Cockpit automation is leading to airline industry complacency warns a new study from the Royal Aeronautical Society Flying Operations Group, which says many crashes would never have happened if pilots were just capable of basic piloting skills and standards were higher.
As the 12th anniversary of AF447 looms, the chorus of concern over the lack of progress on the degradation of flying standards has now been joined by the highly respected RAeS flying group, a body hardly noted for exaggeration, with a study that calls for skill-based training and an urgent raising of regulatory standards and oversight, and the application of uniform standards of compliance. They are not alone in this view.
In 2009, just before the loss of AF447, University of Southern California engineering professor and aviation safety expert Najmedin Meshkati suggested that the aviation industry and its regulators had become “star-struck by technological solutions”. He surmised that this was due to the fatality-free record at that time of aircraft such as the A330 and 777 in commercial service.
“We have become complacent by thinking that technology will solve all the problems,” he said just four days before AF447 plunged into the mid-Atlantic.
Meshkati warned at the time that he believed that all the wizardry of modern technology was masking a deterioration and de-skilling in basic flying ability and that the lessons learned by generations of pilots “may be lost to the new breed of pilots.”
Fast forward 12 years to 2021 and Captains John Leahy, Robert Scott, and Alex Fisher, assisted by other experienced members of the RAeS Flight Operations Group are issuing a similar blunt warning in a new paper. They emphasize that now is the moment for decisive industry action, given the COVID pause – a period of much-reduced aviation activity
Their study, Airline Pilot Training – It is time to revisit the basics, warns that “many recent airline accidents have shown clear evidence of a common cause, whether from fatal crashes or devastating hull losses without fatalities. That common cause is the inability of the pilots, in far too many cases, to cope with the situation they faced. Sometimes it was when the automatic systems failed, requiring them to fly manually. In others, they were trying to deal with what should have been a relatively benign situation and they simply did not cope.”
It adds that “pilot training is currently a combination of learning basic handling skills and the ability to manage complex automated systems but with an ever-increasing emphasis on the latter. So, although management of automation has improved, much less time is now spent on developing and maintaining the basic skills that are so necessary when automation fails or causes confusion.”
The problem is not new
Tragically, the problem is not new and reflects the findings of a 1995 comprehensive NASA Research Centre study based on Royal Air Force Institute of Aviation Medicine data by Dr. Marianne Rudisill who surveyed more than 1,000 pilots from 20 airlines and aircraft manufacturers about pilots’ attitudes and experience with flight deck automation.
The strength of that study was that most respondents had flown aircraft from basic cockpit types like 727s through to Glass 2 types such as A320s and 747-400s. It found the general consensus was that “safety is increased with automation, but automation may lend a false sense of security, particularly with inexperienced pilots.”
Very concerning was that pilots reported that there was a higher sense of “insecurity” during an automation failure and a general temptation to ignore raw information and “follow the green/magenta line.” The most worrying aspect was that pilots said their colleagues were “becoming complacent and relied too much on automation but that was often because airline SOPs mandated reliance on automation.”
And that aspect has not changed since, according to a 2019 International Air Transport Association pilot survey, which found that only 36 per cent of respondents said that their airline policy supported manual flying without restrictions.
In the same survey 92 per cent of respondents said they believed that training should put more emphasis on the unexpected transition from automatic flight to manual flying and vice versa.
In its 2019 Aircraft Handling and Manual Flying Skills report, IATA said that “continuous use of automation does not strengthen pilots’ knowledge and skills in manual flight operations and in fact could lead to degradation of the pilot’s ability to quickly recover the aircraft from an undesired state.”
It added that “poor manual techniques are flagged by a number of accident analyses that cite inappropriate or erroneous control inputs by the flight crew in response to abnormal events. Although the overall Loss of Control in Flight (LOC-I) accident rate has decreased, this accident category continues to outpace other factors as the leading cause of fatal accidents. A number of these accidents may have had a different outcome if the pilots had shown a higher level of monitoring and manual flying skills. Poor manual techniques may also lead to other events such as hard landings, unstable approaches, runway excursions, and others.”
A tragic example is the loss of the Atlas Air Boeing 767-300 at Trinity Bay Texas in February 2019 where the NTSB found that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover.
It added that contributing to the accident was the captain’s failure to adequately monitor the airplane’s flight path and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response.
The RAeS paper expresses concerns that pilot training has changed greatly, particularly in the last two decades. They said in a recent interview with AirlineRatings.com “pilots need to be trained to fly on instruments once again (IF Skills), in all conditions of weather, ‘g’ forces and distracting illusionary factors, and have complete confidence in their ability to do this. That skill deficit is the one most in need of urgent reform.”
The RAeS paper states that pilot training “is now shorter in duration, with less flight time on real aircraft, less exposure to the resultant stress of actual flight and much of it, computer-based. Full Flight (Level 4) simulator time is reduced in many cases to the minimum required to satisfy regulatory requirements.”
That concern is supported by the president and CEO of GHS Aviation Group, LLC, George Snyder, who is troubled by “the dichotomy between OEM’s suggested automation use and the need for operators to ensure that flight crews are equally proficient in both manual flying and use of automation”.
Mr. Snyder, former chief pilot at US Air and responsible for turning Korean Air’s flight standards around just over 20 years ago adds “I am now seeing it show up in the General Aviation sector, most notably in flight schools. I brought out my E6B (circular computer) in front of some primary students recently and it was like they were looking at a fossil. I understand the need for enhanced use of automation and technology, but a balance remains a critical flight safety issue,” Mr. Snyder said.
Of particular concern says the RAeS paper is the high percentage of the accidents that fall into the LOC-I category. “Often this has nothing to do with extraordinary and demanding circumstances but instead the pilots’ failure to cope with the most fundamental activity, that of being capable of using the aircraft flight controls to manage the flight path of the aircraft when the automation fails them. Although the actual loss of control was sometimes triggered by external factors such as adverse weather, it was often compounded by human factors such as poor decision making, technology mode confusion, and inadequate communications between the pilots. In most cases, LOC-I resulted in a non-survivable accident.”
“The fact is LOC-I has been the number one cause of fatalities in aircraft accidents for many years, yet the training required to address this most fundamental pilot activity is obviously not being carried out to the extent that it should. A strong safety culture with an emphasis on pilot performance excellence must be supported at the highest level in any airline, whatever the perceived financial costs.”
One reason says Captain Fisher of the RAeS group is “maybe that accident reports rarely get to the fundamental problem of the pilot’s inability to fly on instruments. Instead, they ascribe the loss of control to ‘sensory illusions’ and “g forces”. But overcoming such illusions is the number one task of any instrument-rated pilot; blaming LOC-I on sensory illusion is like blaming the crash on gravity.”
The RAeS paper asks the question. “How is the [safety] risk evaluated and thus the amount of training which is considered appropriate?’ It would appear that, in some airlines, senior management equates the industry’s low accident rate to low risk and thus any training that extends beyond satisfying regulatory requirements and the recommendations of the airplane manufacturer is an unnecessary expense. This completely overlooks the fact that this decision may then restrict the knowledge and skills of the pilots concerned to a narrow range and make it extremely difficult for them to cope with unforeseen events.”
And the ability to handle unforeseen events was front and center for the crew of Qantas flight QF32 led by Capt. Richard de Crespigny, which suffered a catastrophic failure of its number 2 engine shortly after take-off from Singapore in 2010.
The crew had to nurse their crippled A380 for two hours while dealing with multiple system failures and sometimes confusing information before landing back safely at Singapore.
The Australian Transport Safety Bureau which conducted the accident investigation noted that the well-trained crew had saved the A380.
Discussing that event and wider training issues with the author in a 2011 interview, Captain Dave Evans, who was checking another check captain on that flight noted that some young prospective pilots lacked basic skills because they “learned to fly” using Flight Simulator and had not used rudder pedals and thus their flying skills once they got into the real world were degraded.
Flight Simulator with a single screen also narrowed their perspectives and they lacked “peripheral skills,” Capt. Evans noted.
Those disturbing observations resonated with Captain Robert Sumwalt III, former Chairman, Human Factors and Training Group Air Line Pilots Association International, and now Chairman of the NTSB who co-authored a 2002 paper Enhancing Flight-crew Monitoring Skills Can Increase Flight Safety which found that “effective crew monitoring and cross-checking can literally be the last line of defense.”
At the time Sumwalt cited NTSB’s examination of 37 accidents which found that 84 per cent involved inadequate crew monitoring or challenging of the fellow cockpit crew.
“The NTSB has found that lack of monitoring of instruments is still a major factor in accidents,” Sumwalt said.
An example of this was the loss of Pakistan International Airlines A320 at Karachi in May 2020 and 97 souls where the preliminary report found multiple failures by the crew.
A Wide Disparity in Standards
Another area of concern in the RAeS paper is that on the one hand, many airlines, for example, Qantas, Cathay Pacific Airways and British Airways (as just three examples) have an excellent safety record acquired over many decades while on the other, far too many do not.
“It is the view of the group that this is not just a matter of luck. It is abundantly clear from our many years of working in the industry that some airlines set a high standard that far exceeds the minimum required by the regulations. This may include such measures as only recruiting superior candidates from the best training colleges, and training them to the highest standards, not only at the entry stage but on an ongoing basis during their time with the airline.
That claim is backed up by a former Airbus check and training captain who told Airlineratings.com that top-line airlines such as Cathay Pacific and Singapore Airlines “would often double the required training hours for their pilots, whereas other airlines, would not even pay for basic ‘Airbus’ training because it was too expensive.”
The situation is complicated says the RAeS paper by the fact that “there are different training methods in use globally and there isn’t universal agreement on which ones are better than the others. In some cases, culture influences the decisions on which ones to use, and in others, the decision can be financial or even based on the recommendations of regulators or OEM’s. A wide variety of modern advanced training tools and techniques (such as AQP, CBTA, MPL and EBT) are popular in the industry but have gained different traction in different operating environments.
The authors of the RAeS paper are concerned about the “wide disparity in safety standards of airlines, and of their pilots, together with a similar disparity in regulators and regulatory oversight. Alignment of training methodology on a global scale would lead to better exchanges of ideas and understanding of each other’s operational challenges and an overall increase in operating standards.”
It warns that “as the accident rate is relatively low compared to the past it could be assumed that all is well in the industry. However, it is not the number of accidents that is the concern, it is the cause and the severity of them. The lack of essential skills and handling ability that have led to many recent accidents is evidence of a low proficiency of some of the pilots currently flying public transport aircraft.
“A major factor is poor training. Many pilots are rushed through inadequate ab initio training courses with the emphasis on getting them through quickly and as inexpensively as possible. Thus, they are poorly prepared for the challenges of converting on to larger, more complex aircraft in an airline setting, carried out in accordance with a significantly reduced training model.
“This environment does not encourage the development and maintenance of the skills and knowledge that are essential to safely and competently operating today’s complex aircraft, something that is borne out by the accident reports.”
This issue is highlighted in IATA’s 2020 safety report with Captain Rubén Morales, Chair, of IATA Accident Classification Technical Group warning that “when we look at the contributing factors present in 2020 accidents, manual handling is at top of the contributing factors associated with flight crew errors. Other areas of concern are deficient safety management systems, regulatory oversight, and selection systems, all of them latent conditions present in the system before the accident happened. These latent conditions have been present consistently year after year, highlighting the need for improvement in these areas.”
The IATA safety report also states that “for effective Safety Leadership in aviation, airline executives should set a leadership mindset that enables safety-focused behaviors to embed a positive organizational safety culture. Applied globally, this should be supported by clearly defined safety accountabilities to enable an effective safety culture to exist within each, and every, aviation service provider around the world.”
The role of the regulators is coming under much greater scrutiny with the global compliance of the ICAO country audits ranging from only 56.32 per cent for Aircraft Investigation to 81.23 per cent for Airworthiness with an overall average just 69.8 per cent. The eight audit areas are Legislation, Organization, Licensing, Operations, Airworthiness, Accident Investigation Air Navigation Services, and Aerodromes.
A disturbing 23 countries were below average for all eight audit criteria, while a further 22 only achieved one or two above-average passes.
These poor results are played out – and underscored the RAeS paper’s concerns – in the IATA 2020 safety report which found that Regulatory Oversight was a major latent factor in aircraft accidents at 45 per cent contribution just behind Safety Management at 47 per cent.
With Flight Crew errors for 2020, manual handling/flight controls topped with a 39 per cent contribution with SOP Adherence/ SOP Cross Verification at 29 per cent.
Disturbingly the five years figures are much the same.
Far worse, however, is the role these latent issues played in Fatal Accidents over the last five years with Safety Management at 71 per cent and Regulatory Oversight at 65 per cent.
Again, Flight Crew errors and SOP Adherence / SOP Cross Verification and Manual Handling / Flight Controls were top contributors in Fatal Accidents in the past five years at 56 per cent and 50 per cent.
These regulatory issues also play out in the EU and FAA banned lists, with 98 airlines from 24 countries banned from European skies and all airlines from 24 countries banned from the USA under the FAA’s International Aviation Safety Assessment program.
Prof. Meshkati considers the aviation industry’s exuberant blind embracement of more automation is promoted for the sake of more efficiency and cost-saving, without considering its serious unwanted consequences and contingencies for ‘what if it fails’ and ‘what to do next’, as a “rendition of Faustian bargain”.
He has an additional and equally serious concern that when an utterly unexpected, unfamiliar, non-routine event occurs, which was unforeseen by the automation system designers, then the flight crew, having exhausted all options by trying all emergency operating procedures, has to resort to problem-solving (instead of simple decision-making) and improvisation.
In this phase, in order to save the day, the crew has to have a shared mental model of the situation, be equipped with a good technical knowledge of interacting subsystems and their safety margins, and finally has to be able to operate at the “knowledge-based level”, according to the late Professor Jens Rasmussen’s taxonomy of levels of cognitive controls.
Prof. Meshkati cites the 2009 emergency water landing and safe evacuation of US Airways Flight 1549, as a great example of a successful improvisation in the face of no more emergency operating procedures. “This shows particularly in the non-verbal communication between Captain Sullenberger and First Officer Jeff Skiles, who although they ‘did not have time to exchange words’, they knew that they were on the same page through ‘observation’ and ‘hearing’. At the NTSB hearings, Captain Sullenberger mentioned the critical role of a dedicated, well-experienced, highly trained crew that can overcome substantial odds, working together as a team,” Prof. Meshkati said.
In his article Resilience – Recovering pilots lost flying skills about the industry in general, Capt. de Crespigny said that many pilots have lost confidence in flying manually because automation has taken much of their hand flying skills away.
Capt. de Crespigny says that pilots of older aircraft such as the 707 and 747 had excellent flying skills. “They usually flew their approaches and landings without using autopilots and auto thrust because these systems were often too inaccurate or unreliable. These pilots built a mental body model that included their aircraft – they wore and manipulated their aircraft like it was a fitted glove,” Capt. de Crespigny said.
He warns that “modern cockpit designs insidiously induce pilots to focus on just the green and magenta targets (airspeed, attitude, altitude, and track) at the expense of awareness of the underlying raw data.”
He stresses that it takes more effort to operate modern jet aircraft than the older jets. Capt. de Crespigny asserts that the benefits of automation come at the expense of learning these complex mechatronic systems. “Pilots must have a deep understanding of the core systems on their aircraft. Because when these automated systems fail, and they will fail, the pilot must be able to land the aircraft with the remaining systems.”
Pilots of today’s computerized aircraft must understand complicated software logic rules and procedures. If you don’t it could be a disaster. You never want to fly an aircraft that takes control away from you. So, you must know when to trust automation and to respect its limitations, when to be skeptical and when to reject it and take manual control.”
Captain Robert Scott of the RAeS Flight Operations Group sums up the situation like this:
“Over the last two decades, we have seen what can only be described as a ‘Dumbing Down of the Airline Pilot’. The intellectual and physical skills once required of the pilot have largely been replaced by an emphasis on ‘soft skills and automation management. The pilot who once cynically challenged sources of information now readily accept information from a variety of sources, many computer-generated, without question. We know from bitter experience that when this information is flawed it is often not recognized as being useless to safe flight path management.
“It seems hardly surprising, therefore, that many pilots lack the technical knowledge of their forbears and may thus feel they are on the periphery of the operation, rather than in charge of it. Regrettably, events often indicate that improvements to human skills have not matched improvements in technology, and until they do, the human operator will continue to make mistakes due to a misunderstanding of the technology, or, more commonly, complacency due to over-reliance on the automated systems.
“An editorial comment in a major aviation publication laid the blame on regulators for the current problems. However, this is an inaccurate and unfair comment. Many CEOs, Directors of Operations, and Flying Training Managers have been seduced by the idea that modern aircraft are so reliable that traditional skills and knowledge can be reduced to the absolute minimum and replaced by mere management of the automatic systems. Consequently, pilots often receive the minimum amount of training, which is borne out by some recent accidents. Regrettably, while the names and reputations of the pilots involved in some aircraft accidents will always be associated with incompetence, the people who bear much of the responsibility for their lack of skills, the CEOs, Directors of Operations and Flying Training Managers will enjoy comfortable anonymity.” The RAeS paper states that the days are now over where the senior management team can avoid scrutiny.
Is there a solution?
The authors of the RAeS paper believe there is, and moreover, now there is a once-off opportunity to do it. Capt. Leahy says “This unique period of relative inactivity provides what is probably the last chance to make a major correction in the trajectory of this juggernaut of an industry; the objective must be to get pilots back to a level of skill that permits them to understand and oversee the automatics, yet still be able to take over when they fail. This chance should not be wasted.”
So now that we know the problem, is there a realistic solution?
The RAeS authors say the list is long, but they suggest six immediate actions;
- Some Industry Regulators need to review and if applicable, raise their own standards, and comply with mandated standards from ICAO. The current bar is set too low in places, and enforcement is too patchy.
- CEOs and Boards of airlines also need to review their own standards and never hide behind poor regulation. They now have a massive incentive: – If they fall short, they may well be held accountable for the next accident(s) as was Boeing and their CEO after the two Max disasters. Boeing was found as culpable as the FAA. That is something completely new that should promote a whole new way of thinking at the very top.
- The Chief Pilots and Training Managers must speak up and be heard by the CEO. They usually know where the problems lie but are often unable to convince the financial people of the need to improve. It’s hard to prove a payback to a hard-pressed CFO since there seems to be no definitive evidence. This paper, and many like it in the past, show that there is a great deal of evidence and it is being ignored.
- Some training colleges need to train to a raised standard, not to simply get their cadets to pass a list of “check box” items to achieve a CPL aimed at squeezing lucrative fee-paying cadets into airlines that will accept them.
- The pilot training establishment needs to wake up to the lack of basic instrument flight capability and take immediate steps to correct it.
- And of course, airlines need to understand that just passing an ATO college final exam doesn’t prove that a candidate is totally up to the standard they demand. That has to be established by a rigorous personality interview and ‘capability testing’ prior to starting the Type Rating course.
If those six were to be addressed, it would make a massive difference to the quality of future generations of flight crew say the RAeS authors.
The last words go to Capt. de Crespigny in his book QF32 when he warns; “There is one potential problem with automation: that it will be accompanied by complacency and ignorance.”