6-1 CHAPTER 6. PILOT MONITORING
6.1 General. Several studies of crew performance, incidents, and accidents have identified inadequate monitoring and cross-checking as vulnerabilities for aviation safety. Effective monitoring and cross-checking can be the last barrier or line of defense against accidents because detecting an error or unsafe situation may break the chain of events leading to an accident. Conversely, when this layer of defense is absent, errors and unsafe situations may go undetected, potentially leading to adverse safety consequences. Flightcrews must use monitoring to help them identify, prevent, and mitigate events that may impact safety margins. Therefore, it is imperative that operators establish operational policy and procedures on PM duties, including monitoring, and implement effective training for flightcrews and instructors on the task of monitoring to help the PM expeditiously identify, prevent, and mitigate events that may impact safety margins.
This section describes effective monitoring, how to define and train PM duties, and integration of monitoring into SOPs. Additionally, the section discusses special considerations for monitoring autoflight operations.
6.2 Effective Monitoring. A pilot is effectively monitoring if he or she is:
1. Following SOPs consistently;
2. Clearly communicating deviations to other crewmembers;
3. Effectively managing distractions;
4. Remaining vigilant;
5. Advising the PF if the flight guidance modes or aircraft actions do not agree with expected or desired actions and intervening if necessary;
6. Continuously comparing known pitch/power settings to current flightpath performance; and
7. Considering that the primary flight displays (PFD), navigation displays (ND), and other sources of information (for example, electronic flight bag (EFB)), might be displaying incorrect information and always on the lookout for other evidence that confirms or disconfirms the information the displays are providing.
6.3 Challenges and Barriers to Effective Monitoring. There are several potential challenges and barriers to effective monitoring:
6.3.1 Time Pressure. Time pressure can exacerbate high workload and increase errors. It can also lead to rushing and “looking without seeing.”
6.3.2 Lack of Feedback to Pilots When Monitoring Lapses Occur. Pilots are often unaware that monitoring performance has degraded.
6.3.3 Design of SOPs. SOPs may fail to explicitly address monitoring tasks.
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6.3.4 Pilots’ Inadequate Mental Model of Autoflight System Modes. Pilots may not have a complete or accurate understanding of all functions and behaviors of the autoflight system. Some aspects of automated systems for flightpath management are not well matched to human information processing characteristics.
6.3.5 Training. Training may overlook the importance of monitoring and how to do it effectively. Lack of emphasis on monitoring may occur in training and evaluation.
6.3.6 Pilot Performance. High workload, distraction, and inattention can all lead to monitoring errors.
In addition, human performance limitations should be acknowledged as potential challenges for effective monitoring. The human brain has difficulty with sustained vigilance and has quite limited ability to multitask. Pilots are vulnerable to interruptions and distractions and to cognitive limitations that affect what they notice and do not notice.
It can be difficult for humans to monitor for errors and deviations on a continuous basis when errors and deviations rarely occur. This is true for the range of workload conditions experienced by the flightcrew members. Monitoring during high-workload periods is important since these periods present situations in rapid flux and because high workload increases vulnerability to error. However, studies show that poor monitoring performance can be present during low-workload periods as well. Lapses in monitoring performance during lower-workload periods are often associated with boredom, complacency, or both.
6.4 Defining Pilot Monitoring Duties. In a two-pilot operation, one pilot is designated as PF and one pilot is designated as PM. A review of operators’ manuals indicates that the roles and associated tasks of the PF and PM are not always clearly defined. Each operator should explicitly define the roles of the PF and PM to include:
1. At any point in time during the flight, one pilot is the PF and one pilot is the PM.
2. The PF is responsible for managing, and the PM is responsible for monitoring the current and projected flightpath and energy of the aircraft at all times.
3. The PF is always engaged in flying the aircraft (even when the aircraft is under AP control) and avoids tasks or activities that distract from that engagement. If the PF needs to engage in activities that would distract from aircraft control, the PF should transfer aircraft control to the other pilot, and then assume the PM role.
4. Transfer of PF and PM roles should be done positively with verbal assignment and verbal acceptance to include a short brief of aircraft state.
5. The PM supports the PF at all times, staying abreast of aircraft state and ATC instructions and clearances.
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6. The PM monitors the aircraft state and system status, calls out any perceived or potential deviations from the intended flightpath, and intervenes if necessary.
7. The PF provides a briefing to a pilot returning from a break. The briefing should include appropriate information to ensure the pilot returning from the break is updated on aircraft and systems states and current ATC instructions and assignments.
6.5 Operational Policies and Procedures. Operational policies and procedures should be reviewed or developed to ensure the division of duties and responsibilities between flightcrew members protects the ability of the PF to control the flightpath. Assigning non-flightpath-related tasks to the PF should generally be avoided. Operational data should be collected and used to revise definitions of PF and PM roles and responsibilities to ensure their effectiveness. Operators are encouraged to take an integrated approach in operations and training (e.g., initial and recurrent) to emphasize the responsibilities and importance of PF and PM roles.
A critical aspect of monitoring duties includes intervention when a deviation is identified.
Each operator’s policies, procedures, and training should adequately cover flightpath intervention including human-to-human intervention.
6.6 Intervention Strategies.
6.6.1 What Intervention Strategies Should Include. Intervention assumes an actual, or potential, problem has been detected. Effective PM can help detect a problem, which is necessary before intervention can begin. This is an important point since the pilot cannot intervene unless a condition requiring intervention is correctly recognized. If the monitoring activity is successful (problematic condition is recognized) then the pilot must know what intervention is appropriate for that situation.
Policies and procedures for expected interventions should be established and include:
1. Deviation parameters;
2. Required callouts; and
3. Conditions for takeover.
6.6.2 Human-to-Human Intervention. If a flightpath problem occurs, the PM should notify the PF about the problem and expect that the PF will then correct the problem. One way for the PM to accomplish notifying the PF is to verbalize a deviation callout followed by an expected response from the PF to that callout with corrective action.
6.6.2.1 SOPs should indicate what to say, how to say it, when to say it, and with what level of appropriate assertiveness. SOPs should also address if or when the PM should take over the PF role if it is determined that the PF is not correcting the flightpath problem in a timely manner. Considerations for the decision to take over control should include subtle incapacitation or no
6-4 response or flightpath correction after two challenges. The SOP should also specify what the specific callouts and associated actions are required with a takeover to ensure a positive exchange of aircraft control occurs. Policies must be clear to ensure there is no confusion over who is PF at any time.
6.6.2.2 Similarly, SOPs should describe how the PF notifies the PM about a flight guidance issue. For example, in some operations, if the AP is off with the flight director (FD) on, the PF hand-flies the aircraft, but the PM makes all flight guidance inputs. In this situation, consider the case where the PM makes an erroneous flight guidance input, and the PF notices it. In this case, Humanto-Human intervention would involve the PF verbalizing to the PM the error and desired correction. (e.g., “approach mode still isn’t armed – arm approach, please.”). To capture all of this, the recommendation wording may be something like: “PM communicating effectively to the PF about the flightpath problem, expecting that the PF will then correct the problem, or the PF communicating to the PM about a flight guidance problem (if the PM is responsible for flight guidance inputs), expecting that the PM will correct that problem.”
6.6.2.3 Another example is where a PM calls “1-dot high” and the PF responds with “correcting” and returns to glidepath in a timely manner. If, for example, the PF does not respond to two successive challenges, then, per operator’s SOP, if safety indicates, the PM calls “I have control, going around” and initiates a go around as PF.
Note: Flightpath control is the responsibility of the PF, whereas flightpath guidance may be the responsibility of either pilot, depending on the operator’s SOPs.
6.7 Training for PM. An operator should train its pilots on all policies and procedures related to monitoring the flightpath (e.g., callouts, double-pointing, etc.). This training should also include any of the operator’s recommended practices.
1. Pilots should be trained on the responsibilities of the PM to monitor the flightpath. In particular, pilots should be trained to recognize when the PF is not adequately controlling the flightpath or when the PM is not adequately monitoring the flightpath. This training should include pilot task loading and signs of diminished performance. Some examples include lack of communication, channelized attention, and failure to make required callouts.
2. Pilots should be trained on applicable common errors in monitoring the flightpath. This includes training on appropriate methods of recognizing precursors to, and signs of, degraded monitoring and on resolving monitoring errors and/or lapses.
3. Pilots should be trained on the concept that there are predictable situations during each flight when the risk of a flightpath deviation is increased, heightening the importance of proper task/workload management. If the PM is
6-5 trained to recognize the flight phases or situations when they are most vulnerable to flightpath deviations (including when little time exists to correct deviations), he or she could strategically plan tasks and workload to maximize monitoring during those phases.
4. Pilots should be trained on CRM/threat and error management (TEM) principles and human performance vulnerabilities related to monitoring, the importance of monitoring, and the operator approved practices that achieve effective monitoring of the flightpath.
5. Pilots should be trained on system failures that may distract from effective monitoring and proper flightpath management.
6. Pilots should be trained to manage distractions that interfere with monitoring the flightpath. Provide guidance on managing task priorities and train them to effectively switch between other tasks and monitoring of the flightpath so that flightpath vigilance is always maintained. Include information and task management strategies that enable pilots to use charts, EFB, ACARS, etc.
while also effectively monitoring the flightpath and airplane energy state.
7. Pilots should be trained on intervention methods that the PM can use to help the PF regain proper control of the flightpath and provide opportunities for the PM to practice these methods (e.g., calling out deviations, levels of assertiveness).
8. Pilots should be trained on and be able to demonstrate understanding of operationally relevant combinations/levels of flight guidance and flight control automation (e.g., given a certain set of circumstances, what will happen next?).
9. Ensure pilots can transition seamlessly between combinations/levels of flight guidance/flight control automation (including manual flight) by training them to anticipate, recognize, and recover from known flight guidance (includes Flight Management System (FMS)) and flight control (includes AP and, autothrottles) system-behavioral challenges (e.g., subtle mode reversions), and environmental/ circumstantial traps that are known to lead to flightpathrelated errors (e.g., vectors off, then back on, a Standard Terminal Arrival Route (STAR) during a “descend via” clearance).
10. Flight guidance and flight control systems training should include an assessment of a pilots understanding of those systems and what will happen ‘next’ given a certain set of flight circumstances, and the reasons why. The training should incorporate FMS degradations and failures and operational consequences requiring flightcrew action, known flight guidance and flight control system-behavioral challenges (e.g., subtle mode reversions), and environmental/circumstantial traps (e.g., vectors off, then back on, a STAR during a “descend via” clearance) that are known to lead to flightpath-related errors.
6.8 Incorporate Monitoring into SOPs. Monitoring performance can be significantly improved by: (1) developing and implementing effective SOPs to support monitoring and
6-6 cross-checking functions, and appropriate interventions, (2) by training crews on monitoring strategies, and (3) by pilots following those SOPs and strategies.
If not designed appropriately, some SOPs may actually detract from effective monitoring.
For example, one operator required a passenger address (PA) announcement when climbing and descending through 10,000 feet. This requirement had the unintended effect of “splitting the flight deck” at a time when frequency changes and new altitude clearances were likely. When the operator reviewed its procedures it realized that this procedure detracted from having both pilots “in the loop” at a critical point and consequently decided to eliminate it. Operators should review existing SOPs and modify those that can detract from monitoring.
6.9 Autoflight Considerations.
6.9.1 Autoflight Mode Confusion. Safety data (including accident, incidents, Line Operations Safety Audit (LOSA), FOQA, and ASAP data) have shown that autoflight mode confusion is a potential vulnerability in flight operations and merits special attention during monitoring tasks. Pilots should be able to demonstrate the knowledge and skill necessary to correctly select, interpret, and anticipate normal autoflight modes as well as be able to demonstrate appropriate remedial actions for inappropriate or unexpected autoflight modes. This should include the ability to:
1. Correctly identify and interpret individual flight mode annunciations;
2. Describe the respective mode’s impact on the related systems and airplane operation; and
3. Understand pitch mode annunciations and their relationship to available thrust as well as the aircraft’s energy state (e.g. the risk of using vertical speed mode to climb at high altitudes with limited available thrust).
6.9.1.1 Equipment and operator culture may influence how mode awareness protocols are designed and implemented. Therefore, an operator should create mode awareness procedures that reflect the equipment and how the operator employs the equipage and train/assess the procedures. When formulating mode awareness SOPs, consider the following:
1. When to require verbal callouts of mode status and changes, keeping in mind workload during specific phases of flight, pilot tasks, and unanticipated mode changes;
2. Operators should describe the mode confirmation methodology for the PF/PM roles. It is important that an operator’s procedures for mode confirmation take into account differences in phases of flight, pilot tasks, and high workload situations.
3. One example is briefing current autoflight mode status to any pilot that is returning to a pilot seat after a physiological break or distraction from flying (communicating with dispatch, flight attendant, etc.). Following a distraction,
6-7 pilots should discuss flight deck status. For a pilot that is returning to a pilot seat after a break, develop a formal briefing that is appropriate for the equipment with required items to ensure the pilot is updated on systems status.
4. Create phase of flight procedures/dialog boxes (for example: takeoff, climb, cruise, descent, approach) that include mode changes and indications for each level of automation allowed.
5. Include mode change indication in maneuver procedures/dialog boxes. When possible, associate callout names and timing to match mode changes. For example, some operators have implemented operator standard procedures such as “Confirm, Activate, Monitor, Intervene (CAMI),” or “Verbalize, Verify, and Monitor (VVM),” or similar systems, or even variations thereof.
Such procedures provide the flightcrew with a structured method to conduct operations within the flight deck that help to trap errors. Regardless of the form of the strategy, the objective is to ensure that everyone in the flight deck understands the active mode, the effects of the newly engaged mode, and skillfully reacts to ensure the aircraft trajectory and energy remains as desired.
Some effects of input and selection are delayed (e.g., armed to active) and latent errors may not become apparent until some time has passed.
Verification of intended path/functions and awareness of modes is important throughout all phases of flight, including ground operations.
6.9.2 Autoflight Mode Awareness. The Flight Mode Annunciator (FMA) provides the flightcrew with information on the status of the autoflight/automated systems, specifically with respect to the guidance and control functions being utilized. Whether manually controlling the aircraft, using the automated systems to control the aircraft flightpath and energy, or various combinations of both, the FMAs are the information source for depicting “who is doing what.”
6.9.2.1 It is important that flightcrews are thoroughly trained to understand the implications and relationships of each mode since the respective mode communicates the source of the aircraft flightpath and energy. It is also imperative that both crewmembers, as a team, understand the current mode status and its controlling system to effectively manage flightpath and energy.
Just as the monitoring function is the concurrent responsibility of both pilots (and potential auxiliary crews when in the flight deck), awareness of the FMAs and their affects are also the duty of both pilots. Understanding the consequences of modes, either expected or unanticipated, and the ability to anticipate subsequent modes and the comprehension of the significance and system effects of the mode is central to flightpath management.
6.9.2.2 Autoflight system mode awareness requires effective monitoring of autoflight modes. Below are a few strategies that could be trained to improve monitoring of the autoflight modes:
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1. Stay in the loop by mentally flying the aircraft even when the AP or other pilot is flying the aircraft.
2. When you have been distracted, ensure that you always check the FMAs and your flight instruments to get back in the loop as soon as possible.
3. Monitor the flight instruments just as you would when you are manually flying the aircraft.
4. Be diligent in monitoring all flightpath changes – pilot actions, system modes, aircraft responses.
5. Always make monitoring of the PF a priority task when flightpath changes are being made.
6. Always check the FMA after a change has been selected on the AP mode control panel.
7. Maintain an awareness of the autoflight systems and modes selected by the crew or automatically initiated by the flight management computer (mode awareness) to effectively monitor flightpath.
8. Maintain an awareness of the capabilities available in engaged autoflight modes to avoid mode confusion.
9. Effectively monitor systems and selected modes to determine that the aircraft is on the desired flightpath.
Appendix A A-1 APPENDIX A. RELATED GUIDIANCE AND INFORMATION A.1 Related FAA Guidance (current editions).
• Information for Operators (InFO) 08029, Approach and Landing Accident Reduction (ALAR): Recommended Flight Crew Training.
• InFO 08049, Preventing Wrong Runway Takeoffs.
• Safety Alert for Operators (SAFO) 07003, Confirming the Takeoff Runway.
• SAFO 12003, SOP for Title 14 CFR Part 135 Certificate Holders and Part 91K Program Managers.
• SAFO 13002, Manual Flight Operations.
• SAFO 15011, Roles and Responsibilities for Pilot Flying (PF) and Pilot Monitoring (PM).
• AC 91-73, Parts 91 and 135 Single Pilot, Flight School Procedures During Taxi Operations.
• AC 91-79, Mitigating the Risks of a Runway Overrun Upon Landing.
• AC 120-35, Flightcrew Member Line Operational Simulations: Line-Oriented Flight Training, Special Purpose Operational Training, Line Operational Evaluation.
• AC 120-48, Communication and Coordination Between Flight Crewmembers and Flight Attendants.
• AC 120-51, Crew Resource Management Training.
• AC 120-54, Advanced Qualification Program.
• AC 120-64, Operational Use and Modification of Electronic Checklists.
• AC 120-74, Parts 91, 121, 125, and 135 Flightcrew Procedures During Taxi Operations.
• AC 120-92, Safety Management Systems for Aviation Safety Providers.
• AC 121-32, Dispatch Resource Management Training.
• FAA-H- 8083-2, Risk Management Handbook.
• FAA Human Performance Considerations in the Use and Design of Aircraft Checklists, January 1995 [FAA 1995].
• FAA Order 8900.1, Flight Standards Information Management System (FSIMS).
Appendix A A-2 A.2 Related Reading Material.
• Barshi, I.; Degani, A., Loukopoulos, L.; Mauro, R.: (2016). Designing Flight Deck Procedures Report to the Federal Aviation Administration, September 7, 2016.
• Burian, B. K. (October 2006). Design guidance for emergency and non-normal checklists in aviation. In the Proceedings of the Human Factors and Ergonomics Society 50th Annual Meeting, San Francisco.
• Flight Safety Foundation. (August-December, 2000). FSF ALAR briefing note: 1.1 - Operating philosophy. Retrieved from FSF website:
http://flightsafety.org/files/alar_bn1-1-ops_philosophy.pdf.
• Flight Safety Foundation Approach-and-Landing Accident Reduction Tool Kit, 2000.
• Flight Safety Foundation. (2009). FSF ALAR briefing note 1.2 - Automation (Issue Brief No. 1.2). Alexandria, VA: Author.
• Flight Safety Foundation. (2009). FSF approach and landing accident reduction toolkit briefing note: 1.1 - Operating philosophy (Issue Brief No. 1.1). Alexandria, VA: Author.
• Flight Safety Foundation (2014). A Practical Guide to Improving Flight Path Monitoring. Final Report of the Active Pilot Monitoring Working Group, November 2014.
• Degani, A., & Wiener, E. (1993). Cockpit checklists: Concepts, design, and use.
Human Factors, 35(2), 28-43.
• Degani, A., & Wiener, E. (1998). Design and operational aspects of flight-deck procedures. Proceedings of the International Air Transport Association (IATA) Annual Meeting, Montreal, Canada.
• Degani, A., & Wiener, E. (1990). Human factors of flight-deck checklists: The normal checklist (NASA Contractor Report 177549). Retrieved from SKYbrary:
http://www.skybrary.aero/bookshelf/books/1568.pdf.
• Degani, A., & Wiener, E. L. (1994). On the design of flight-deck procedures (NASA Contractor Report 177642). Retrieved from NASA website:
http://ti.arc.nasa.gov/m/profile/adegani/Flight-Deck_Procedures.pdf.
• Degani, A., & Wiener, E. L. (1994). Philosophies, policies, procedures, and practices:
The four ‘P’s of flight deck operations. In N. Johnston, N. McDonald, & R. Fuller (Eds.), Aviation Psychology in Practice (pp. 44-67).
• Dismukes, R. K., & Berman, B. A. (2010). Checklists and monitoring in the cockpit:
Why crucial defenses sometimes fail (NASA Technical Memorandum Report No.
2010-216396). Moffett Field, CA.
• Commercial Aviation Safety Team (2007). “Wrong Runway Departure,” August 2007.
Appendix A A-3
• National Aeronautics and Space Administration, & Federal Aviation Administration.
(2000). NASA/FAA Operating documents project: Developing operating documents:
A manual of guidelines -- E-Version. Retrieved from NASA website: http://humanfactors.arc.nasa.gov/opdoc-workshopIV/Opdocfinal.pdf.
• National Aeronautics and Space Administration, & Federal Aviation Administration.
(September, 2015). ASRS Callback: A checklist (Issue 428).
• National Aeronautics and Space Administration, & Federal Aviation Administration.
(March, 2014). ASRS Callback: Checklist checkup (Issue 410). Retrieved from:
http://asrs.arc.nasa.gov/publications/callback/cb_410.html.
• UK Civil Aviation Authority (2006). CAP 676: Guidance on the design, presentation and use of emergency and abnormal checklists. Retrieved from http://www.caa.co.uk/docs/33/CAP676.pdf.
• UK Civil Aviation Authority (2013). Monitoring Matters - Guidance on the Development of Pilot Monitoring Skills: CAA Paper 2013/02. Paper produced by the UK CAA Loss of Control Action Group.
• Veillette, P. R. (May, 2006). A non-error resistant checklist. Business & Commercial Aviation. Retrieved from: http://aviationweek.com/awin/non-error-resistant-checklist.
• Veillette, P. R. (January, 2012). Give e-checklists an A+. Business & Commercial Aviation. Retrieved from FAA website:
http://lessonslearned.faa.gov/Northwest255/E_Checklists.pdf.
• Veillette, P. R. (August, 2008). The benefits of proper checklist design. Business & Commercial Aviation. Retrieved from: http://aviationweek.com/awin/benefits-properchecklist-design.
• Veillette, P. R. (August, 2007). The problem of checklist errors. Business & Commercial Aviation. Retrieved from: http://aviationweek.com/awin/problemchecklist-errors.
• Veillette, P. R. (May, 2006). The what and whys of good procedures. Business & Commercial Aviation. Retrieved from: http://aviationweek.com/awin/what-and-whygood-procedures.
• Veillette, P. R. (May, 2006). The who, what, when of your SOPs. Business & Commercial Aviation. Retrieved from: http://aviationweek.com/awin/who-whatwhen-your-sops.
Advisory Circular Feedback Form If you find an error in this AC, have recommendations for improving it, or have suggestions for new items/subjects to be added, you may let us know by contacting the Air Transportation Division (AFS-200) at 9-AWA-AVS-AFS-200-Air-Transportation-Division@faa.gov or the Flight Standards Directives Management Officer at 9-AWA-AFS-140-Directives@faa.gov.
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