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However, if the automatic
system is allowed to
operate without any conscious
supervision, it is vulnerable
to certain types of
error, especially a type of error
called habit capture. For
Category 1
Communication
- "Copilot was a new hire and new in
type; first line flight out of training IOE.
Copilot was hand-flying the aircraft on
CIVET arrival to LAX. I was talking to
him about the arrival and overloaded
him. As we approached 12,000 feet (our
next assigned altitude) he did not level off
even under direction from me. We descended
400 feet low before he could recover.
I did not realize that the speed
brakes were extended, which contributed
to the slow altitude recovery." (# 360761)
In this example, the Captain was
attempting to help the new First
Officer, but the combination of flying
the airplane and listening to the
Captain was too much for the new
pilot. Tellingly, the act of talking
distracted the Captain himself from
adequately monitoring the status of
the aircraft.
Thirty-one of these incidents
involved altitude deviations or failure
to make a crossing restriction.3 In 17
of these 31 incidents (and 68 of the
total 107 incidents) the crews reported
being distracted by some form of
communication, most commonly
discussion between the pilots, or
between a pilot and a flight attendant.
Most, although not all, of these
discussions were pertinent to the
flight. However, in many cases the
discussion could have been deferred.
We later discuss how crews can schedule
activities to reduce their vulnerability
to distraction.
Research studies have shown that
crews who communicate well tend to
perform better overall than those who
do not. But conversation has a potential
downside because it demands a
substantial amount of attention to
interpret what the other person is
saying, to generate appropriate responses,
to hold those responses in
memory until it is one’s own time to
speak, and then to utter those responses.
One might assume that it is
easy to suspend conversation whenever
other tasks must be performed.
However, the danger is that the crew
may become preoccupied with the
conversation and may not notice cues
that should alert them to perform
other tasks. (The accompanying
sidebar explores the nature of interference
between competing tasks.)
Special care is required to avoid
distraction when others enter the
cockpit, because they may not recognize
when the pilots are silently
involved in monitoring, visual search,
or problem-solving.
Category 2
Head-Down Work
- “…Snowing at YYZ. Taxiing to runway
6R for departure. Instructions were taxi to
taxiway B, to taxiway D, to runway
6R.…as First Officer I was busy with checklists
[and] new takeoff data. When I looked
up, we were not on taxiway D but taxiway
W…ATC said stop….” (# 397607)
In a review of airline accidents
attributed primarily to crew error over
a 12-year period,4 the NTSB concluded
that failure to monitor and/or challenge
the Pilot Flying contributed to
31 of the 37 accidents. In 35 of the
ASRS incidents we studied, the Pilot
Not Flying reported that preoccupation
with other duties prevented
monitoring the other pilot closely
enough to catch in time an error being
made in flying or taxiing. In 13 of
these 35 incidents (and 22 of the total
107 incidents), the Pilot Not Flying
was preoccupied with some form of
head-down work, most commonly
paperwork or programming the FMS.
Monitoring the Pilot who is flying
or taxiing is a particularly challenging
responsibility for several reasons.
Much of the time the monitoring pilot
has other tasks to perform. Monitoring
the other pilot is much more
complex than monitoring altitude
capture because the other pilot is
performing a range of activities that
vary in content and time course. Thus,
it is sometimes difficult for the monitoring
pilot to integrate other activi6
Issue Number 10
ties with monitoring because he or she
cannot entirely anticipate the actions
of the other pilot. Furthermore,
serious errors by the pilot who is
flying or taxiing do not happen
frequently, so it is very tempting for
the pilot who is not flying to let
monitoring wane in periods of high
workload.
Periods of head-down activity, such
as programming the FMS, are especially
　
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