Do Pilots Rely On Automation Enough?

By now everyone in the commercial aviation world knows about the Boeing 747 Dreamlifter landing at the wrong airport in Kansas.  This aircraft is modified to fly large sections of the 787 Dreamliner to facilities where portions of the manufacturing process are performed.  This modified aircraft does, however, have the standard FMS flight guidance systems of a typical B747-400.  There were no injuries to the cargo or crew outside of embarrassment.  Embarrassment is that feeling we get when we have remorse for our actions.   The more public the mistake the more the embarrassment.  Usually there is the obligatory “I’ll never do that again.”

It is ironic that in the midst of an industry wide discussion about commercial pilots’ deterioration of manual flying skills we have an incident that could have been prevented by less manual flying.  It is very hard to fly an instrument approach to the wrong airport.  Landing on the wrong runway maybe, but not the wrong airport.  There were many clues inside the cockpit that could or would have shown the pilots they were not where they thought they were.  Sadly, many pilots crashed in the early days of instrument flying because they did not use or believe the information that was available to them.

This is the lesson that we should all learn from this crew’s embarrassment, “We are all capable of landing at the wrong airport.”  It is not because we are bad pilots.  It is not because we are too reliant on automation.  It is not because we do not have enough information to verify our position.  It is not because the ground proximity warning system is inadequate.  It is not because we have insufficient procedural guidance.  It is because we lack identification with those pilots who have made these mistakes before.  We think we are better than that.  The biggest threat we all face in aviation is the feeling that it won’t happen to us.

Buy In

My last post was meant to initiate a discussion about the priority of standard operating procedure in airline operations.  Is it important?   Why or why not was the type of comment I hoped readers would articulate?  Unfortunately, there were few comments pro or con.  Therefore, I am going to try to argue both sides of this issue.  Those of you that know me understand my appreciation of the “one liner”.  So, considering the fact that I am going to have to conduct the debate by myself, here’s a great one.

 “I may be a schizophrenic, but at least we have each other.”

I have shared my objective for this blog before. It is to initiate a dialog between airman and aviation related professionals to discuss what we do as well as how and why we do it.  Aviation is a very unique activity and therefore requires active participation over a considerable time period to make introspective and vulnerable comments on related complex issues.  It is very easy for management or simulator/instructor pilots to be critical and judgmental of the line pilot. It is not an arrogant critique; I have been there myself.  The judgment does come, however, from a lack of identification with the everyday challenges that are line flying.

Many companies espouse the primary importance of a safe operation, but out of the other side of their mouths preach efficiency.  They have endless charts depicting data that shows where the pilots can be more efficient.  There are detailed presentations showing the company’s operational performance compared with the competition.  When it comes to a safe operation, however, the strategy is simply procedural compliance.  Unfortunately, it’s not that easy.

This reminds me of the young petroleum engineer who asked his mentor, “How can I be successful in the oil business?”  The seasoned “oil man” replied, “It’s easy, get up early, work hard, find oil.”

Line Operational Safety Audits, LOSA, demonstrates the vulnerability of safe operations to intentional or unintentional non-compliance with SOP.  Error avoidance is always desired, however, error management achieves the same goal and is the essential link between procedure and safe operation.  Threat and Error Management IS bridge between procedure and safe operations.

Safety and efficiency are competing priorities, however, not mutually exclusive goals.  You can be safe and efficient at the same time, but not without vision, resources, mentoring and experience.  The job of the professional airman, specifically that of the airline pilot, has never been more challenging.  The machine and the environment have never been more complicated or crowded with threats.  A set of best practices is invaluable for airline flight crews.  Navigating this “mine field” takes absolute and complete focus by the crew.  Every other group the crew interfaces with has their own agenda.  Gate, ramp, mx, ATC as well as the customer all have their minds focused on an “on time” operation while at the same time assuming a safe operation.  The crew cannot “assume” a safe operation.  They are the “keeper of the flame”.  They must not lose sight of the primary goal, a SAFE OPERATION, in pursuit of procedural compliance.  Delayed flights, lost bags, misconnected passengers, mx delays are all unfortunate situations, but all can be overcome.  An aircraft incident or accident cannot be erased.  Safe Operations is all about prevention.   A replay is not an option.  If threats and errors are not managed the outcome is not assured.   If the outcome is unsatisfactory, there can be no “do overs”.

Standard Operating Procedure, SOP, is recognized as the best way to ensure a safe operation, however, it is not that simple.  Getting flight crews to be highly compliant with SOP is not easy.  Crews are not defiant, but they are generally not committed either.  By “not committed“, I mean they don’t understand why the procedure is in place and why it is crucial to a safe operation.  The rationale is obvious to the one who wrote the procedure, but not necessarily to the line pilot.  The line pilot is faced with literately hundreds of competing dynamic threats on each flight, therefore the rationale for a procedure is very important.  Prioritization, or “workload management” as it is referred to, is the line pilot’s world.  If absolute procedural compliance were really practiced, airlines would rarely operate on time.  Some procedures or regulations are written simply for the sake of liability.  When things go wrong, the excuse “We told them not to do that”, allows plausible deniability for those upstream in the organization.  Very rarely, if ever, do crews that understand the justification for a procedure blatantly disregard it.

Let me emphatically restate my position, Standard Operating Procedure, SOP, is the best way to pursue a safe operation.  However, it is not that simple.  To get a high level of compliance it requires “buy in”.  “Buy in” is the understanding and the internalization of the rationale for a procedure.  When airline flying was less complex the “buy in” was much easier.  Nowadays the environment is far too complex for the procedural rationale to be self evident or assumed.  For “buy in”, airline operators must be able to articulate the answers to the following 7 questions for every procedure.  Not every line pilot will ask these questions, but when one does it must be answered satisfactorily.  Many procedural justifications are self-evident many are not.  Either way, every instructor/management pilot must be supplied with and understand the answers to these questions so that they may educate the line pilots and earn “buy in”.

• What is the threat that the procedure is designed to mitigate or manage?
• What is the justification for the procedure? What does the data say?
• Does the procedure conflict with any other policy or procedure? 
• How does the procedure specifically manage or mitigate the threat?
• Is there a potential for undesired consequences from the mitigation strategy?  (Additional threats)
• What is the strategy to prevent these undesired consequences?
• How is the procedure trained?

If these questions can be answered and communicated effectively to the line pilots and there is still intentional non-compliance the airline needs to reevaluate their hiring criteria.  Once airlines have committed to hire pilots that understand and value a safe operation, the company’s operational leadership owns the responsibility for “buy in” to SOP. 

I will continue the discussion of “buy in” in a future post, but to quote Simon Sinek, the author of START WITH WHY, “there are only two ways to motivate people.  You can either manipulate them or inspire them.”

Are airline pilots so unsophisticated that they must be manipulated with a carrot and/or a stick to achieve the goal of a safe operation?

It Hurts When I Do That

Why ask "why"? 

Because the outcome of everything I do is a result of why I do it.

The great comedian Henny Youngman provides the best rationale for avoiding negative consequences.  If it’s going to hurt, don’t do it.

There just seems to be a pernicious lack of connection between today's airline pilot and his modern aircraft.  Often at cruise and sometimes even during climbs and descents the flying pilot is involved in various activities other than supervising the aircraft's vertical and horizontal flight path.  Some say that the most acute problem for airline pilots is a loss of stick and rudder skills.  I believe the bigger problems are more that of disengagement and distraction particularly when the autopilot is being controlling the aircraft. 

Lately, the aviation community has also targeted the area of "monitoring skills" as one that needs improvement.  This was the fundamental problem that allowed the crew of an airliner to over fly its destination. The crew failed to monitor because they were mentally (and physically by the automation) disengaged from the airplane.  Ineffective monitoring skills may have contributed to some recent approach and landing incidents.

A big reason for these areas of concern is a mental disconnect between the pilot and the airplane. It takes discipline and motivation to remain mentally connected to the airplane when physically detached by the use of automation.  Piloting has evolved from flying the aircraft to manipulating the automation. Once it's been programmed, the pilot is unintentionally or unconsciously giving the automation the responsibility for managing the aircraft. The problem is that the pilot always has authority over the aircraft and the automation and therefore cannot delegate responsibility for either.  A pilot may delegate a task to another pilot or the automation, but never the authority or responsibility for its outcome.

A classic example of this was demonstrated recently on approach to LAX.  The crew was cleared for a visual approach to 24R.  They were on a heading to intercept final just outside the marker.  The autopilot was on with the approach mode armed. Since the intercept was about 40 degrees and only about 7 miles from the runway, the autopilot captured the localizer late and went through final about 1 dot as it turned to capture the localizer.  So here they were with CAVU weather and flying a visual approach and the aircraft overshoots final.  Who was flying the airplane or was it flying itself.  I guess that "program the automation and see what happens" was the plan.

Whereas the genesis of a pilot’s mental disengagement is the physical disconnection with the airplane, the root of complacency and intentional non-compliance is a disconnect with why we, as pilots, do what we do!  With respect to flight crews, the term intentional non-compliance has been used to describe a range of behaviors.  Here I am using the term to refer to a mostly unmanaged disconnect by a disengaged or distracted pilot.  I am not talking about the rogue or defiant pilot.  Defiant behavior is an entirely different discussion.   

These problems all start with the motivation behind why pilots, particularly Captains, do what they do or do not do.  From choosing a runway to programming the automation to running a checklist, the motivation or reason why pilots do what they do and when they do it is critical to their ownership and the quality of the result.  A pilot is much more likely to be complacent or intentionally non-compliant depending on how they answer the following question, "Why do I respect a particular procedure, regulation or limitation?"

1.    "Because they said so."  "Don't ask why, just comply."

2.    "Because I am managing a threat." It will promote safe operations by managing a threat or trap an error.

How a flight operation wants their pilots to answer that question, "Why do I respect a particular procedure, regulation or limitation?" will determine the philosophy and mission of their department as well as the entire operation. Is the answer procedural compliance or threat management?

If it is the first, their mission will be to teach and evaluate standard operating procedure SOP.  If it is the second, their mission will be to teach and evaluate threat and error management TEM.  The primary objective must be one or the other it cannot be both. 

Procedural compliance can be and is an effective strategy for managing a threat, but if it is the only strategy, anything less than 100% compliance is unacceptable.  However, it is also unachievable.  This was the motivation for the work published in 1997 by Drs. Merritt & Helmreich at UT and others in the area of error management (the 5th generation of CRM).  Humans have never been and will never be 100% compliant even when they know and understand the rationale.  "To err is human......" is not a recent quote, but it has taken aviation a long time to accept it.  However in 2013, it is still not a universal mindset.  The medical community has been even slower to embrace and manage rather than criticize and hide their errors. 

Those flight operations that primarily target procedural compliance usually emphasize standards over training.  They put their emphasis and resources toward directing their pilots in what to do (procedural compliance) without necessarily establishing the rationale (threat management) for the procedure. Some connections between a procedure and a threat are obvious, but data shows many are not.  The movement to make cross verification of automation selections a procedure has only been partly successful because many crews see compliance, not threat/error management, as the objective.

By contrast, the flight operations whose objective is threat management emphasize rationale (threat management) in conjunction with procedure use evaluations to monitor the quality of the training process (effective threat management skills) rather than simple procedural compliance of the pilot.     Just as programming the automation does not relieve the pilot of responsibility for the outcome, publishing procedure does not satisfy the responsibility of flight operations leadership.

The adoption of a threat management based flight operation is a bold move. It takes belief, resources and commitment.  It requires flight operations management to give up some control and trust that the training they have delivered has prepared their pilots to make effective decisions in a dynamic environment.  Effective decision-making is the crucial difference in a safe operation.  The lessons learned from LOSA (Line Operational Safety Audit) support this.  From THREAT AND ERROR MANAGEMENT:DATA FROM LINE OPERATIONAL SAFETY AUDITS, Klinect, Wilhelm, and Helmreich summarized in part:

"Intentional noncompliance errors were the most frequently committed and also the least consequential.  Proficiency and operational decision errors were the most difficult for flightcrews to manage."

"The most common errors committed were associated with automation and checklists.  The majority of these errors were not typical slips, but a failure to cross-verify settings or incorrect usage."

Some flight operations have opted to retain the old paradigm of writing extensive policy and procedure and teaching their pilots to depend on compliance as their decision-making strategy.  Absolutely, procedural compliance is crucial to safe operations, however, as the sole basis for decision-making, this path has its limitations.  Procedure cannot provide an answer for every situation. I am reminded of the saying; "reality is more interesting than fiction because it is not limited by what someone can imagine." 

There is an interesting similarity between the relationship of pilots and their automation and the relationship of some flight ops management and their pilots.  The pilots program the automation and expect a certain result they same way managements issue procedure and expect a certain result.  Neither the pilots nor the managers would characterize the relationship that way, but it is often the reality.  Automation and procedure are tools that when used effectively promote safe operations.  When manipulations of the automation or blind procedural compliance become the objective the outcome is often in doubt.