MODULE 22

MONITORING & INTERVENTION

Table of Contents

Session plan ........................................................................................................................ 2

Monitoring & intervention ................................................................................................. 3
Introduction to monitoring & intervention ................................................................ 4
Inadequate monitoring is detrimental to flight safety ............................................. 4
What is monitoring? .......................................................................................................... 6
Definition .................................................................................................................... 7
How do we monitor? .................................................................................................. 7
Barriers to monitoring ....................................................................................................... 8
What are the barriers to monitoring? ....................................................................... 8
The root causes .......................................................................................................... 9
Promoting good monitoring ........................................................................................... 10
What promotes good monitoring ............................................................................ 10
Monitoring strategies for single pilot operation .......................................................... 13
Typical monitoring environment .............................................................................. 13
Tips and hints for good monitoring ......................................................................... 14
Personal traits associated with monitoring competencies ................................... 16
How do you train monitoring skills? .............................................................................. 17
Impart monitoring knowledge ................................................................................. 18
Through CRM training .............................................................................................. 18
Through TEM training............................................................................................... 18
Through practice ...................................................................................................... 18
Intervention ....................................................................................................................... 19
At what point should the Pilot Monitoring (PM) intervene?................................... 20
How should the PM intervene and what challenges might they face? ................ 20
Summary................................................................................................................... 21

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Module 22

Monitoring & intervention

Session plan

Module no 22

Module title Monitoring & intervention

Duration 45 mins

Optimal class size 6 to 12

Learning By the end of the session you will be able to:

Objectives
• Describe ways in which we monitor

• Identify barriers to monitoring & methods to promote good monitoring

• Establish methods for training monitoring skills

Delivery method Facilitation

Trainer Trainer to have completed 5 day CRM Trainer core course.

qualifications

Student None
prerequisites

Trainer materials PowerPoint

Whiteboard
Flipchart

Participant Handouts:
materials Factors affecting monitoring lapses.
Monitoring tips and hints.
Root causes and mitigation strategies.
Behavioural markers pertinent to monitoring ability

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Monitoring & intervention

Slide - Header

Slide – Monitoring & intervention

Slide – Aims

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Slide – Objectives

Introduction to monitoring & intervention

To ensure the highest levels of safety each flight crewmember must carefully monitor the
aircraft’s flight path and systems, as well as actively cross-check the actions of each other.
Effective crew monitoring and cross-checking can literally be the last line of defence; when
a crewmember can catch an error or unsafe act, this detection may break the chain of
events leading to an accident scenario. Conversely, when this layer of defence is absent
the error may go undetected, leading to adverse safety consequences.

Inadequate monitoring is detrimental to flight safety

Inadequate flight crew monitoring and cross-checking has been cited by a number of
sources as a problem for aviation safety.
Referring to accident statistics, the NTSB determined in a safety study of crew-caused air
carrier accidents that 84 percent of the 37 reviewed accidents involved inadequate crew
monitoring or challenging(1).
Further, research conducted to support the Flight Safety Foundation’s Approach and
Landing Accident Reduction (ALAR) efforts revealed that 63 percent of the reviewed ALA
accidents involved inadequate monitoring and cross-checking.
Additionally, inadequate monitoring was a factor in 50 percent of the CFIT accidents
reviewed by ICAO (2).
Incident data also illustrate how inadequate crew monitoring can lead to safety problems.
In 1997, researchers at the U.S. National Aeronautics and Space Administration (NASA)
Aviation Safety Reporting System (ASRS) explored inadequate monitoring by examining
200 incident reports submitted to ASRS.(3) These reports provided evidence that
monitoring errors can lead to adverse safety consequences. Some serious monitoring
errors revealed in their study include altitude deviations, controlled flight towards terrain,
stall onset, loss of aircraft control, and course/ heading / track deviations. The research
team concluded that “the consequences of inadequate monitoring can be hazardous, and
a proactive plan to improve crew monitoring is appropriate.”7
Data collected in over 2000 audited airline flights using Line Operations Safety Audits
(LOSA) further demonstrate the importance of crew monitoring. Sixty-four percent of

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“unintentional errors” in the University of Texas LOSA archives went undetected by flight
crew.
In one LOSA conducted in 2000, 19 percent of errors and 69 percent of “undesired
states” could have been eliminated by more effective crew monitoring and cross-checking.
“Undesired state” refers to any unwanted situation or occurrence affecting aircraft safety
or operations, such as exceeding an aircraft limitation or landing on a closed runway.
These figures suggest that better monitoring performance by the flight crew can improve
safety by detecting and correcting errors before they get out of hand.

Monitoring matters

Slide – Monitoring matters

The CAA in conjunction with the Loss of Control Action Group, have produced a very
informative document called Monitoring Matters. CAA Paper 2013/02. This CAA paper is
publically available and can be downloaded from the internet.
The document gives guidance on the Development of Pilot Monitoring Skills.
The Loss of Control Action Group is a joint Civil Aviation Authority/industry initiative
supported by: British Airways, easyJet, Flybe, Jet2, Thomas Cook Airlines, Thomson Airways
and Virgin Atlantic Airways.
Abstracts of this document are included in this module.

CAA significant seven

When the UK Civil Aviation Authority reviewed its priorities for safety action, it came up
with a list it calls "The Significant Seven".

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Slide – Significant Seven

Loss of Control is prioritised as the most important of the significant seven safety issues
and the application of effective pilot monitoring is identified as a key safety net in the
prevention of and recovery from Loss of Control accidents and incidents. Monitoring is an
essential ingredient in achieving synergy with highly automated and complex aircraft
systems and effective crew co-ordination.
There have been many fatal accidents attributed to Loss of Control, resulting in a large
loss of life. Crew monitoring is frequently the last line of defence that stands between safe
operation and an accident scenario.

What is monitoring?
A good analogy of monitoring can be ‘plate spinning’ – whilst all the plates are going round
evenly a cursory tap keeps them on the stick. However as soon as one starts to wobble
and requires more attention than the rest you take your eye off the ball and before you
know where you are others are wobbling too and eventually all are on the floor.

Slide – What is monitoring

Monitoring is not quite this dramatic but whilst you are ahead of the game, concentrating
on the next event, keeping an eye on all the flight parameters, system modes etc.

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everything runs fairly smoothly. But as soon as something draws your attention away and
you become out of the loop it becomes difficult to play catch up.

Definition
In the context of flight operations, the term monitoring it is defined as:

Slide – Definition of monitoring

Monitoring is the name given to the extensive behavioural skill set which all pilots in the
cockpit would be expected to demonstrate.
The designated Pilot Flying (PF) is responsible for flying the aircraft in accordance with the
operational brief and monitoring the flight path. The Pilot Monitoring (PM) will have an
explicit set of activities designated by the Standard Operating Procedures (SOPs), and as
such will have a specific and primary role to monitor the aircraft’s flight path,
communications and the activities of the PF.
Both pilots will be responsible for maintaining their own big picture gained through cross
checking each other’s actions, communication of intent and diligent observation of the PF
selections, mode activations and aircraft responses.

How do we monitor?
Question

By what means do we monitor?

Facilitate a short discussion on how we monitor. You may stimulate the discussion by
incorporating the notes below:
The process of monitoring uses all of our senses in particular visual and auditory.
However, tactile inputs from the controls can feedback important information for example,
in the event of a stall and similarly the smell and taste senses can alert us to fumes in the
cockpit.
Intent forms a very important part of monitoring and provides a baseline against which to
monitor. It relates to system behaviour (what it is going to do), aircraft handling (predicted
flight path/aircraft manoeuvrability) and Pilot Flying’s intent (the plan).

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All accurate monitoring activities result in an output following judgement and decision
making and this can take the form of:
▪ Verbalization to other pilot or self.
▪ Non-verbalisation in the form of gesture/eye contact.
▪ Note-taking in the case of auditory monitoring.
▪ Reinforcement of collective Situation Awareness (SA).
▪ Maintenance of mental model.

Barriers to monitoring
What are the barriers to monitoring?
There are many factors that hamper monitoring including system and ergonomic design,
organisational factors, external environment and human vulnerabilities.
It should be emphasised that in nearly all accident case studies there are multiple causal
factors including design deficiencies and pilot handling responses but for the purpose of
this session we will focus on monitoring lapses.

Group task – Flip chart

Split into 2 groups. Discuss your assigned task and note your answers on flip chart:
Group 1 - List the barriers to monitoring
Group 2 – What promotes good monitoring

Elicit information from Group 1 - Barriers

Slide – Barriers to monitoring

Generate a discussion as appropriate based on what their answers bring out. Then follow
on with some information on root causes before looking at group 2 contributions.
Answers may include:

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▪ Inattention.
▪ Fixation/preoccupation - Fixated on a particular display or instrument
may lead to failure to complete the scanning process.
▪ Distraction.
▪ Workload. When the workload is high or poorly managed, monitoring
can be treated as a low priority task.
▪ If the workload is too low this can lead to complacency, boredom, low
arousal level.
▪ Stress.
▪ Tiredness & fatigue.
▪ Startle reaction.
▪ Incapacitation.
▪ Confirmation bias.
▪ Looking but not seeing - The pilot may become habituated in carrying
out the instrument and display scanning task and fail to accurately
process the information.
▪ Physical ergonomics – seating position, degraded vision, degraded
hearing.
▪ Authority gradients in the cockpit can impair monitoring if the PM is
intimidated by the PF and is unwilling to question their judgement.
▪ Lack of knowledge, poor situational awareness (SA) and confusion.
▪ Limited attentional resource, tiredness.
▪ Attention tunnelling.
▪ Disorientation.

The root causes

Handout – Factors affecting monitoring lapses

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Slide – Factors affecting monitoring lapses

Factors affecting monitoring lapses

In order to identify the root causes we can examine the contributory factors that relate to
the effects and conditions shown in the outer (yellow) circle in the diagram. The effects
cannot always be taken in isolation and they often inter relate or are causal factors in their
own right.
This diagram represents all the root causes and as might be expected is very broad. It
represents the set of threats that need to be mitigated against.

The root cause analysis process, is carried out in 3 steps:

Step 1 – Consider the human vulnerabilities which could accompany a monitoring lapse.
Step 2 – Take each of the vulnerabilities and consider causal factors from 4 different
perspectives:
▪ Self (physiological, psychological and personal).
▪ Work place (cockpit).
▪ Organisation (commercial air transport operators).
▪ Environment (geographical, meteorological, airport facilities, ATC).
Step 3 – List the root causes and consider mitigation strategies.

Promoting good monitoring

What promotes good monitoring
Elicit information from group 2 – What promotes good monitoring

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Slide – Promoting good monitoring

Generate a discussion as appropriate based on what their answers bring out. Then follow
on with some information on good monitoring.

Task management
Good monitoring relies upon effective task management and ‘making time for monitoring’.
It is evident from many case studies that carrying out tasks associated with the landing
checklist, emergency drills, landing charts and handling the FMS can take priority over
monitoring tasks.
Flight path monitoring/selective radial instrument scan must be a priority task that is not
compromised by other priority tasks.

Task scheduling
For example, carrying out the normal checklist.

Sharing
For example; balancing the monitoring workload and being aware when the PM has very
limited capacity.

Shedding
For example; prioritising tasks, this is considered as a strategy to achieve good monitoring
practice.

Knowledge, skill, experience, attitude and communication

Good monitoring requires knowledge, skill, experience, attitude and communication. None
of these can be taken in isolation. Knowledge is provided through training, experience is
the application of the knowledge and skill is the product of both knowledge and
experience. Attitude is a personal trait that can be shaped and developed. Communication
is fundamental to monitoring as both an output and input. To elaborate in more detail:

Knowledge
An essential component of the monitoring task is knowledge. The monitoring task
becomes easier when you are familiar with displays and controls functionality and
layout, system responses and handling manoeuvres. The application of knowledge

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equates with intent which is fundamental to the monitoring task. If you do not know
how the system is going to behave or how the aircraft is going to respond, then you will
not be able to make a judgement on correct operation (monitoring task). Similarly, if
you are unaware of the other crew member’s intent then this will also impair the
monitoring task.

Skill
Monitoring the flight path is simply flying with your eyes, observing cockpit displays
and indications to ensure that the aircraft response matches mode selections and
guidance target entries. Monitoring skill therefore can be considered, in part, to be the
ability to judge whether the aircraft attitude, speed and trajectory matches your
expectations.
Monitoring skill relates to the ability of the pilot to:
▪ Recognise and respond to any deviations from the plan in a timely and
effective manner.
▪ Recognise and advise on deviations in appropriate configuration
states.
▪ Recognise and advise on abnormal conditions.
▪ Alert changes in automation modes (in accordance with SOP).
▪ Advise on achievement of approaching clearance heights.
▪ Advise on external threats (weather, terrain, traffic).
▪ Recognise and advise on any errors by Crew Member.

Experience
Good monitoring correlates highly with mental capacity which in turn may be factored by
the pilot’s amount of flying experience. The more familiar you are with a set of
procedures/system operation, the greater the ability to operate effectively on mental
autopilot. Therefore, carrying out some of the operational tasks utilising lower levels of
concentration can release more capacity for the monitoring task. However, this doesn’t
necessarily mean that pilots with a lot of flying hours are good monitors.

Attitude
A good monitor will possess a healthy scepticism on the integrity of the systems and
will cross check the autopilot performance against the raw flight path parameters.
They will also be aware of and also possibly be a little suspicious about the capability
of other crew members thereby cross checking actions judiciously. They will act
dutifully in the execution of their monitoring task and be assertive when necessary.

Communication
Effective communication is intrinsically linked to monitoring skills. It involves
communications between; flight crew and controller; flight crew members; flight crew
and cabin crew. Communication allows sharing goals and intentions to enhance crew’s
situational awareness and monitoring.

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Monitoring strategies for single pilot operation

When the role of PF and PM are combined as in the case of a single pilot it presents a
different set of monitoring disciplines. The processes and procedures will be equivalent to
multi crew operation except there will only be one person in the cockpit and the systems
may be less automated. Hence the need to monitor the flight profile, flight instruments,
fuel state, engines, radio, etc. diligently. The instrument scan must be carried out very
frequently, especially during departure and approach in order to monitor the aircraft state
and planned profile.
The light aircraft environment operating in uncontrolled airspace requires additional
internal and external monitoring as illustrated below.

Typical monitoring environment

Slide – Typical monitoring environment

The following is an extract from an AAIB report11 of a fatal accident involving a solo pilot
flying a Bolkow 208C light aircraft from Long Marston Airfield to Peterborough Sibson
Airfield. It serves to emphasise the importance of planning and monitoring particularly in
unfamiliar territory

The aircraft was on final approach to land at Sibson Airfield when it struck the
uppermost cable of a set of power transmission lines situated approximately
0.5 nm from the airfield. The runway in use had a significantly displaced
threshold to provide aircraft on approach with adequate clearance from the
transmission lines. Evidence suggested that the pilot made an approach to
the start of the prepared runway surface, rather than the displaced threshold.
The pilot’s unfamiliarity with the airfield, distraction due to a departing aircraft
in front and inadequacies in the briefing material available to him may have
been contributory factors to the accident.

There is still the requirement to carry out the checklist drills and emergency briefings.
▪ Resist the temptation to take short cuts and avoid repeating the well-
known checklists from memory. Although it may be embarrassing, there
are times when just saying a drill out loud will re-enforce the actions

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and ensure nothing is missed. Departure and approach briefings or

reviews are an essential element of safe operations. An update of the
airfield procedures or approach plates would highlight restrictions,
terrain or limitations, even for a well-known airfield.
▪ Emergency briefings become a self-disciplined action. However,
completing a briefing (to yourself) re-enforces the thought process –
‘Have I thought of everything’. Similarly, have a ‘what if plan‘. Consider,
any airfield restrictions, surrounding terrain, weather, temperature,
aircraft weight and payload. What are you going to do if the engine
fails? On the runway.
▪ Just after take-off, below 1000ft.
▪ Above 1000 ft. and just beginning the departure.
▪ Is the weather/terrain acceptable for a forced landing ahead, or
▪ Does the weather/terrain allow for a return to the runway?
▪ What is my decision point/speed required?
▪ Always carry out an independent check of fuel contents with respect to
flight plan before take-off.
It is a good practice to review the engine failure or major emergency actions by self-
briefing and accomplishing a touch drill of all the relevant switches and levers. The touch
drill improves the memory for actions required under stress and is an accepted training
method. For example, in martial arts training, students practice a move against an
imaginary opponent some hundreds of times to become proficient.
Ensure that emergency checklists are accessible and can be executed whilst still flying the
aircraft. Consider having the major critical emergency drills on a knee board type check
list, which is always available and won’t fall off. The relevant checklist may then be
completed once the situation is under control prior to the approach.
In most emergencies, the best strategy is to land as soon as possible. Therefore, have a
plan.
Self-monitoring, to detect lapses becomes important. In a single pilot situation taking a
break is not an option so ensure that you are well rested and fit to fly.

Tips and hints for good monitoring

Handout – Monitoring tips and hints

These are a few strategies that could be employed to enhance good monitoring behaviour:
▪ Stay in the loop by mentally flying the aircraft even when the autopilot
or other pilot is flying the aircraft.
▪ When you have been distracted ensure that you always check the Flight
Monde Annunciator (FMA) and your flight instruments to get back in the
loop as soon as possible.
▪ Monitor the flight instruments just as you would when you are manually
flying the aircraft.

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▪ Be diligent in monitoring all flight path changes – pilot ACTIONS,

system MODES, aircraft RESPONSES.
▪ Always make monitoring of the PF a priority task when flight path
changes are being made.
▪ Always check the FMA after a change has been selected on the
autopilot mode control panel.
▪ During briefings include ‘monitor me’ type comments to encourage
intervention – ‘remind me if I haven’t asked for the after take-off
checks’.
▪ Provide the occasional monitoring reminders e.g. – ‘make sure that the
tail wind doesn’t exceed 10 kt’.
▪ During flight the captain should ensure that the shared mental model
remains intact this can be achieved through:
▪ Application of TDODAR (Time, Diagnose, Options, Decide,
Act/Assign, Review) (agree the plan);
▪ Expression of intent (I will be flying the descent at 200kt); and
▪ Providing a situation update to the PM when he/she has been
carrying out a non-monitoring task.
▪ Manage the workload:
▪ When the workload gets too high, prioritise which parameters to
monitor – don’t multi-task for too long;
▪ When dealing with emergency situations ensure adequate time
and space to enable the continuation of the monitoring tasks;
and
▪ Avoid programming the FMS at critical phases of flight.
▪ Don’t rely on memory when receiving aural communications – write it
down or request it again.
▪ Mentally rehearse during low periods of workload, monitoring tasks
that will occur in the next phase of flight.
▪ Make cross checking achievement of the autopilot targets a force of
habit.
▪ Verbalise your observations or checklists (especially if single pilot).
▪ At the end of the flight discuss how well the monitoring was carried out
– did you both share the same plan.
▪ When the aircraft is carrying defects that are acceptable in the MELs
consider the impact on the monitoring task – make a note (mental or
otherwise) of the affected flight parameters, modes or systems that will
require more attentive monitoring (discuss this during briefing).
▪ Judicious use of acronyms are a good way of remembering monitoring
tasks or techniques:

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▪ FREDA (Fuel, Radio, Engines, Direction, Altitude)

▪ FEFL (Fuel, Engines, Flight Instruments, Location)
▪ CAMI (Confirm FMS, Activate Mode, Monitor, Intervene)
▪ PACE (Probe, Alert, Challenge, Emergency) (Structured
intervention)
▪ AMR (Action, Mode, Response)
▪ When referring to charts/checklists/QRH hold them in a position that
facilitates the scanning of flight parameters
▪ The PF can put the A/C into a situation where it is unsafe but PM can
stop it ‘Never whisper when you know it’s time to shout’.

Handout - Root causes and mitigation strategies

This handout shows root causes and gives consideration to mitigation strategies. However,
it should be stressed that this is not necessarily the only solution and the benefit in fully
appreciating the broad range of circumstances leading to monitoring lapses will be gained
in developing your own table.

Personal traits associated with monitoring competencies

The traits and their characteristics relevant to good monitoring are

Slide – Traits - conscientiousness

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Slide – Traits - vigilance

Slide – Traits - assertiveness

How do you train monitoring skills?

Slide – Training monitoring skills

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Impart monitoring knowledge

It is important to provide a foundation of knowledge relating to monitoring in terms of what
it is, why it is so important and how human vulnerabilities/stressors can impact upon
monitoring lapses. Crew should be made aware during ab-initio training and it should be
reinforced throughout recurrent training.

Through CRM training

During the CRM training, emphasis should be placed on how behaviours that reflect good
monitoring are integrated within existing NOTECHS

Handout – Behavioural markers pertinent to monitoring ability

Through TEM training

Monitoring plays a powerful role as a countermeasure in TEM. Good monitoring will enable
a pilot error (handling, procedural or communication) to be detected before it leads to an
undesired aircraft state and to a potential unsafe outcome.
Anticipation of likely threats enables cross monitoring mitigation strategies to be put in
place:
▪ Weather (thunderstorms, turbulence, icing, wind shear, cross/tail winds
etc.).
▪ ATC (traffic congestion etc.).
▪ Airport (contaminated/short runway, contaminated taxiway etc.).
▪ Terrain (high ground, slope, etc.).
▪ Aircraft (MEL/Configuration Deviation List (CDL), system malfunction
etc.).
▪ Crew member error (misheard an instruction, misperceived an
indication etc.).
Thus these would form briefing topics both pre and during flight.
A recommended training exercise is to consider a monitoring lapse as the threat. By
considering all of the factors that contribute to a monitoring lapse the pilot can develop
his/her own mitigation strategy.

Through practice
It goes without saying that the only effective way of developing monitoring skills is through
flight exposure during simulator training and line flying. The monitoring is far more
demanding for the PM when the PF is manually flying the aircraft mainly due to the
likelihood of flight path and speed excursion compared with when the AP is managing the
flight (assuming all the flight plan inputs have been cross monitored previously). Therefore,
manual flying is the best way to develop the predictive monitoring skills. The other
monitoring skills (passive, active, periodic and mutual) relate mainly to SOP adherence
which will improve with practice and feedback.

The instructors must ensure that:

▪ All monitoring/cross checking SOPs are followed.

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▪ They are cross monitoring each other (ideally this will become a force of
habit).
▪ There is a gap between the challenge and response to make sure that
they have actually checked it (encourage them to say what they see).
▪ They are holding any checklist/chart/QRH in a position that facilitates
continued monitoring (alternatively recognise when there is no spare
capacity to carry on monitoring and encourage them to focus attention
on QRH).
▪ They have their seat at the design eye position so that they are able to
monitor the required instruments, panels, displays and controls.
The old adage ‘we all learn from our mistakes’ is true and events which introduce
failures that good monitoring should capture, should be considered.

Intervention
Slide – Intervention

Group task

Ask the group to work together (split into multiple groups if large numbers) and to list
their contributions for the following questions:
▪ At what point should the Pilot Monitoring (PM) intervene?
▪ Consider how the PM should intervene
▪ What challenges might the PM face and how can they mitigate this?

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Slide – Intervention

At what point should the Pilot Monitoring (PM) intervene?

Work through the group’s contributions and promote discussion as appropriate. Their
answers may include the following:
Positive intervention should be considered when:
▪ Flight parameters are not met or as expected.
▪ There is deviation from SOPs.
▪ If the pilot flying performs an unsafe act (i.e. that may lead to an
undesired aircraft state).
▪ There is no response to a challenge (i.e. possible subtle incapacitation).

How should the PM intervene and what challenges might they face?
Work through the group’s contributions and promote discussion as appropriate. If
their answers don’t include the following points, then consider adding this information
to the discussion.
System design and automation may aid intervention, as too may procedures and
regulation, which can be referenced and cited in the event of a needing to challenge.
Use assertive communication, do not be afraid to speak up, ‘if you see something –
say something’.
In the event that a subordinate crew member needs to challenge the performance of a
Captain, the situation can be very difficult for junior crew members, particularly if they
are still in their new-hire, probationary period.
If the culture of the organisation does not address fear, intimidation, and reprisal, then
crew members might be very reluctant to suggest to an established Captain that
mistakes are being made.
Other factors affecting the intervention process may be company culture, national
culture, personality and confidence.

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To handle interventions under these circumstances, the acronym "P.A.C.E." can be

utilised.
▪ Probing for a better understanding;
▪ Alerting Captain of the anomalies;
▪ Challenging suitability of present strategy;
▪ Emergency Warning of critical and immediate dangers.
These four steps define an ordered progression of inquiries designed to reduce risks
at each level of the intervention sequence. The "P.A.C.E." skills will enable subordinate
flight crew members to effectively intervene when a Captain is not performing up to
reasonable professional standards. The "P.A.C.E." inquiry procedural steps will ensure
that intervention by Co-pilots will always increase the margins of safety;

Summary
Slide – Summary

Slide – Objectives

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Slide – Any questions

References
1. NTSB. Safety Study: A review of flight crew involved, major accidents of U.S. Air
Carriers, 1978 through 1990. Report no. NTSB/SS-94/01. Washington, D.C.,
United States: NTSB, 1994.
2. International Civil Aviation Organization (ICAO). Safety Analysis: Human Factors and
Organizational Issues in Controlled Flight into Terrain (CFIT) Accidents, 1984–
1994. Montreal, Quebec, Canada: ICAO, 1994
3. The NASA Aviation Safety Reporting System (ASRS) is a confidential incident-
reporting system. The ASRS Program Overview said, “Pilots, air traffic controllers,
flight attendants, mechanics, ground personnel and others involved in aviation
operations submit reports to the ASRS when they are involved in, or observe, an
incident or situation in which aviation safety was compromised. ASRS de-identifies
reports before entering them into the incident database. All personal and
organizational names are removed. Dates, times and related information, which
could be used to infer an identity, are either generalized or eliminated.”

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