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“CRM Strikes Again”
Monitoring and Flying A Balancing Act
    Communications-Related Incidents in
General Aviation Dual Flight Training
2
A recent survey of the ASRS database revealed that one
third of all incidents involving General Aviation (GA)
aircraft also involved a reported communications-related
difficulty, such as failure to comply with an ATC
clearance or a communications equipment malfunction.
Other research based on accident data and pilot
interviews has raised the question of whether
communications deficiencies contribute to incidents,
accidents, and fatalities during dual instruction.
An analysis was undertaken of 200 ASRS reports that
involved GA dual instruction and contained explicit
evidence of verbal communications between the instructor
and trainee. The main purposes of this research were to
identify the operational context in which communicationsrelated
incidents occurred during GA dual instruction, as
well as the types of problematic communications between
instructors and trainees.
The authors found that half or more of the communicationsrelated
GA incidents occurred within the airport environs
or airspace, within 10 nautical miles of the airport, at
altitudes less than 1,000 feet AGL. Ongoing
communications with control towers were a prominent
element of both surface and airborne incidents. Analysis
of instructor/trainee communications revealed that
trainees delayed actions or acted inappropriately because
instructors made confusing or misleading comments,
misinterpreted trainees’ comments, or delayed feedback.
More than three-fourths of all the study incidents resulted
in an ATC clearance violation or a related infraction, such
as a runway incursion or ground conflict.
Drawing from study findings, the authors offer practical
suggestions to enhance safety and prevent ATC clearance
violations during dual flight instruction.
Editor’s Note: In May 1997 ASRS presented several
research papers at The Ohio State University’s Ninth
International Aviation Psychology Symposium. Brief
summaries of two of the papers are presented below.
Inadequate flight crew monitoring has been recognized as
a safety problem by a number of aviation organizations.
In independent accident studies conducted in 1994, both
the International Civil Aviation Organization (ICAO) and
the National Transportation Safety Board (NTSB) found
that monitoring failures contributed to a large number of
the accidents under review. Monitoring is also a
relatively neglected subject in Crew Resource Management
(CRM) courses, which usually offer few procedures or
guidelines to enhance flight crew monitoring.
This study analyzed 200 ASRS air carrier reports to
identify factors that contribute to monitoring errors, and
to offer operationally-oriented approaches aimed at
improving crew monitoring. Several patterns emerged.
Three-fourths of the monitoring errors were initiated
when the aircraft was in some “vertical” flight mode—
climb, cruise-descent transition, descent, or approach.
FMS programming was most frequently the task being
performed when the monitoring error occurred. Flight
crews and ATC were far more likely to detect the
monitoring errors than were onboard alerting systems,
such as altitude alerters and Ground Proximity Warning
Systems (GPWS).
The paper translates research findings into operational
approaches that may help prevent monitoring errors. The
authors note that an air carrier’s automation philosophy
can either support, or conflict with, the monitoring
function. As an example of the latter, some air carriers
require that one pilot be exclusively dedicated to
monitoring and controlling the aircraft, regardless of the
level of automation. Several alternatives to this common
practice are discussed, and suggestions are also offered
for enhancing crews’ monitoring effectiveness on longrange
flights.
ASRS Request Form
Readers may obtain free copies of papers by filling
out this request form and mailing it to:
Aviation Safety Reporting System
c/o Administrative Staff
P.O. Box 189
NASA Ames Research Center
Moffett Field, CA, 94035-0189
Please send me the following ASRS papers
(Check selection below):
What ASRS Data Tell About Inadequate Flight
Crew Monitoring
Communications-Related Incidents in GA Dual
Flight Training
ASRS Research Snapshots
  1   What ASRS Data Tell About Inadequate
Flight Crew Monitoring
A Monthly Safety Bulletin
　
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