MANAGING SITUATION AWARENESS ON THE FLIGHT DECK
OR
THE NEXT BEST THING TO A CRYSTAL BALL

Sheryl L. Chappell*
NASA Aviation Safety Reporting System

* The author would like to thank the Situation Awareness Management Tiger Team of the Industry Human Factors/CRM Developers Group for their insights and hard work in the development of the model and their input on the content of this article. It was really a team effort and the contributions of every member are greatly appreciated.

If you had a crystal ball, you would be aware of everything that is happening and is going to happen to your aircraft and the airspace you fly through, because the consequences of a lapse in awareness can be deadly. Reports to NASA's Aviation Safety Reporting System (ASRS) show many ways that situation awareness can slip away. Some of the lessons learned by others provide a recipe for managing awareness. What we're going to try to do in the next few pages is figure out how to direct our attention so that it's always where it needs to be. Put another way, we'll be learning how to be aware. The goal is to build skills that result in more awareness; it's the next best thing to having a crystal ball.

From the very first flight lesson, we were taught to 'aviate, navigate, communicate' in that order. To aviate, navigate and communicate, you must be aware of the plane, the path, and the people (crew, passengers, dispatchers, and air traffic controllers). Not only do you need to monitor and evaluate these three things now, but you need to anticipate what's going to happen in the future and also consider contingencies. The current and future state of the plane, the path, and the people are the components of the plan.

The skills for being aware of what's happening now are different than the skills for anticipating what is going to happen later and considering what could happen. These appear in the matrix below and will each be discussed. To many pilots these skills are second nature. They are continuously aware of the plane, the path, and the people and can project into the future and maintain this awareness. However, like all skills, these can be refined and that's our goal here.

Now

Monitor. The first skill is monitoring. Unfortunately, we humans have limits to how much we can see and hear at the same time. If we had to put our monitoring goal into one rule, it would be: Be aware of what you need to and ignore everything else. That's real easy to say and probably impossible to do. Let's look at some techniques that can move us toward this goal.

Think of how you focus and direct your attention as you would focus and direct a flashlight. Imagine that everything you are aware of is in the beam of the flashlight. You can hold it steady in one direction and focus the beam (your attention) very narrowly so that you are able to see a small area extremely well. This allows you to ignore all else and concentrate on that small area. Knowing what you can ignore, if even for a moment, allows you to focus on that which you need to be aware of. Narrowly focused attention can be appropriate when you are solving a difficult problem, as long as someone else is attending to the other plane/path/people issues. The checklist is probably the most common tool for focusing attention. Each crew member knows what they are to look at, when, and very importantly, they know what the other crew members are looking at.

On the other hand, if you broaden the flashlight beam and move it around, you are aware of everything about the plane, the path, and the people. You have the big picture, but less detail in any one area. Well, naturally your job requires you to do both, to focus on a problem and to keep the big picture. This is difficult. There is no way to know when to step back from what you are attending to and move that flashlight around, or move it to a developing problem area for a closer look. Remember, everything has to be covered all the time, so if someone has their flashlight (their attention) focused narrowly in one direction, the other crew member(s) should broaden their beam and keep it moving.

You can point your attentional flashlight in the wrong direction and get sidetracked. There are also things that get in the way of where you're directing the flashlight. Things arise that block your view, both literally and figuratively. These are distractions and they come in many forms. Often in the incident reports received by NASA, a distraction is the first link in the chain of events that lead to an incident, sometimes embarrassing and sometimes dangerous. More about distractions later.

Monitoring on the three dimensions of the plane, the path, and the people is a balancing act that you, as a pilot, constantly have to perform.

• Focus on a broad region -- keep the big picture
• Focus on a narrow region -- pay attention to detail
• Focus on the right information -- don't get sidetracked or distracted

Evaluate. It should be pointed out that in addition to monitoring the plane/path/people, you need to evaluate the status of each. The evaluation entails first comprehending what you see and hear. Secondly, you make an assessment of the status of each, the plane/path/people. This leads to an understanding of what the situation is now, this gives you situation awareness for the current state.

Future

Anticipate. A key to maintaining situation awareness is to anticipate; stay ahead of the airplane. If you project what is going to happen later, you will go a long way toward that crystal-ball view. It's like having the answers before the test. Anticipating simply involves projecting the current situation into the future. Most of the time everything follows the laws of physics and the prediction is very accurate. Standard procedures allow you to anticipate what other crew members will do in a given situation. A crew that is skilled in managing their situation awareness has a shared vision of what's going to happen in the next few minutes and on into the future. Anticipation is particularly important for high workload situations. If you as a crew know what each person's responsibility is ahead of time, the awareness level can remain high on each person's part, even when a lot is going on.

Consider Contingencies. Sometimes things happen that cannot be anticipated. These can be aircraft malfunctions, ATC clearances, or simply a normal event at an unexpected time. These are the things that simulator checks are made of. Playing the 'what if' game has a tremendous advantage in the management of situation awareness. As a common example, when properly briefing an approach, the entire crew is made aware of the required flight path for the missed approach. Should a missed approach be executed, each crew member has a shared awareness of the sequence of actions, the airport environment, and the navigational information. They collectively know the 'what', 'where', 'when', and 'who' of the missed approach procedure.

There is no substitute for thinking things through ahead of time and dividing the tasks and the information so that both become manageable., Using the flashlight analogy again, this allows focus on the big picture and the necessary details, no matter what situation you are presented with.

Plan

The plan is comprised of the current and future states of the plane, the path, and the people. This plan is the foundation all crew members are building their situation awareness upon. The plan is constantly being updated based on the awareness activities. As a crew monitors, evaluates, anticipates, and considers contingencies they continuously modify the plan. Ensuring the entire crew has the same shared plan will ensure that they have a shared situation awareness.

Traps

Below are some traps that can take away situation awareness, if you allow yourself to fall into them. Knowing they are there will hopefully make them easy to avoid.

Keeping the priorities straight is a constant challenge, as this report describes.

"After we exited the runway, the first officer asked me a question about the ground control frequency, and I looked down at the airport diagram which was on the yoke in front of me. When I looked up, I saw the runway markings for the approach end of runway 7L in front of me. I then looked right and observed a wide-body aircraft approaching our intersection on his takeoff run on runway 25R. I slammed on the brakes and we came to a stop about 20 feet short of the runway. Two flight attendants were out of their seats, but fortunately no one was injured, although I did have a plane load of concerned passengers. My airline has been emphasizing 'situational awareness' lately, but although I was familiar with LAX and well aware of runway 24L, I monetarily lost track of where I was while I dealt with the question about ground control frequency. This brief lapse could have been fatal and it underlined the importance of knowing where you are at all times, and above all, control the aircraft first and worry about the incidentals once that is accomplished." ASRS Report 135526

Be sure to take your awareness vitamin before every flight. Even those who have had the situation awareness vaccination can have lapses.

As humans we are aware of many cues from our surroundings for which we cannot always identify the origin. These cues are very real. Don't ignore them, even when they only manifest themselves in a feeling of uneasiness. Excerpts from the cockpit voice recorder prior to the tragic accident in Cali, Columbia emphasize this point. The flight crew turned their aircraft into a mountain.

Studies of humans performing many different tasks show us that we will be less likely to detect something when we're busy attending to something else. We will also be less likely to detect something when we're not attending to much of anything. During times of low and high workload try to compensate for this human characteristic and be more vigilant. Work out crew procedures to keep each other in the loop during these times. Predetermine roles for high workload times, especially abnormal situations.

As highly trained flight crews you have developed very complex habit structures. These enable you to perform all the tasks required to skillfully fly your aircraft. There are times when these habits can get in the way of safety. If you are required to perform a task differently than you normally would, watch out, because the habit pattern may take over without your even realizing it. The best way to combat this natural tendency is to create a barrier, so that you prevent or at least are aware of what you are doing. For example, when receiving an aircraft with a failed generator, one airline directs its crews to put a coffee cup over the flap handle so that later, during the approach, the flap handle will look and feel different and alert them not to lower the flaps according to the normal landing checklist. This procedure was adapted after many instances of pilots failing into their normal habit patterns during the high workload approach phase and failing to use the non-normal checklist.

Above we discussed the importance of anticipation. The downside of anticipation is that it can bias your hearing or seeing what is really there. It is very common that the reports to the ASRS contain the phrase "we heard what we expected to hear." This trap often comes in the form of published 'expect' altitudes on arrival charts or familiarity with an airport, resulting in an altitude deviation. The following report is a typical example.

"I anticipated the next crossing restriction to be FL220 at MAYOS and programmed it into the legs page of the FMC As we descended through 25,800 feet, Washington Center issued the following: 'Your discretion to FL240, expect to cross MAYOS at FL220.' However, I anticipated and heard the following: 'Your discretion to 240, cross MAYOS at 220.' Very routine, however incorrect. Fatigue and anticipation had led me to hear what I wanted to hear. The captain working the radio read back the clearance as he had heard it, correctly. I once again heard what I wanted to hear. ... Moral of the story: same old thing!! Stay in the loop!! and keep the communication flowing!!" ASRS Report 141158

When you are expecting something, double check to make sure that it really was the way you expected it to be.

It is especially true in the cockpit with all the things going on, that if you're doing something over a period of time, it is less likely to get done correctly. Fuel cross-feeding is an example that most of us are familiar with. The problem is that you get interrupted with other tasks during the time that you're cross-feeding so that the time seems shorter, or you might even forget that you have the cross-feeds on. Take special precaution when a task takes a long time, is subject to interruption, or is something that you can't do right away and have to remember to do later. Fuel cross-feeding, checklists (especially before-start) and contacting the tower at the outer marker, are examples of things that have shown up in ASRS reports as not getting done right or not at all. We'll talk later about creating reminders that will help alleviate a lack of awareness for these tasks.

We know logically that all the systems we rely on to get an airplane from point A to B can fail. We practice this stuff in the simulator. However, research has shown that people actually stop cross-checking reliable systems. When the system fails it can go undetected. This is especially true in glass cockpits where systems are very reliable and failures are difficult to detect. The only cure for this is to force yourself to double check information against other sources. The following report illustrates this point.

"What I failed to notice was that by inserting the arrival in the FMS, the computer dumped the crossing restriction I had inserted just a few moments earlier. ... Through about 17,500 feet, Approach Control asked if we would make the BUMBY restriction (10,000 feet) and it was immediately obvious that we would not.. The cause, I believe, was a combination of cockpit management workload during the approach phase coupled with an overconfidence in the FMS to present valid descent profile information. I allowed myself to get too busy during the descent to make essential cross-checks to confirm the FMS was working as advertised. The correction: always double check the FMS data against other available navigational data to ensure that your programming is correct and that the aircraft is following accurate FMS guidance. Overconfidence in the FMS and increased workload in the cockpit during bad weather and approach preparation are no excuse for sound pilotage and the maintenance of situational awareness." ASRS Report 272508

Probably the hardest task we have being pilots and being human, is to detect something that isn't there. Much of what we need to be aware of is the absence of something. You'll probably notice that the engine fire bell/light isn't on, but harder to detect is that the other crew member didn't say, "after-takeoff checklist complete" or that the green arc didn't move to reflect the new crossing restriction you thought you entered correctly. Sometimes even serious aircraft malfunctions can be manifested in the absence of a subtle cue, at least at first. The only way to detect something that isn't there is to specifically look for it's absence. These checks have to be built into your flying techniques, your personal checklists.

The information in the glass cockpit is sometimes less obvious than in the traditional cockpit. A simple error in a numerical entry, if not caught at the time of input, can be nearly impossible to detect and correct. The following report of an altitude deviation illustrates this vulnerability.

"This situation resulted from three crew errors: 1) My first priority was data entry rather than situational awareness. 2) I entered the crossing fix incorrectly in the legs page, and 3) my first officer did not detect my data entry error before I executed the command Cross-checking data entry before execution is company policy and part of my cockpit briefing." ASRS Report 254092

Crew distractions are a serious impediment to safety. Probably the most documented case was the Eastern Air Lines L-1011 crash in the Florida Everglades that was the result of the crew's preoccupation with a landing- gear problem. This brings us back to the juggling act between focusing on a specific area and keeping the big picture. Distractions result when the attentional flashlight beam is too narrowly focused and not moving. Many things pop up in that beam of light that get in the way of seeing everything that is going on. A list of distractions compiled by Capt. Monan (1978) from 169 reports to the ASRS show some examples of distractions that led to a variety of safety incidents.

The ASRS incident reports describe many cases of pilots being faced with an aircraft malfunction that distract the situation awareness of the crew. Sometimes the malfunctions are big and obvious, sometimes they're small and illusive. Someone has to attend to the malfunction and figure out the appropriate course of action. What often happens is that everyone is engaged in solving the problem and no one is flying the airplane. No one has the big picture, the wide, sweeping beam of attention. Capts. Sumwalt and Watson (1995) took a further look at ASRS reports, examining 230 reports of inflight aircraft malfunctions. The attentional demands on the flight crew during the resolution of the aircraft malfunction caused adverse safety consequences in 38 reports. The safety consequences included altitude deviations, course/track/heading deviations, non-adherence to other ATC clearances, and non-compliance with FARs or company procedures. When a malfunction occurs, it should trigger a 'red flag' for a heightened sensitivity to a potential loss of situation awareness.

Sometimes distractions come from something that has already happened and is over. Many incidents have been the result of a crew dwelling on something that has previously happened and neglecting the current situation. You have to recognize that you're doing this and shake it off. Think and talk about it later, on the ground.

How to build a Crystal Ball

There are a few tricks that you can use to get and keep the awareness you need to fly safely. You can use 'plane, path, people' as a checklist. Take a moment to assess the current state of each. What are the plane, path and people doing now? What is likely to be the state of each later? Finally, consider all the 'what if possibilities for each. If you periodically run this checklist, you'll find that your awareness has increased. Most of the surprises will go away and the ones that pop up will be more manageable.

Manage Crew Awareness

Crew procedures are designed to focus attention and keep the big picture, by dividing the awareness responsibilities. When functioning as a crew, you not only have to concern yourself with what you're doing, but also with what other people are doing. You need to check that the other crew members do certain things that fall into their area of responsibility. You also need to check that they do not do certain things that are inappropriate or unsafe. Crew shared awareness is high when doing a checklist. Attention is focused on each item as one crew member reads and another checks. It's obvious what's being looked at and by whom. We've developed other techniques, e.g., for handing off the job of listening to ATC, saying "you've got the radio." Many of the other things we do in an airplane are less structured. It's these other situations that cause a crew to misunderstand who's aware (or not aware) of what.

A study by the National Transportation Safety Board (1994) showed that monitoring/challenging failures were identified in 31 of the 37 accidents reviewed. Crew members failed to monitor and challenge the errors or the lack of awareness of the other crew members. As a crew member, you have to watch each other for what actions are taken and what actions aren't taken.

"What do they know that I need to know?" As team members we need to utilize all our sources of information to be aware of everything we need to be. Many of those sources are other people's eyes and ears. The following ASRS report shows how information from the tower, the flight attendants and the relief pilot were critical in detecting a tail strike and making a prudent decision to discontinue the flight.

Shortly after takeoff tower reported they had seen sparks from the rear of the aircraft. ... From the cockpit the rotation had seemed normal to all three crew members and nothing abnormal was felt by the pilot flying. ... Aft flight attendants ... said they had heard scraping on takeoff. ... With all systems normal and no other adverse information, it was decided by the captain and company maintenance it would be OK to continue to our destination. After leveling off at 25,000 feet, the captain asked the relief pilot ... to inform the flight attendants what the noise had been on takeoff. On return to the cockpit, he informed the captain that the flight attendants in the aft had also heard a loud metallic bang or crashing sound on rotation. The captain then called this flight attendant to the cockpit for more information. After receiving this new information, the captain felt it would not be prudent to continue over water not knowing if there was damage to the aircraft fuselage. A request for return to JFK and fuel dump was received. ... Upon inspection, paint was missing the from tail skid. ... It was found that the cargo bins had come loose. ... I believe that on takeoff the cargo bins shifted aft causing a slight movement of the center of gravity to the rear causing tail skid contact. ASRS Report 243137

Use all the sources of information you have available to maximize your situation awareness.

"What do I know that they need to know?" Periodically ask yourself, "Do I know something my other crew members don't that they should know?" If the answer is yes, then tell them. If the answer is that they don't need to know, but they should know that you're keeping an eye on it, then tell them that you are. When something takes your attention away from what the other crew members are expecting you to keep an eye on, tell them that too. There will be times when, despite your crystal ball, you will have a reduced level of awareness due to fatigue, distraction or some other factor. Let the other crew members know when this is the case, so that they can back you up more carefully.

"What do none of us know that we need to know?" The other question to ask yourself is, "What are we as a crew not paying attention to?" If everyone is looking at the same thing, then something's getting missed. If you are unsure whether another crew member is maintaining awareness of something, be sure to clarify. The request "keep an eye on that for me" comes in handy.

Create Reminders

A powerful way to ensure awareness is to create reminders. There are many that are employed by flight crews, both formally and informally. Checklists are formal reminders. Some people have developed informal reminders, such as turning the checklist upside down on the yoke clip when it is interrupted, as a physical reminder that it has not been completed. Other reminders include selecting the radar test pattern when cross-feeding fuel and putting the nose landing light upon being cleared to land. These are obvious visual reminders that are in the scan of normal flying activities. Reminders can be aural as well. Some pilots have the technique of selecting the audio for the outer marker when they have been instructed to contact the tower at the outer marker way out on the approach. This gives them a reminder that they don't have to look at during a busy time in the flight.

As we discussed above, things that take longer, things that are subject to interruptions, or that can't be done until later are less likely to get done right. Creating reminders for these things is probably the best, if not the only, defense against forgetting them. Reminders work for other things as well. Reminders should be unique and consistently used for the same thing. That's why the string around the finger never worked.

Summary

So, in summary there are a few key things to do to manage your situation awareness:

• focus attention on details while keeping the big picture
• anticipate, stay ahead of the airplane
• consider contingencies, have a plan for the 'what if situations
• predetermine who will watch what in busy times
• have a plan for handling distractions, especially malfunctions
• use all your team members for awareness
• create reminders

OK, so the bottom line is: Be aware of where you attention is, and is not. Don't fall into the awareness traps. Just like money, situation awareness is very hard to get and very easy to let slip away. Periodically stop and ask yourself, "Is there something that we're not aware of that can bite us?" If you do manage your situation awareness, you'll have the next best thing to a crystal ball.

References

Monan, W. P. (1978). Distraction -- a human factor in air carrier hazard events. NASA Aviation Safety Reporting System: Ninth Quarterly Report, 2-23. Moffett Field, CA: National Aeronautics and Space Administration.

National Transportation Safety Board (1994). A review of flightcrew-involved, major accidents of U.S. air carriers, 1978 through 1990. Safety Study. (Report No. PB94-917001 NTSB/SS-94/01). Washington, DC: National Transportation Safety Board.

Sumwalt, R. L. & Watson, A. W. (1995). What ASRS incident data tell about flight crew performance during aircraft malfunctions. The Ohio State University Eighth International Symposium on Aviation Psychology, 758-764. Columbus, OH: The Ohio State University.

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