent of poor monitoring errors occurred during climb, descent or approach. Crews who brief after top of the descent (TOD) made 1.6 more errors than crews who briefed before TOD. Monitoring errors often occur while one pilot is programming the FMS. Sumwalt said, “It’s critical to plan tasks strategically to be sure we don’t do things during critical phases. Don’t be doing something else as you pass through the transition level or you’ll forget to reset the altimeter. Don’t do anything else within 1,000 feet of your assigned altitude. Make sure the airplane levels off.
“We used to say a good pilot was someone with good stick-and-rudder skills,” Sumwalt concluded. “Then we added good CRM skills to that mix. But now pilots also need good monitoring skills.”