Examples

The following is an example of how crew actions can help build awareness.

On this flight from GTF to BZN, the PF TT 3000 hours, 600 hours time in type, had been recently upgraded to Captain. I am the company Chief Pilot acting as copilot (PNF). Cruising at FL190 we were cleared to 15000 feet and began our descent. While I was completing the descent checklist we were cleared for the approach to the BZN airport. The PF asked me if we were cleared for the approach. I advised we were and completed the checklist. I noticed then that we were passing through 11000 and questioned why we were so low AGL 30 DME from our destination. He replied we were cleared for the approach and he had a glideslope indication. We were VIS at this time. I told him not to descend any lower. He stopped the descent at 10800 feet in VIS conditions just as the controller called and asked us our altitude. I told the controller 10800 feet. He told us to return to 12000 feet, which we did.

I then asked the controller to repeat our clearance. It was, “Cleared for the approach to the BZN airport, cross the BZN VOR at 12000 feet.”? This time without distractions we both heard, understood the clearance and complied with it. What we both had missed previously was, “Cross the BZN at 12000 feet.”? The PF knew Runway 12 was the active runway at BZN and since we were heading 150 degrees, he thought we were cleared to intercept the Runway 12 ILS. The glideslope indication he was receiving was erroneous and he decided to begin his descent prior to having a LOC capture. We were in VIS conditions, which led to my becoming complacent and not mentally flying the airplane as I should have been. After landing we discussed all problems, misconceptions, mistakes and potential ramifications that occurred during this flight.

We are two professional pilots that attend recurrent training semi-annually. This consists of ground school and stage II simulator training.

It is obvious to me that we have to work even harder to improve cockpit management, eliminate complacency and assign priorities while in our flying environment.

This example shows that experienced pilots, even when flying with reliable crew members, need to stay active and alert to remain aware of the situation. As an aside, it is important to note positive examples of situation awareness-related actions that can be found in this example. Crewmembers discussed the situation and tried to analyse what went wrong, after landing. By discussing the situation, they were trying to ensure that they could avert a similar occurrence and by waiting until the flight was over to do their analysis, they were not distracted from the important flight elements.

The following is an example of how leadership actions have an effect on situational awareness.

Aircraft was enroute to Memphis flying off of the GRW 352 degree radial. We were given a crossing restriction of 6000 feet MSL at WALET Intersection, approximately 30 NM from the fix. At this time, the Captain initiated a 500 FPM descent. We were at 15000 feet. As we continued with the descent, appropriate checklists were run and completed. The descent continued and it became apparent that the current descent rate would not be sufficient to make the assigned restriction.

Although I was concerned, I made no mention of it to the Captain for reasons I will explain later. After being handed off to Memphis approach, we were asked if were aware of the assigned restriction and we answered in the affirmative. We were then given a 10 degree turn to the left and told to intercept the 225 degree radial from Memphis. As we continued, it was obvious to me that we would cross the intersection well above our altitude restriction. As I was about to make this known to the Captain, Approach asked if we would make our restriction. The Captain told me that we would so I relayed the message to Approach. At this point, the Captain increased our descent rate to 3100 FPM. We were at approximately 11000 feet and 10 miles from the fix. It was still clear that we would probably not make this restriction and with much irritation, Approach cleared us direct Memphis. We eventually crossed near WALET intersection at 7400 feet MSL. Nothing else was mentioned by ATC and flight ended normally.

What I consider to be the factor contributing to the problem was a very solo oriented and belligerent Captain. This Captain did not use or believe in CRM.

Time and again, I tried to make suggestions and was told he would take care of it or to let him do it.

In this example, the Captain lost the information that he could have received from his FO because he made it clear that he did not want to listen to him. He reduced his own awareness by essentially shutting out an important information source and as a result, the FO’s awareness had no effect on the flight problem.

The FO could have been more assertive – “Captain you must listen”.

The following is an example of the importance of verbalizing actions

On the ground at PDX the F.O. called for ATC clearance to SEA; clearance was as filed – maintain 9000 – expect flight level 200 3 min. after departure; departure frequency and transponder code was also given. I missed the first portion of the clearance and picked it up as FL200 (the center stored ALT) and got the frequency and transponder code. I set 20,000 in the altitude alert unit and set the transponder code as the F.O. read back the clearance. Again, I did not hear the 9000 restriction and asked if we were cleared as filed – the F.O. answered yes. I thought I understood the entire clearance.

The F.O. made the take-off and I changed to departure control and reported leaving 1000 ft. and climbing to FL200. The controller said “roger” and gave us additional climb instructions which included a heading change at 2500 ft. At about 8000 ft. the F.O. asked if we had been cleared to 20,000 and I replied, yes – at 10,000 ft. the controller asked what altitude we had been cleared to and again I replied 20,000. He said we should have been stopped at 9000 then cleared us to FL200 and asked us to expedite through 11,000 which we did. The F.O. later said we had been cleared to 9000 originally, but thought we had been recleared to FL200 and he had missed the re-clearance.

The crew composition helped create this situation as the F.O. regularly flew this trip, the captain was a management pilot who hadn’t flown the route recently and the S.O. was a reserve who was totally unfamiliar with the route. The F.O. on taxi-in at PDX, unknown to the captain, had set 9000 ft. in altitude alert system in anticipation of what he knew was a normal altitude restriction for departure, when the captain thought he was given FL200 with the clearance he set in that altitude replacing the 9000 ft. This was missed also by the F.O. as he read back the clearance and was not rechecked for a proper setting prior to take-off. The captain checked in with departure control after takeoff and stated he was climbing to FL200 and received no correction. When the F.O. asked if we had been cleared to 20,000 ft. and got a positive answer he assumed he had missed something and continued to climb through 9000 ft.

Where did communication break down and how could it have been “fixed”?

For example, if the FO had told the Captain that he was setting 9000 in preparation for their departure, the Captain would have been alerted to the restriction, also the Captain or Pilot Flying during their Take Off brief could have covered the clearance requirements.

The Support Process

The support process is a tool that enhances crew co-ordination and situational awareness. The support process has 4 distinct phases;

  • Guidance
  • Procedural
  • Solution statement
  • Emergency statement

Phase 1

Guidance phase is not mandatory and exists to give flight crew members a guide to the appropriate level of assertion used during less formal communication when a standard operating call may not be appropriate.

Statement examples at this phase are:

  • There is… It is…
  • Will you… Do you… Have you…
  • I am concerned that… I think that…

Phase 2

Procedural phase requires either a response or a positive action from the other flight crew member. This stage is triggered by the repetition of a standard operating procedure, an exceedance call or an urgent guidance request by a flight crew member without achieving an adequate resolution. The statement begins with the formal title of the flight crew member so as not to be confused with normal flight deck communication.

Phase 3

Solution statement conveys the need for the other flight crew member to do something or take particular action to prevent some circumstance. The statement contains two distinct parts separated by an “or”. First, the flight crew member uses the other crew member’s title to address them and continues with the proposed action. After the “or”?, the statement is completed by reiterating the feared consequences that must be avoided.

  • Captain increase rate of descent or we will be too high.
  • Captain we must return now or we will run out of fuel.

Phase 4

Emergency statement is rarely used. It is the last attempt to either raise that flight crew members situational awareness to that of the rest of the crew or for that flight crew member to explain their actions and intent to the rest of the flight crew. The emergency statement stresses that action must be taken now, and finally reiterates the action necessary to avoid incident, accident or a major breach of safety.

  • (Position/title)YOU MUST ACT NOW (action to be taken)!
  • “Captain, you must listen.”

Failure of the crew member to respond to the Emergency statement should be considered as some form of incapacitation and positive take over of control is mandatory.

  • CAPTAIN, I HAVE CONTROL