The Naval Safety Center's Aircrew Coordination Training Program

by R.A. Alkov, Ph.D. (1991)

Aircrew error mishaps accounted for 63% of all flight mishaps in Navy/Marine rotary wing aviation during calendar year 1988 for a rate of 6.5 per 100,000 flight hours. Of these two-thirds had some degree of poor aircrew coordination as a contributing factor. For the EA-6 and A-6 aircraft communities, aircrew error during fiscal year 1988 accounted for 46% of all of their flight mishaps. of these, 78% were related to poor aircrew coordination, a loss of situational awareness, or pilot judgment. The human error rate for all A, B, and C flight mishaps in this community was 7.61 in 1988.

With advances in aircraft design, maintenance procedures, and standardized operations, aircraft have become more reliable. However, their aircrews, who are highly trained in dealing with programmed mechanical problems, are not preventing aircraft accidents. Concentrating on human engineering design of cockpits, ,better pilot training programs, and improved NATOPS procedures has helped, but pilot factor mishaps continue to occur. Aircraft mishaps tend to be attributed less to mechanical failure and more to human error. In recent years, there has been a growing realization of the significance of the lack of crew coordination and situational awareness as contributing factors to multi-crewed aircraft mishaps. Along with this realization has come the understanding that training can help.

Factors such as flight experience, proficiency, life style and personality affect the quality of cockpit communications. crew coordination is adversely affected where communications break down in the cockpit. Naval Flight Officers and copilots should be encouraged to offer verbal assistance, including opinions on mission parameters, regardless of the pilot Is seniority. Naval aviators must be impressed with the need to heed the inputs of their copilots and NFOs. Mission briefing must include a discussion of specific cockpit procedures and communication feedback responsibilities.

In 1984, an aviation psychologist at the Naval Safety Center, Dr. R. A. Alkov, requested funding from CNO (Op-09BF) for the five-year period FY 1987-91 in order to undertake a pilot program to determine if training could make a difference. In fiscal 1987 a contract was let to the Allen Corporation of America, later to become CAE-Link, to develop a trial program to teach aircrew coordination skills to helicopter fleet Replacement Training Squadrons (RTSs). Instructor training began in January, 1988. The training went beyond the usual leadership and assertiveness training used by various airlines under their cockpit resource management training themes curriculum content covered aircrew' judgment, loss of situational awareness, stress coping, risk management, workload assessment, cockpit communications, and flight planning.

The goal of the program was the development of a standardized aircrew coordination training program to be managed and run by Navy and Marine Corps aviation training squadrons. A cadre of Navy and Marine helicopter flight instructors was trained at the contractor's site in Dallas. They then returned to their RTSs to set up the training with the help of the contractor. The program was designed as a "turn-key" effort with the contractor leaving the squadron capable of carrying on its own training at the end of contract.

The development of a follow-on contract to expand the program into TACAIR was begun in 1988. Funding was continued during FYs 1989 and 1990 for adding training for the aircrews of all multi-placed aircraft including the P-3, C-130, and C-9. The Naval Air Training Command received the program during FY 191.

It is hoped that this training will plant the seeds for a successful ongoing Aircrew Coordination Training effort, fleet wide. A successful ACT effort should help reduce the mishap rate and improve combat readiness. Some of the topics covered in the course are briefly described below:

LOSS OF SITUATIONAL AWARENESS

A continuing problem in naval aircraft mishaps is loss of situational awareness. This leads to disorientation, mid-air collisions, flight into terrain or water, getting lost and running out of fuel, wheels-up landings, flight into heavy weather, etc. It frequently happens at low altitudes.

Situational awareness is the accurate perception of the factors and conditions affecting the aircraft and the flight crew during a specific time period. It is knowing what's going on around you, knowing what has happened in the past and its relation to what is going on now, and its affect on the future.

Causes/Symptoms of Loss of Situational Awareness

a. Fixation or Preoccupation Focusing in on a problem leads to a failure to detect other important cues.

b. Ambiguity When information is confusing or unclear, when there is a disagreement between two independent sources of information, the discrepancy must be resolved before acting.

c. Complacency Familiarity breeds contempt for hazards. Highly experienced individuals fall for the "I've done this a hundred times" trap.

d. Euphoria The feeling that everything is going just perfectly can lead to a loss of the big picture. A failure to anticipate danger. My flight instructor once told me "If you're not making a decision every second, you're in trouble".

e. Gut Feeling/Confusion This is one of your most reliable clues. The body is able to detect stimuli long before we have consciously put it all together. Trust your gut feelings, stop and look around before proceeding.

f. Distraction Letting a particular detail trap your attention to the exclusion of others that are equally or more important.

g. Overload/Underload Getting too busy to stay on top of it all. Delegate responsibility! Allowing oneself to get bored because of low workload can lead to complacency. Go back over details.

h. Poor Communication When ideas are not getting across, when there are difficulties in expressing ideas or understanding.

i. No One Flying The Aircraft or Looking Outside The proper assignment of responsibilities is essential to safe flight.

j. Failure to Meet Targets Encountering unexpected fuel consumption or cruise performance without knowing why. When targets for airspeed, rate of climb, power settings, checkpoint times, etc., are missed we need to question why.

k. Improper Procedures This is the number one cause. Departure from SOP, violations of regulations, etc. lead to exceeding safe operating limits. Violating minimums leads to loss of awareness because you have no reliable frame of reference.

Maintaining Situational Awareness

a. Experience and Training This allows us to develop mental data files for future use. This file allows us to associate existing information to new situations to determine the required action.

b. Hone Flying Skills If you are having to think about flying the aircraft, you use up large amounts of working memory that can't be used to scan the environment for clues to maintain situational awareness.

c. Spatial Orientation Knowing where you are at all times is essential to maintaining safe flight. You must be able to detect subtle changes in aircraft attitude. This means improving your scan, sharpening instrument flying skills through practice.

d. Personal Health To detect subtle changes in the environment, you have to have all your senses at their sharpest. To detect and process information effectively, you must be in top physical condition.

e. Attitude Your mental attitude will actually affect your detection and response to changes in the environment, as well as your ability to make good decisions.

f. Crew Coordination Everyone's ability to constantly monitor and scrutinize the environment, willing to communicate any uneasy feeling, comparing the present situation to the ideal flight concept. Working together as a team.

Regaining Situational Awareness

a. Verbalize Loss of Situational Awareness Admit the problem, tell somebody. This snaps the crew back to reality so solutions can be sought.

b. Deal With Unanticipated Problems You have a decision to make. Do you continue or abort? If you are at a critical phase of flight immediate termination might be wise. If it is not critical, you have to search for information to help you regain your situational awareness.

c. Return to Conscious Monitoring Now that you have your crew's attention, they can return to conscious monitoring as an active, dynamic phase of the crew coordination cycle.

Situational awareness discriminates excellence from marginal performance in the cockpit. Understanding the elements of situational awareness is essential to safe flight.

AERONAUTICAL DECISION MAKING

Conventional wisdom used to hold that judgment was something you were born with, it couldn't be taught. Although judgment is difficult to put into concrete terms, the elements that go to make up decision-making can be taught to enable the student aviator to render decisions in a rational manner even under stressful conditions where workload is high. Also the importance of the negative effect of personal attitudes on an aviator's ability to make wise judgments can be assessed.

Decision-Making VS. Risk Management

Judgment and decision-making must involve the assessment of risk. Risk management is an ongoing evolution; it starts in the brief and continues throughout the flight. If risks aren't properly assessed good judgments and decisions won't be made.

a. Judgment is the total mental process used to arrive at a decision.

b. Decision-making is the process of identifying a problem, gathering data, and using sound judgment to reach a logical conclusion in a timely manner.

c. Risk management is an individual measure for an acceptable outcome to a given decision or judgment.

Analytical and Intuitive Decision Making

Analytical thinking is very useful for dealing with those structured problems that can be systematically approached. It is more thorough because more information items can be taken into account. However, it is a time consuming and costly process due to the expense of the resources and personnel involved.

Structured Decision-making

The decision-making process is a synthesis of the elements of good aircrew coordination training (ACT) and situational awareness already discussed. It involves an interface among communication, situational awareness and command authority. In defining decision-making in terms of ACT, all the resources available to the crew are pulled together to achieve "synergy", the achievement of a whole team effort that is greater than the sum of individual efforts. Synergy is easier to achieve in an environment of good communications and leadership.

The Decision-Making Process

a. INQUIRY - The process of receiving, acquiring and evaluating information. The effective leader must be open and receptive to messages that reveal discrepancies. A good leader continuously challenges all information, and develops a healthy skepticism concerning the flight environment. This process ensures early detection, allowing correction, thus reducing the possibility of a mishap. It requires questioning of what other crew members are doing, since everyone makes errors.

b. ADVOCACY - Communicating facts, ideas, values, opinions, beliefs, and fears to other crew members. Simply stating a position is not enough. A willingness to change a position in light of new information is required.

C. CONFLICT RESOLUTION - Resolving disagreement between two or more conflicting inputs. Conflict almost always exists within the crew. If conflict does not surface, there is an indication of poor communication in the cockpit. Disagreements are healthy, but they must be voiced if they are to be resolved.

d. CRITIQUE - Reviewing past, present, and future actions or events. Critique can only be effective if it is open and honest. Without critique mistakes cannot be revealed and lessons learned from them. In other words, critique is the validation of a plan through subjecting it to the scrutiny of each crew member.

e. DECISION - Implementation of a plan. Communication of the plan to the crew, getting the commitment of the crew to the plan, briefing tasks and priorities to avoid task overload/underload and remaining open to changing the plan if new information warrants are key elements in the decision-making process.

Defective Decision-Making

There are two basic principles that emerge in the analysis of aircraft mishaps that are caused by defective decision-making.

a. one bad decision leads to another in a "snowball" effect.

b. A series of bad decisions reduces the alternatives for continued safe flight. A lack of situational awareness and failure to see a challenge reduces the chances of controlling the change. As time goes by, available alternatives decrease.

Hazard Detection and Evaluation

Once a hazard has been detected, an aircrew will often focus on that hazard and not consider its potential effect on all elements of the planned flight.

The Poor Judgment Chain

Most aircraft mishaps in naval aviation result from a combination of circumstances rather than from a single cause. Mishaps usually involve a chain of causes, and occur after a series of errors, called the poor judgment chain.

Decisions are based on information the aircrew member has about situational variables dealing with the aircraft, the environment, operations and other crew members. A poor judgment is less likely to be made if this information is accurate However, every poor judgment made increases the availability of false data which may then negatively influence judgments that follow. As the poor judgment chain grows, the crew's situational awareness becomes more impaired and the alternatives decrease. If a poor alternative is selected, the chance to select other options may be lost.

Breaking the Chain

There are five steps to breaking the poor judgment chain:

a. RECOGNITION OF POOR JUDGMENT:

FEEDBACK - The aircrew must recognize when a poor decision has been made and admit the error. If recognition does not occur, the ability of the aircrew to prevent further poor judgments is reduced. To recognize poor judgment, feedback is needed.

Asking another crew member for feedback may be difficult because he may be hesitant to admit an error in judgment. Yet relevant feedback is necessary in order to break the poor judgment chain quickly.

b. CHECKING FOR STRESS - A high level of stress can reduce the ability of an aircrew to exercise good judgment. An awareness of each aircrew member's stress levels and self awareness of each of their own stress is necessary to good decisions.

c. CHALLENGE-RESPONSE - Identify hazardous situations resulting from poor judgments and rectify.

d. LOOKING OUT FOR OTHER POOR DECISIONS - Poor decisions tend to occur in chains. If a poor decision affecting the safe operation of an aircraft is recognized, others may be present. vigilance must then be maintained against more bad judgments.

e. REVIEWING THE ORIGINAL BAD DECISION - After the poor judgment chain has been broken, a review of the original bad decision must be made as soon as possible after the flight. This review will provide feedback to avoid similar poor judgment chains in the future.

Aircraft mishaps are often the result of poor judgment chains. As poor judgment occurs, the probability that others will follow increases. Breaking the chain is essential to the maintenance of safe flight. The first step is the identification of the bad decision through feedback. Then check for stress, engage in challenge-response and search for other poor decisions. The original poor judgment must be reviewed in order to learn from it.

HAZARDOUS ATTITUDES

Two researchers at The Ohio State University, Drs. R.S. Jensen and R.A. Benel, stated that every decision a pilot makes is influenced by existing physiological, psychological and social pressures at the moment the decision is made. These influences are virtually impossible to measure. Jensen and Benel attempted to identify the thought patterns that accompany the self-image manifested by a pilot displaying poor or irrational judgment. It was necessary for them to identify specific thought patterns which would render a pilot willing to violate SOPs and regulations, extend the margins of safe performance, exceed legal limitations, or attempt to operate aircraft beyond his own or the aircraft's capabilities.

outlined below is a list of the. hazardous thought patterns and some. of the factors influencing poor judgment. If aircrew are taught to recognize these patterns in their own thinking they can apply corrective action.

Errors of Judgment

1. Interface Areas:

a. Human - Attention, perception, experience, maturity, attitudes, education, training, stress management, motivation, risk assessment, fitness to fly, fatigue.

b. Machine - Design of displays and controls, cockpit lighting, performance envelope, anthropometry, ease of maintenance access, serviceability, up status.

c. Environment - Weather (winds, temperature, humidity, visibility, precipitation), altitude, sea state glare, mission parameters, ops tempo

2. Action Ways

a. Do - The individual did something which should have been done (out-come good).

b. No Do - The individual did not do something which should have been done (did not complete checklist).

c. Over Do - The individual did too much, when less should have been done (over-filled fuel tanks).

d. Under Do - The individual did not do enough when more should have been done (plane captain didn't ensure adequate fuel in tanks).

e. Early Do - The individual acted too soon, when action should have been delayed (deployed speed brakes before slowing down).

f. Late Do - The individual delayed action, didn't move soon enough (wheel runs over flightdeck crew).

3. Mental Processes Modifiable Through Training

a. Automatic Reaction - Psychomotor skills.

b. Problem Solving - Cognitive processing.

c. Review and Feedback - Keeps the individual aware of all of the factors that are changing in the environment.

4. Psycho-Physiological Factors Adversely Affecting Judgment

a. Fatigue, stress, hunger, thirst, disease, cold, etc.

b. Boredom, complacency, overconfidence.

c. Lack of attention, low vigilance

d. Distraction.

e. Preoccupation.

f. Perceptual illusions.

g. Haste.

h. Fear, apprehension, panic.

THE ROLE OF THE SUPERVISOR

1. Supervisory Error

a. Mis-assignment of Personnel ordered to perform beyond their capability.

b. Inadequate training or brief.

c. ops tempo exceeds capability of personnel.

d. Personnel shortages.

e. Lack of surveillance.

f. Perceived lack of authority Supervisor fails to delegate authority to subordinate.

g. Lack of Accountability Supervisor fails to hold subordinates accountable.

h. Failure to allow for adequate crew rest.

Hazardous Thought Patterns and Their Antidotes

A PROGRESS REPORT

Navy and Marine Corps helicopter and fighter/attack aircraft training squadrons were the first to receive aircrew coordination training (ACT) because of their high aircrew error mishap rates. The project was funded by fiscal year (FY) which runs 1 October - 30 September. The course content and curriculum were developed during FY 1988. The program was introduced into the aviation training squadrons' syllabi during FY 189. By FY 190, aircrews instructed in the training squadrons began to take the principles they learned there into fleet operational squadrons.

Except for the multi-crewed fighter aircraft community, the training squadrons receiving the program have largely reported that they benefited from it and wish it to continue. Many COs of fleet replacement squadrons, although skeptical at the onset, now endorse the training for all aircraft squadrons. They report that it has contributed to better communications between FRS IPs and replacement pilots. Because of better preflight briefings and post flight debriefings, ACT has increased the overall efficiency of their syllabus flight time. What of the mishap experience? Any savings in aircrew error mishaps would be the proof of the program's worth.

On 15 December 1989, the crew of a Navy HH-46D experienced a single engine failure while hovering out of ground effect and landed in the water. The crew performed a single engine takeoff and returned to land on a staged single-spot ship. The squadron CO attributed the successful outcome to superior airmanship and the, 11 ... recent emphasis placed on aircrew coordination training." He went on to say, "This is an excellent demonstration of the cost effectiveness of aircrew coordination training." A similar incident occurred to the crew of a Marine HH-46D on 1 " December 1989. Their CO credit excellent aircrew coordination which resulted from their, 11 ... aggressive safety program that includes weekly guided discussion-type aircrew coordination classes for all SAR aircrew. 11 On 2 January 1990, a Navy CH-46D was saved when it experienced compressor stall on the number one engine during a hoisting evolution on a ship. The CO of the squadron stated, "I must emphasize the predeployment aircrew coordination training received at the squadron to be a valuable asset in preparing this crew to deal with an emergency." Another Marine CH-46 experienced a dual generator failure during night vision goggle operations on 3 March 1990. The CO commented, "The use of good judgment and aircrew coordination obviously prevented a serious mishap from occurring." The pilots had received ACT in their squadron. (Helicopter squadrons were the first to receive ACT in FY 1988.)

LT. Phil Logan, a Navy instructor trained under our Link contract, and his copilot were named Pros of the Week by COMNAV-AIRLANT in January, 1990 for saving an SH-2F that had suffered a total loss of DC power. Pro of the Week f or COMNAVAIRLANT for the first week in June was LT. Robert S. Spratt an A-6 IP who received aircrew coordination training in his replacement training squadron (the training was set up for this squadron one year before). His aircraft suffered a failure of the flight hydraulic system while executing a low altitude bombing run. He and his student B/N declared an emergency and returned to base. While setting up for an arrested landing on the off duty runway, the tower delayed switching the runway lighting on, due to landing a low fuel state aircraft on the duty runway. As a result they were required to execute a wave-off. While waving off, they experienced an additional failure of their combined hydraulic system. Utilizing the emergency back-up hydraulic system which provides only very limited rudder and horizontal stabilizer control, the aircrew was able to maintain control of their aircraft, level off and, using only rudder, turn the aircraft and return for a safe arrested landing on the duty runway. This amazing feat marked the first time in over 25 years of service, in any fleet, that an A-6 aircrew has successfully landed using only the back up hydraulic system. The Commander of Naval Air forces US Atlantic Fleet stated "LT. Spratt and LTJG Chase are applauded for their exceptional display of NATOPS knowledge, airmanship and aircrew coordination, turning what most certainly should have been a class "All mishap into a bravo zulu. Well done."

The aircrew error mishap rate has declined dramatically in the aircraft communities into which the program was first introduced (see figure 1).

Figure 1 Impact of ACT

Unfortunately, fighter training squadrons did not accept our two and a half day ACT seminar concept, electing instead to conduct a four hour stand-up lecture on the hazards of flying fighter aircraft. Their aircrew error rate had shown a steady decline through the 1980's, so no urgency was perceived. However, when the rate actually increased in FY 1989 they began aircrew coordination training in earnest. Their aircrew error-mishap rate has since decreased (see figure 2).

Figure 2

CURRENT STATUS

Currently the contractor is working with the Chief of Naval Air Training's staff to introduce the concepts of ACT to his six training wings. Instructors from each airwing have been trained as ACT instructors.

As a result of the success of the project, the US Air Force's Air Training Command and the US Army Apache helicopter training brigade at Fort Hood, Texas have now adopted our ACT program, purchasing from CAE-Link "off-the-shelf.

The contractors on all new aircraft procurements will be required to include ACT as part of their training and simulator development packages. The first weapons system procurement project to include ACT from the drawing board to final concept is the Marine Corps V22 "Osprey" aircraft.

The ACT program is now under the sponsorship of the Chief of Naval Operations, (CNO OP-59), although the Naval Safety Center continues to administer the contract. Plans are forming for continuing follow up training of replacement instructors.

The Marine Corps Combat Development Command at Quantico is currently contracting Link Training Services to train additional ACT instructors so that all operational marine aviation squadrons will have the ability to conduct ACT in-house. The Naval A4 Systems Command (NAVAIR PMA-205) has been tasked with "institutionalizing" ACT throughout the fleet. They, in turn, have directed (and funded) the Naval Training Systems Center in Orlando with assessing the impact of the Naval Safety Center-Link ACT program. As new information and techniques are developed they will be included in the training. ACT, as a viable and useful training program, must grow and change to meet the new challenges to aircrews that the next generation of aircraft will impose.

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