Submitted by Paul Ratté, Director of Aviation Safety Programs at USAIG and 2014 Air Charter Safety Foundation Safety Symposium Speaker.
Recently, I was making a presentation at a conference for facility managers from a network of technical work centers. Along with the standard folder bearing the agenda and nametag, I received an empty manila clasp envelope. A quick glance around the room confirmed that everyone had envelopes. I wondered about it as I headed for my seat.
The facilitator solved the mystery soon enough. “All right, we’re about to get started, so cell phones off and into the envelopes please.” There was a shuffle across the room as this obviously familiar ritual was carried out. Aiming to be polite visitors, my colleagues and I quickly conformed to local custom. This seemed like a good practice for centering a group’s attention, and it also struck me this was a firsthand glimpse into the organization’s culture.
The discussion for the next two hours centered on procedural compliance in the work centers. While I suspect a small number of phones never made it into the envelopes in the first place, over the course of several presentations and a short break, many more came out and stayed out as their owners not-so-discretely went back on the grid. Yes, a Standard Operating Procedure (SOP) had been set forth. Yes, there had been investment (the envelopes). Yes, it was supported initially by the majority as beneficial and easy-to-follow. No, a group in charge of establishing SOPs and enforcing procedural compliance could or would not comply with it for two hours while discussing procedural compliance. Irony noted. When compliance broke down, no corrections occurred on either the macro level from the facilitator, or the micro level among people seated side-by-side. No, this SOP has not ‘stuck’ in the organization’s culture.
I’ll leave analysis of the irresistible nature and societal impact of smartphones to the experts, but this got me thinking about how some SOPs just never get traction. They exist in doctrine, but really just serve up a false sense of security that risks have been controlled through standardization, when they haven’t. Many procedures developed to guide pilot monitoring suffer that fate. Standard verbal responses are usually tightly followed in a checklist, but for standard callouts or confirming actions that are part of broad and less-rigorously scripted guidance for approach and transition sequences, we tend to readily forgive freelancing or outright lapses in ourselves and others. Kind of like the folks and their phones at my conference.
Pilot monitoring is a hot topic these days, especially in light of several tragic and highly publicized recent accidents in which flawed acts or omissions by the flying pilots inexplicably went uncorrected by other cockpit crewmembers. “Monitoring” has just fairly recently been adopted as the name for what’s expected from pilots in the cockpit while they are not functioning as the flying pilot at the controls. I recall one of my Coast Guard commanders in the early1990s wanted that position referred to as the “Safety Pilot” but it didn’t catch on. The old reference to the Pilot-Not-Flying (PNF) was traded in for the more apt Pilot Monitoring (PM) because the former was passive, negative sounding, and non-descriptive. The name change was a good move, but certainly is not a cure-all for deficient monitoring.
The monitoring pilot’s task is to observe the flight in real time and maintain an independent cognitive assessment of how it’s progressing and what’s expected. A similar assessment is separately maintained by the pilot flying. When those agree and the actions of the flying pilot and aircraft match expectations, safety and confidence are maximized. The first to experience any doubt about the flight’s progress or actions being taken is charged with acting immediately to resolve it. Either pilot’s view or understanding can be flawed, so the priority, at the onset of any perceived difference between expectation and performance, is to quickly identify what’s flawed, what’s right, and get both pilots realigned to the accurate view. Done consistently, this process will keep vital elements such as flight path, altitude, speed, and configuration under redundant human control.
As tidy as that model seems, we know there’s more to it. Besides sitting there sensing, calculating, and comparing like a flight computer, we’re also, well, being human. Distraction, socialization, complacency, emotions, fatigue, trust, and cultural barriers all threaten effective monitoring. Like the weather, we can’t wish those things away. We need the ability to consistently succeed in spite of, and while immersed in, these factors.
We internally assign criticality rankings to things expected of us, and those change with the situation. We’ll heed a “no trespassing, high voltage” sign most all the time, or resist the buzz of a new text message during a meeting with the boss, but reason nobody’s going to be harmed if we check email during this conference, in spite of stated group rules. Even with an improved name, pilot monitoring is still getting factored too low on those priority scales. Despite tacit agreement by virtually all pilots with the idea and importance of monitoring, evidence continues to show inconsistent follow-through. The results are sometimes disastrous and, when so, seem incomprehensible because we thought we’d already managed that risk with a multi-place cockpit and a monitoring doctrine. At the 2014 Air Charter Safety Symposium, I look forward to a discussion with flight organizations focused on elevating the quality and consistency of monitoring in their cultures.
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