ACTIVE

MONITORING
By Karen GARCIA, Flight Safety Director –
Accident/Incident Investigator,

The importance of active monitoring is one of

the growing key messages in our industry.
A recent investigation report concluded that
one contributing factor related to a CFIT
accident during a non-precision approach was
the inadequate monitoring of primary flight
parameters during the go-around, which may
have been worsened by the PM's attention all
tunneling on the management of the
aircraft flap configuration.

A focus on flight path monitoring has been In-service experience and feedback from

“
made by the industry in several studies and type-rating and recurrent training also
related safety improvement strategies over highlight that active monitoring is greatly
the past 25 years. The National enhanced by the knowledge of automation.
Transportation Safety Board determined in a For example, ATR training captains identified
study of air carrier accidents that 84 percent the three following scenarii as classical
of the 37 reviewed accidents involved examples where the knowledge of Auto Flight
inadequate crew monitoring or challenging1. Control System and setting of FMS
The International Civil Aviation Organization parameters weakens.
(ICAO) found inadequate monitoring to be a
1. Automatic mode reversion of AP/FD
factor in 50 percent of controlled flight into
into basic mode
terrain accidents2.
Regional operations have a specific LATERAL VERTICAL
MODES
BASIC

operational environment that need to be HDG HOLD PITCH HOLD

accounted for, while the categorized risks are ROLL HOLD
.
the same as for the entire commercial
WING LVL
industry; the level of exposure to the
identified threats may be higher, given the In case of automatic mode reversion, a triple
increased number of cycles per day, as well click warning is triggered; the crew must
as, the specific environmental and immediately check the FMA and take
infrastructural conditions. appropriate actions.
The importance of active monitoring is one of 2. Appropriate navigation source setting

”
the recurrent key messages provided during
Appropriate insertion of navigation
ATR Flight Safety conferences.
Presentations such as “Watch your speed in source and coupling to prevent
cruise”, “Watch your speed in approach” and inaccurate guidance.
“Prevention of loss of control” all emphasized
this point. 3 4

1
NTSB (1994). “Safety Study: A Review of Flight crew-Involved Major Accidents of U.S. Air Carriers, 1978 through 1990.” NTSB/SS-94/01, PB94- 917001.
2
International Civil Aviation Organization. “Safety Analysis: Human Factors and Organizational Issues in Controlled Flight Into Terrain (CFIT) Accidents,
1984–1994.” Montreal, Quebec, Canada: ICAO, 1994.
3
2016 Flight Safety Conference - Watch your speed in cruise and Watch your speed in approach presentations
4
2018 Flight Safety Conference -Prevent Loss of control in flight presentation
https://safety.atr-aircraft.com Mail : safety@atr-aircraft.com
 3. Flight plan discontinuities clearance Defining what monitoring is and training

“
specific monitoring tasks for Pilot Flying (PF)
Clearing route discontinuities and undesired
and Pilot Monitoring (PM) positions.6
waypoints so the FMS flight plan only reflects
Promoting an atmosphere in which either
the anticipated waypoints to be flown.
pilot can challenge the other in spite of his
position is essential, as monitoring becomes
ineffective when the identified deviations are
not pointed out or acted upon. Pilot task
allocation can integrate this notion, ensuring
that each pilot understands his/ her
responsibility for monitoring and the
importance of the monitoring task.7
Other monitoring good practices include,
being aware of the phases where high
When flying over a waypoint followed by a workload situations are expected, such as
discontinuity, the AP will revert to the basic the approach and the moments when there is
lateral mode. In addition, degraded a change in the energy state of the aircraft.
predictions, which are defined beyond the When an unexpected high workload is
discontinuity, may be generated. established, if necessary, increasing the time
The previous scenario occurred on the available to assess and treat the situation or
accident of a cargo aircraft, which, impacted reduce and prioritize tasks performed by the
short of the runway during a non-precision crew.
approach; the programming of the FMS Train the monitoring skills, including
without clearance of a flight plan discontinuity scenarios to develop, enhance and preserve
generated an unrealistic glideslope for the pilot monitoring skills, by making use of tools,
approach. The crew followed the projected such as EBT training, in service feedback,
path, inadvertently descended below the FFS and LOFT training.
minimum approach altitude and
Adhere to standard operating procedures,
subsequently into terrain. The investigation
monitor when it matters, and remember to
report stated that the flight crew's failure to
follow ATR SOPs golden rules.
properly configure and verify the flight
management computer for the profile 1 - FLY, NAVIGATE, COMMUNICATE - IN
approach was a main contributing factor to THAT ORDER
the accident. 2 - ONE HEAD UP AT ALL TIMES
3 - KNOW AND UNDERSTAND YOUR FMA
How to improve monitoring?
AT ALL TIMES
Specific guidance on how to improve 4 - WHEN THINGS DON’T GO AS
monitoring encourage crews to “Stay in the EXPECTED: TAKE OVER
loop by mentally flying the aircraft even when 5 - USE THE PROPER LEVEL OF
the autopilot or other pilot is flying the AUTOMATION
aircraft.”5
Enhance monitoring by knowing what the

”
system is doing (Understand), why it is doing
what it does and what it will do next
(Anticipate), to either detect and
communicate any deviations (Shared
Situation Awareness), or take timely
corrective actions when things don’t go as
expected (Take Over).

5
CAA Paper 2013/02 Monitoring Matters - Guidance on the Development of Pilot Monitoring Skills
6
IATA (2016) - Guidance Material for Improving Flight Crew Monitoring
7
Flight Safety Foundation (2014) A Practical Guide for Improving Flight Path Monitoring – Recommendations 2 and 16
https://safety.atr-aircraft.com Mail : safety@atr-aircraft.com