Human Performance

Human Performance
Flight Operations Briefing Notes Human Factors Aspects in Incidents / Accidents
Flight Operations Briefing Notes

Human Performance
Human Factors Aspects in Incidents / Accidents
I Introduction
This Flight Operations Briefing Note provides a summary of human factors issues
identified in incidents and accidents.
This summary may be used either to assess :
• The company exposure and develop corresponding prevention strategies; or,
• The reader’s individual exposure and develop corresponding personal
lines-of-defense.
Ultimately, human factors are involved in all incidents and accidents.

Whether crew-related, ATC-related, maintenance-related, organization-related or
design-related, each link of the safety chain involves human beings and, therefore,
human decisions and potential human errors.
Acknowledging that a chain is as strong as its weakest link, human factors need to be
addressed in all domains (i.e., design, manufacturing, operations, maintenance,
air traffic control, …).
II Background Information - Statistical Data

A study performed by NASA reveals that more than 60 % of incidents ( source : NASA
ASRS – 1993 ) have their origin in the pre-flight phase of operations.
These incidents were found to be the result of a perceived time-related pressure
resulting in rushed actions and errors ( this condition is usually referred to as the hurry-
up syndrome ).
Overall, high workload is a factor in 80 % of incidents and accidents resulting from crew
error ( source : NASA ASRS – 1993 ).
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Human Performance
III Human Factors Issues in Operational Events
III.1 Operational and Human Factors Markers :

The operational and human factors analysis of operational events ( as performed by
Airbus ) is based on a set of markers that are used to qualify the contribution of each
operational and human factor to a given event.
These markers are grouped into four clusters and nineteen domains, as follows :
• Situation recognition and crew diagnosis :

− Cockpit alerts, other cockpit / cabin effects, crew diagnosis, human-machine-
interface aspects.
• Procedure(s) :
− Type of procedure, access to procedure, procedure contents.
• Human performance :
− Procedure execution by flight crew, other crew actions, threat management,
crew-error management, aircraft attitude / flight path control, crew coordination.
• Operating environment and circumstances :

− Operational environment, weather conditions, runway conditions, aircraft
systems condition / configuration, crew factors, organizational factors.
The observation of individual factors or patterns of factors involved in operational

events is used to identify lessons-learned in terms of design procedures and training.
These lessons-learned, along with the lessons-learned stemming from industry studies
and incidents or accidents investigation reports, have been used to illustrate the various
Flight Operations Briefing Notes.
The following paragraphs provide an excerpt from the Flight Operations Briefing Notes
that contain reference to human factors issues.
III.2 Standard Operating Procedures (SOPs) :

To ensure effective compliance with published SOPs (and associated normal checklists
and standards calls), it is important to understand why pilots intentionally or
inadvertently deviate from rules or standards.
Pilots rarely deviate intentionally from SOPs (i.e., violation of SOPs), in most cases
the procedure that was followed in place of the published procedure (i.e., deviation
from SOPs) seemed to be more appropriate for the prevailing circumstances,
considering the information available at the time.
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The following factors and conditions often are cited in discussing deviations from SOPs:
• Task saturation (i.e., task overload);
• Inadequate knowledge of and/or failure to understand the rule, procedure or action;
this includes:
− training;
− quality of wording or phrasing; and/or,
− perception of rule or procedure or action as inappropriate;
• Insufficient emphasis on strict adherence to SOPs during transition training and

recurrent training;
• Lack of vigilance (e.g., fatigue);
• Distractions (e.g., due to cockpit activities);
• Interruptions (e.g., due to pilot/controller communications);
• Incorrect management of priorities (i.e., absence of decision-making model for
time-critical situations);
• Reduced attention (tunnel vision) in abnormal or high-workload conditions;
• Incorrect CRM techniques (i.e., for effective cross-check, crew coordination or
backup);
• Company policies (e.g., regarding schedules, costs, go-around and diversion
events);
• Other policies (e.g., crew duty time);
• Personal desires or constraints (i.e., personal schedule, focus on mission
completion);
• Complacency;
• Overconfidence; and/or,
• High time on aircraft type (i.e., condition possibly conducive to complacency and
overconfidence).
III.3 Use of automation :

Errors in using and managing automatic flight systems and/or lack of awareness of
operating modes are observed as causal factors in more than 20 % of approach-and-
landing accidents and near-accidents.
These factors can result in flying an unintended flight path, which - if not recognized -
can cause a less-than-desired terrain separation or a CFIT.
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The following common errors in handling auto-flight systems can increase the risk of
accident during any flight phase, but particularly during approach-and-landing:
• Inadvertent selection of an incorrect mode;
• Failure to verify the selected mode by reference to the flight mode annunciator
(FMA);
• Failure to arm a mode when required (e.g., failure to arm the localizer or approach
mode, when cleared for LOC or ILS interception);
• Failure to select a required guidance target (e.g., failure to set the ILS final
approach course);
• Inadvertent change of a guidance target (i.e., changing the speed target instead of
changing the selected heading);
• Selection of an incorrect altitude and failure to confirm the selection on the primary
flight display (PFD);
• Selection of the altitude target to any altitude below the final approach intercept
altitude during approach;
• Preoccupation with FMS programming during a critical flight phase, with consequent
loss of situational awareness; and/or,
• Failure to monitor the automation, using raw data.
The Flight Operations Briefing Note Operations Golden Rules addresses aspects that are
considered frequent causal factors in incidents and accidents, such as:
• Lack of situational / positional awareness;
• Interaction with automation;
• Overreliance on automation; and/or,
• Lack of crew crosscheck.
III.4 Briefings :
The importance of briefings and briefing techniques often is underestimated, although
effective briefings contribute to enhance crew standardization and communication.
The routine and formal repetition of the same points on each sector may become
counterproductive; adapting and expanding the briefing by highlighting the special
aspects of the approach or the actual weather conditions and circumstances of the day
result in more lively and effective briefings.
In a nutshell, briefings should attract the attention of the PNF.
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Briefings should help both the PF (giving the briefing) and the PNF (receiving and
acknowledging the briefing) to understand the sequence of events and actions,
the safety key points, specific threats / hazards and circumstances of the takeoff,
departure, cruise segment, approach and landing.
An interactive briefing fulfills two important goals of the briefing: provide the PF and the
PNF with an opportunity to:
• Share a common action plan; and,
• Set priorities and task sharing.
III.5 Pilot / Controller Communications :

Effective communication is achieved when our mental process for interpreting
the information contained in a message accommodates the message being received.
This mental process can be summarized as follows:

• How do we perceive the message ?
• How do we reconstruct the information contained in the message ?
• How do we link the information to an objective or an expectation ? and,
• What bias or error is introduced in this process?
Crew Resource Management (CRM) researches highlight the importance of the context
and expectations in this mental process.
The following factors may affect the correct understanding of communications:

• High workload;
• Fatigue;
• Non-adherence to “sterile cockpit” rule;
• Distractions;
• Interruptions; and/or,
• Conflicts and pressures.
This may result in :

• Incomplete communications;
• Omission of call sign or use of an incorrect call sign;
• Use of nonstandard phraseology; and/or,
• Failure to listen or respond.
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III.6 PF / PNF Communications :

Interruptions and distractions in the cockpit break the flow pattern of ongoing cockpit
activities (i.e., actions or communications), such as:
• SOPs;
• Normal checklists;
• Communications (i.e., listening, processing, responding );
• Monitoring tasks; and/or,
• Problem solving activities.
The diverted attention resulting from the interruption or distraction usually leaves
the flight crew with the feeling of being rushed and being faced with competing or
preempting tasks.
Unless mitigated by adequate techniques in order to set priorities, this disruption and
lapse of attention may result in:
• Not monitoring the flight path (possibly resulting in an altitude or course deviation
or a controlled flight into terrain);
• Missing or misinterpreting an ATC instruction (i.e., possibly resulting in a traffic
conflict or runway incursion);
• Omitting an action and failing to detect and correct the resulting abnormal condition
or configuration, if interrupted during a normal checklist (e.g., altimeter setting);
and/or,
• Leaving uncertainties unresolved (e.g., regarding an ATC instruction or an abnormal
condition).
III.7 Altimeter Setting and Altitude Deviation Issues :

The incorrect setting of the altimeter reference often is the result of one or more of
the following factors:
• High workload;
• Inadequate pilot/system interface;
• Incorrect pilot/controller communication;
• Deviation from normal task sharing;
• Interruptions and distractions; and/or,
• Absence of effective backup between crewmembers.
Strict adherence to the defined task sharing (for normal or abnormal/emergency

conditions) and correct use of normal checklists are the most effective lines-of-defense
against altimeter setting errors.
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III.8 Rushed and Unstabilized Approaches :

The following circumstances, factors and errors often are cited when discussing rushed
and unstabilized approaches:
• Fatigue, regardless of short/medium-haul or long-haul operation;
This highlights the need for developing countermeasures to restore the level of
vigilance and alertness for the descent, approach and landing;
• Pressure of flight schedule (e.g., making up for takeoff delay);

• Any crew-induced or controller-induced circumstance resulting in insufficient time to
plan, prepare and execute a safe approach;
This includes accepting requests from ATC for:
− flying higher and/or faster than desired; and/or,
− flying shorter routings than desired;
• Insufficient ATC awareness of crew or aircraft capability to accommodate

a last-minute-change;
• Late takeover from automation (e.g., in case of AP failing to capture the GS, usually
due to crew failing to arm the approach mode);
• Lack of awareness of tail wind component;
• Incorrect anticipation of aircraft deceleration characteristics in level-flight or on
a 3-degree glideslope;
• Failure to recognize excessive parameter-deviations or to remember the excessive-
parameter-deviation criteria;
• Belief that the aircraft will be stabilized at the stabilization height or shortly
thereafter;
• PNF excessive confidence in the PF in achieving a timely stabilization;
• PF/PNF excessive reliance on each other in calling excessive deviations or in calling
go-around; and/or,
• Visual illusions during the acquisition of visual references or during the visual
segment.
III.9 Runway Excursions and Overruns :

The following factors are recurrent in runway excursions and overruns (i.e., highlighting
human factors involving controllers, flightcrew and maintenance personnel alike):
• No go-around decision, when warranted;
• Inaccurate weather information on:
− surface wind and/or windshear; and/or,
− runway condition.
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• Incorrect assessment of crosswind limit for prevailing runway conditions;

• Incorrect assessment of landing distance:
− for prevailing wind and runway conditions; or,
− following a malfunction affecting the configuration or braking capability;
• Captain (when PNF) taking over control and landing following the call or initiation of
a go-around by the First Officer (as PF);
• Late takeover from automation, when required (e.g., late take over from autobrake
in case of system malfunction);
• Inoperative equipment not accounted for per MEL (e.g., one or more brake being
inoperative); and/or,
• Undetected thrust asymmetry (i.e., forward / reverse asymmetric thrust condition).
III.10 Adverse Wind / Crosswind Landing :

The following human factors often are cited in discussing events involving adverse wind
and / or crosswind conditions:
• Reluctance to recognize changes in landing data over time (e.g., wind direction
shift, wind velocity change or wind gustiness increase);
• Seeking any evidence to confirm the initial information and initial options
(i.e., reluctance to change pre-established plans);
• Reluctance to divert to an airport with less crosswind conditions; and/or,
• Lack of time to observe, evaluate and control the aircraft attitude and flight path
in a highly dynamic situation.
IV Summary of Key Points

Addressing Human Factors issues in incidents and incidents and accidents is an effort
that must include :
• Defined company safety culture and policies;
• Related prevention strategies;
• Robust standard operating procedures;
• Effective CRM practices; and,
• Personal lines-of-defense.
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V Associated Briefing Notes

The following Briefing Notes can be referred to as a complement to the above
information, to amplify or expend a specific aspect, as desired:
• Operating Philosophy - SOPs
• Operations Golden Rules
• Standard Calls
• Normal Checklists
• Conducting Effective Briefings
• CRM Issues in Incidents / Accidents
• Effective Pilot / Controller Communications
• Managing Interruptions and Distractions
• Altimeter Setting - Use of Radio Altimeter
• Altitude Deviations
• Flying Stabilized Approaches
• Preventing Runway Excursions and Overruns
VI Regulatory References
• ICAO – Annex 6 – Operation of Aircraft, Part I – International Commercial Air

Transport – Aeroplanes, Appendix 2, 15.
• ICAO – Procedures for Air navigation Services – Aircraft operations (PANS-OPS, Doc
8168), Volume I – Flight Procedures (Post Amendment No 11, applicable
Nov.1/2001).
• ICAO – Accident Prevention Manual (Doc 9422).
• ICAO – Human Factors Training Manual (Doc 9683).
• ICAO – Human Factors Digest No 8 – Human Factors in Air Traffic Control (Circular
241).
• FAR 121.406, 121.419, 121.421 or 121.422 - CRM Training for pilots, flight
attendants and aircraft dispatchers.
• JAR-OPS 1.945, 1.955 or 1.965 - CRM Training.
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This Flight Operations Briefing Note (FOBN) has been adapted from a corresponding Briefing Note developed by Airbus
in the frame of the Approach-and-Landing Accident Reduction (ALAR) international task force led by the Flight Safety
Foundation.
This FOBN is part of a set of Flight Operations Briefing Notes that provide an overview of the applicable standards,
flying techniques and best practices, operational and human factors, suggested company prevention strategies and personal
lines-of-defense related to major threats and hazards to flight operations safety.
This FOBN is intended to enhance the reader's flight safety awareness but it shall not supersede the applicable regulations
and the Airbus or airline's operational documentation; should any deviation appear between this FOBN and the Airbus or
airline’s AFM / (M)MEL / FCOM / QRH / FCTM, the latter shall prevail at all times.
In the interest of aviation safety, this FOBN may be reproduced in whole or in part - in all media - or translated; any use of
this FOBN shall not modify its contents or alter an excerpt from its original context. Any commercial use is strictly excluded.
All uses shall credit Airbus and the Flight Safety Foundation.
Airbus shall have no liability or responsibility for the use of this FOBN, the correctness of the duplication, adaptation or
translation and for the updating and revision of any duplicated version.
Airbus Customer Services

Flight Operations Support and Line Assistance
1 Rond Point Maurice Bellonte - 31707 BLAGNAC CEDEX FRANCE
FOBN Reference : FLT_OPS – HUM_PER - SEQ01 - REV02 – MAY 2004
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Human Performance
Flight Operations Briefing Notes CRM Aspects in Incidents / Accidents

Human Performance
CRM Aspects in Incidents / Accidents
I Introduction
Overall, incidents and accidents involve the entire range of CRM and Human Factors
aspects.
In incident and accident reports, the flight crew’s contribution often is considered to be
just what the flight crew did or did not do.
The following discussion is a focused but limited overview of the broad CRM subject.
CRM concepts and techniques enhance effective cross monitoring and backup by each
crewmember.
The minimum content of CRM training is defined by regulations and airlines should
consider additional CRM training to account for specific requirements, such as
multi-cultural flight crews and different areas of operation.
II Statistical data
CRM issues have been identified as circumstantial factors in more than 70 %
of approach-and-landing incidents or accidents.
Because CRM practices are a key factor in flightcrew adherence to and performance of
normal and non-normal procedures and in the interaction with automated systems,
CRM issues are involved to some degree in every incident or accident.
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III Company Culture and Policies

It should be recognized that many factors associated with incidents and accidents are
embedded in the organization of the whole aviation system.
The flightcrew is considered to be the last link in the error-chain but it is also the last
line-of-defense.
Company safety culture and policies should therefore:
• Support the implementation of CRM practices;
• Facilitate the mitigation of organizational factors; and,
• Identify and address precursors of potential incidents or accidents.
IV International Cultural Factors

As more operators access to global international operation with multi-nationality
crewmembers, cross-cultural issues should become an important part of a customized
CRM training.
The discussion of cross-cultural factors should include:
• Highlighting the importance of cultural and national sensitivities; and,
• Promoting the use of standard phraseology as a common working language.
V Leadership
The PIC must demonstrate the focus and energy required to motivate the crew to work
together as a team.
The role of the pilot-in-command (PIC) in complex and demanding situations should be
emphasized during CRM training.
This includes, for example, approaches with marginal weather conditions or abnormal /
emergency conditions that are beyond the scope of published procedures.
VI Teamwork
Effective teamwork requires effective command and leadership by the PIC and effective
support by all crew members.
Teamwork enhances the crew problem-solving capability in dealing with normal,
abnormal and emergency situations.
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Achieving effective teamwork requires the optimum use of the following crew
resources :
• Communication skills;
• Monitoring skills;
• Technical proficiency;
• Advocacy / inquiry; and,
• Dedication to success.
The captain’s role and attitude in opening the line of communication with the first
officer and cabin crew is of prime importance for setting the flight deck atmosphere and
ensuring effective:
• Teamwork (e.g., creating a synergy among crew members, allowing the authority
and duty for the first officer to voice any concern as to the progress of the flight and
overall safety);
• Crew coordination, mutual monitoring and backup; and,
• Human relations (e.g., effective intra-crew communications).
Performing a pre-flight briefing that includes the flight crew and cabin crew establishes
the basis for effective teamwork.
Flight attendants may hesitate to report technical occurrences to flight crew
(i.e., because of cultural aspects, company policies or intimidation).
To overcome this reluctance, the implementation and interpretation of the sterile
cockpit rule (as applicable) should be discussed during cabin crew CRM training and
recalled by the captain during the pre-flight briefing.
When performing the operational and human factors analysis of operational events,
Airbus qualifies teamwork aspects, using the following markers :
• Flight preparation and planning;
• Intra-cockpit communications;
• Cockpit crew / cabin crew communications ;
• Cultural / language factors;
• Priority setting;
• Quality of briefings;
• Flight monitoring;
• Workload management;
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• Mutual cross-check and back-up;

• Adherence to standard calls;
• Strategic (long term) decision making;
• Tactical (short term) decision making;
• Situational awareness;
• Interruptions and distractions management;
• Effective use of all crew resources.
VII Assertiveness
Incidents and accidents illustrate that if an option (e.g., performing a go-around)
has not been prepared, flight crew may lack the mental resources needed to:
• Make the required decision (i.e., initiate the go-around); or,
• Correctly conduct the required maneuver (i.e., flying the published missed-
approach).
Fatigue or reluctance to change a prepared plan often are the probable causes for
a lack of assertiveness (assessment of situation) and decision-making.
VIII Inquiry and Advocacy

Flight crews often are faced with ATC requests that are either:
• Not understood (e.g., being assigned an altitude below the sector MSA, when
the minimum vectoring altitude is not published); or,
• Challenging (e.g., being requested to fly higher and/or faster than desired or
to take a shorter routing than desired).
Flight crews should not accept such instructions without requesting clarification or being
sure that they can comply safely with the ATC instructions.
IX Time Management
Taking time to make time, developing multi-tasking ability and ensuring task
prioritization are essential factors in staying ahead of the aircraft :
• Buy time by not accepting time pressure; and,
• Beware of tasks that are time consuming, such as FMS programming.
The Flight Operations Briefing Note Operations Golden Rules describes the various steps
of a typical tactical-decision-making model, for use in time-critical situations.
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X Managing Interruptions and Distractions

Coping with unexpected distraction, disturbance and contingency in the cockpit requires
the use of techniques to lessen the effects of any disruption in the flow of on-going
cockpit activities.
Flight crews should “ expect the unexpected ”.
XI Threat Management
A threat is a condition that affects or complicates the performance of a task or
the compliance with applicable standards.
Adverse weather, terrain, airspace congestion, challenging ATC instructions, etc … are
threat that may affect flight operations.
Airbus qualifies threat management aspects, using the following markers :
• Threat anticipated and briefed;
• Threat avoided / prevented;
• Threat not recognized;
• Threat consequential or inconsequential;
• Threat managed / recovered / mitigated; and/or,
• Threat late identification, assessment and management.
XII Error Management
Crew errors often are induced by interruptions and distractions resulting from :
• Intra-cockpit activities; or,
• External threats (e.g., ATC instructions, weather conditions, etc).
Error-management training and techniques should be considered at company level and

at personal level.
The various Flight Operations Briefing Notes list and discuss the influence factors
(i.e., error factors) that are relevant for each subject, in order to identify or suggest
the development of associated:
• Company prevention strategies; and,
• Personal lines-of-defenses.
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The most critical aspect in discussing error management is not the initial error or
deviation but the failure to detect this error or deviation, by mutual monitoring and
backup.
Airbus qualifies error management aspects, using the following markers :
• Detected or undetected inadvertent action;
• Detected or undetected action slip;
• Detected or undetected entry error;
• Detected error challenged or not;
• Detected error corrected or not;
• Error outcome consequential or inconsequential;
• Error resulting or not in an aircraft undesired state; and,
• Successful or unsuccessful recovery technique / action.
XIII Risk Management
The concept of risk combines the notions of severity and probability, with reference to
a given hazard.
A hazard is a condition that has the potential to cause personal injury or death,
property damage or operational degradation.
Runway excursion, runway overrun, CFIT, loss of control in flight or on ground, etc …
are typical hazards in terms of flight operations.
The severity of a given threat rarely can be significantly reduced but its probability of
occurrence can be largely reduced by implementing related prevention strategies
(e.g., safety awareness and training programs).
For the flight crew, risk management often consists in assessing the effects of potential
hazards on the safe conduct of the flight and in finding ways to avoid these hazards or
to minimize their effects.
Decision-making is to be considered as risk-management at flight crew level.
Risk management also should be seen as a balanced management of priorities.
Risk management sometimes is described as opposing:

• A sure inconvenience (e.g., associated with a go-around or a diversion); against,
• A probable-only risk (e.g., risk associated with an unstabilized approach to a long

and dry runway).
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A practical and safety-oriented method of risk management is entirely contained in

the concept and techniques of tactical-decision-making (refer to the Flight Operations
Briefing Note Operations Golden Rules).
XIV Decision Making
SOPs sometimes are perceived as limiting the flight crew’s judgment and decision.
Without denying the captain’s emergency authority, SOPs are safeguards against
biased decision-making.
Effective flightcrew decision-making requires a joint evaluation of possible options prior

to proceeding with an agreed-upon decision and action.
The effect of pressures (e.g., delays, company policies, ATC requests, etc) that may
affect how the crew conducts the flight and makes decisions should be acknowledged
by the industry.
Nevertheless, eliminating all pressures is not a realistic objective. Thus, company

accident-prevention strategies, CRM techniques and personal lines-of-defense should be
used to cope effectively with such pressures.
The use of a tactical-decision-making model for time-critical situations often is an

effective technique to lessen the effects of pressures.
Several tactical-decision-making models (usually based on memory aids or on

sequential models) have been developed and should be discussed during CRM training.
All tactical-decision-making models share the following phases (refer to the Flight
Operation Briefing Note Operations Golden Rules for detailed information) :
• Recognizing the prevailing condition (i.e., identifying the problem);
• Assessing short term and long term consequences on the flight (i.e., collecting
the facts and assessing their operational implications);
• Evaluating available options and procedures (i.e., identifying and evaluating

alternatives);
• Deciding the course of actions (i.e., selecting the best mutually-agreed alternative);
• Taking actions in accordance with the defined procedures and applicable

task-sharing (i.e., implementing the selected option);
• Evaluating and monitoring action results (i.e., confirming expectations versus

observed facts); and,
• Resuming standard flying duties (i.e., resuming operation in accordance with SOP’s,
including the use of standard calls and normal checklists).
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The above decision-making-model should optimize the available crew resources

in terms of :
• Interpersonal communications;
• Inquiry and advocacy;
• Effective listening;
• Tasks prioritization ability;
• Self confidence, but also self-critical-analysis.
Postponing a decision until that option is no more considered or no longer available is

a recurring pattern in incidents and accidents, particularly in approach-and-landing
accidents.
The concepts of next-target and approach-gate are intended to act as milestones for
supporting a timely decision-making process.
XV Other CRM Aspects

The following other CRM aspects have been observed in most incidents or accidents:
• Spatial disorientation (i.e., physiological illusions and/or visual illusions);
• Complacency when operating at a familiar airport (e.g., home base); or,
• Overconfidence;
• Inadequate anticipation (i.e., inability to stay ahead of the aircraft);
• Inadequate preparation to respond to changing situations or to an abnormal /

emergency condition, by precise planning and use of all available technical and
human resources (i.e., by expecting the unexpected);
• Crewmembers personal factors; and/or,
• Absence of specific training of instructors and check airmen to evaluate the CRM
performance of trainees and line pilots.
XVI Factors Affecting CRM Practice

The following organizational or personal factors may adversely affect the effective
implementation of CRM practices:
• Company culture and policies;
• Belief that actions or decisions are correct, although they deviates from
the applicable standards;
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• Effect of fatigue and absence of countermeasures to restore the level of vigilance

and alertness; and/or,
• Reluctance to accept the influence of human factors and CRM issues in incidents or
accidents.
XVII Summary of Key Points

CRM practices optimize the performance of the entire crew (i.e., including cabin crew
and maintenance personnel).
CRM skills effectively:
• Relieve the effects of pressures, interruptions and distractions;
• Provide milestones for timely decision-making; and,
• Provide safeguards for effective error-management, thus minimizing the effects of

working errors.
First and foremost, CRM is a matter of mindset and attitude; the analysis of incidents
and accidents suggest highlighting a key attitude in terms of safety enhancement :
“ Nothing should ever be taken for granted ”
XVIII Associated Briefing Notes

The following Flight Operations Briefing Notes provide expanded information to
complement the above overview :
• Operating Philosophy - SOPs
• Optimum Use of Automation
• Standard Calls
• Human Factors in Incidents / Accidents
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XIX Regulatory References

Transport – Aeroplanes, Appendix 2, 5.15, 5.21 and 5.22.
• ICAO – Procedures for Air Navigation Services – Rules of the Air and Air Traffic
Services (PANS-RAC, Doc 9432).
• ICAO – Procedures for Air navigation Services – Aircraft operations (PANS-OPS, Doc
8168), Volume I – Flight Procedures (Post Amendment No 11, applicable
Nov.1/2001).
• ICAO – Accident Prevention Manual (Doc 9422).
• ICAO – Human Factors Digest No 8 – Human Factors in Air Traffic Control (Circular
241).
• FAR 121.406, 121.419, 121.421 or 121.422 - CRM Training for pilots, cabin crew
and aircraft dispatchers.
• FAA – AC 60-22 – Aeronautical Decision Making.
This Flight Operations Briefing Note (FOBN) has been adapted from a corresponding Briefing Note developed by Airbus
in the frame of the Approach-and-Landing Accident Reduction (ALAR) international task force led by the Flight Safety
Foundation.

FOBN Reference : FLT_OPS – HUM_PER - SEQ02 - REV03 – JUNE 2004
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Human Performance
Flight Operations Briefing Notes Managing Interruptions and Distractions

Human Performance
Managing Interruptions and Distractions
I Introduction
Interruptions and distractions are the main threat facing flight crews.
Note :
A threat is a condition that affects or complicates the performance of a task or
the compliance with applicable standards.
Threats are conditions, created by the operating environment, that may induce errors
( e.g., omissions, inadvertent actions, … ).
The omission of an action or an inappropriate action is the most frequent causal factor
in incidents and accidents, as illustrated by Table 1.
Interruptions ( e.g., due to ATC communications ) and distractions ( e.g., due to
a cabin attendant entering the cockpit ) occur frequently; some cannot be avoided,
some can be minimized or eliminated.
The following aspects should be considered to assess company exposure and personal
exposure, and to develop prevention strategies and lines-of-defense to lessen
the effects of interruptions and distractions in the cockpit :
• Recognize the potential sources of interruptions and distractions;
• Understand their effect on the flow of cockpit duties;
• Reduce interruptions and distractions ( e.g. by adopting the Sterile Cockpit Rule );
• Develop prevention strategies and lines-of-defense to minimize the exposure to
interruptions and distractions; and,
• Develop techniques to lessen the effects of interruptions and distractions.
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II Statistical Data
The US Aviation Safety Action Program ( ASAP ) reveals that 14 % of crew reports
includes reference to an interruption or distraction ( Source – US ASAP – 2000-2001 ).
The following causal factors, frequently observed in approach-and-landing accidents,

often are the result of interruptions or distractions in the cockpit :
Factor % of Events
Omission of action or inappropriate action 72 %
Inadequate crew coordination, cross-check and back-up 63 %
Insufficient or loss of lateral or vertical situational awareness 52 %
Inadequate or insufficient understanding of prevailing conditions 48 %
Slow or delayed action 45 %
Incorrect or incomplete pilot / controller communications 33 %
( Sources : Flight Safety Foundation - ALAR - 1998-1999 )
Table 1
Effects of Distractions and Interruptions in Approach-and-Landing Accidents
III Factors Involved in Interruptions and Distractions

Interruptions and distractions in the cockpit may be subtle or be momentary, but all
can be disruptive to the flight crew.
Interruptions or distractions usually result from three main causes ( Sources : NASA
ASRS – 1998 ) :
• Communications :
− receiving the final weights while taxiing; or,
− a flight attendant entering the cockpit;
• Head-down activity :
− reading the approach chart; or,
− programming the FMS;
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• Responding to an abnormal condition or to an unanticipated situation :

− system malfunction;
− weather or environmental threat; or,
• Searching for traffic following a TCAS / ACAS alert :

− traffic collision avoidance system (TCAS) traffic advisory (TA) or resolution
advisory (RA) – search for traffic following TCAS / ACAS alert.
Successive surveys of the NASA Aviation Safety Reporting System ( ASRS ) data base
identifies the respective contributions of the above factors :
Factor % of Events
Communications 50 to 68 %
Head-down Activity 16 to 22 %
Response to Abnormal Condition / Unanticipated Situation 14 to 19 %
Searching for Traffic Following TCAS / ACAS Alert 8 to 11 %
( Sources : NASA – ASRS )
Table 2
Factors Involved in Interruptions and Distractions
The following contributing factors often are cited when discussing interruptions and
distractions :
• Flight-deck ergonomics;
• Flight-deck noise level;
• Language proficiency ( pilots and controllers );
• Airport infrastructure ( e.g., unclear markings, … ) ; and,
• Flightcrew fatigue.
Minor disruptions ( e.g., a minor equipment malfunction ) can turn a routine flight into
a challenging event !
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IV Effect of Interruptions or Distractions

The primary effect of interruptions or distractions is to break the flow of ongoing
cockpit activities ( i.e., actions or communications ), this includes :
• SOPs;
• Normal checklists;
• Communications ( i.e., listening, processing, responding );
• Monitoring tasks ( i.e., systems monitoring, PF/PNF mutual cross-check and
back-up ); and,
• Problem solving activities.
The diverted attention resulting from the interruption / distraction usually leaves
the flight crew with the feeling of being rushed and faced with competing / preempting
tasks.
When being faced with concurrent task demands, natural human limitations result in
performing one task to the detriment of another.
Unless mitigated by adequate techniques, the disruption and lapse of attention may
result in:
• Not monitoring the flight path ( e.g., possibly resulting in an altitude or course
deviation or a controlled flight into terrain );
• Missing or misinterpreting an ATC instruction ( e.g., possibly resulting in traffic
conflict or runway incursion );
• Omitting an action and failing to detect and correct the resulting abnormal condition
or configuration ( e.g., interruption during the reading of a normal checklist ); or,
• Experiencing task overload ( i.e., being “ behind the aircraft ” ).
The following types-of-event have been observed as a result of interruptions and

distractions ( source : Airbus and non-Airbus events operational and human factors
analysis ) :
• Taxiway or runway incursion;
• Incorrect aircraft configuration for takeoff;
• Late landing gear retraction;
• Premature slats / flaps retraction; or, conversely,
• Flaps placard-speed ( V FE ) exceedance;
• Late response to ATC instructions;
• Failure to select engine anti-ice, when required;
• Altitude / Flight Level bust in climb or descent;
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• Inadequate fuel management ( e.g., late detection of fuel imbalance, … );

• Speed below minimum speed during descent;
• Failure to reset altimeter setting;
• Altitude deviation or stall during holding pattern;
• Late aircraft configuration for landing;
• Failure to capture ( or monitor capture of ) localizer or glide slope;
• Descent below MDA;
• Taxiway excursion; and / or,
• Failure to set parking brake on arrival at gate or parking stand.
V Reducing Interruptions and Distractions

Acknowledging that flight crew may have control over some interruptions / distractions
and not over some others is the first step in developing prevention strategies and lines-
of-defense.
Actions that may be controlled (e.g. SOP’s actions, initiation of normal checklists, …)
should be scheduled during periods of less likely disruption, to prevent interference with
actions that cannot be controlled (e.g. ATC communications or flight attendant
interruptions).
Adhering to the Sterile Cockpit Rule can largely reduce interruptions and distractions.
The Sterile Cockpit Rule reflects the requirement of U.S. FAR – Part 121.542 :
• “ No flight crewmember may engage in, nor may any pilot in command permit any
activity during a critical phase of flight which could distract any flight crewmember
from the performance of his or her duties or which could interfere in any way with
the proper conduct of those duties ”.
For the purpose of this requirement, an “ activity ” includes :

• “…, engaging in non-essential conversation within the cockpit and non-essential
communication between the cabin and cockpit crews, … ”.
The term “ critical phases of flight “ encompasses :

• “ all ground operations involving taxi, takeoff and landing, and all other flight
operations below 10,000 feet, except cruise flight ”.
In the FARs understanding, the 10,000 feet limit is defined as 10,000 ft MSL.
When operating to or from a high elevation airport, a definition based on 10,000 ft AGL
might be considered as more appropriate.
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Complying with the Sterile Cockpit Rule during taxi-out and taxi-in requires extra
discipline as taxi phases often provide a relief between phases of high workload and
concentration.
Interruptions / distractions during taxi is the main causal factor in takeoff accidents and
runway incursions.
The sterile cockpit rule has been adopted by non-U.S. operators and is also covered
(although in less explicit terms) in the JAR-OPS 1.085(d)(8).
Adhering to the Sterile Cockpit Rule is an integral part of Airbus Standard Operating
Procedures ( SOPs ).
The sterile cockpit rule should be implemented with good common sense in order not to
break the communication line between flight crewmembers or between cabin crew and
flight crew.
Adherence to the Sterile Cockpit Rule should not affect :

• Use of good CRM practices by flight crew; and,
• Communication of emergency or safety related information by cabin crew.
The U.S. FAA acknowledges that it is better to break the Sterile Cockpit Rule than to fail
to communicate !
The implementation of the Sterile Cockpit Rule by cabin crew creates two challenges :
• How to identify the 10,000 ft limit ?
• How to identify occurrences that warrant breaking the Sterile Cockpit Rule ?
Several methods for signaling to the cabin crew the crossing of the 10,000 feet limit
have been evaluated ( e.g., using the all-cabin-attendants call or a public-address
announcement ).
Whatever method is used, it should not create its own distraction to the flight crew.
The following occurrences are considered to warrant breaking the Sterile Cockpit Rule :
• Fire, burning smell or smoke in the cabin;
• Medical emergency;
• Unusual noise or vibration ( e.g. evidence of tailstrike on takeoff );
• Engine fire ( e.g., tail pipe or nacelle torching flame );
• Fuel or fluid leakage;
• Uncertainty about condition ( i.e., suspected incapacitation, … );
• Emergency exit or door unsafe condition ( although this condition is annunciated
to the flight crew );
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• Extreme local temperature changes ( e.g., suspected bleed air duct leakage );
• Evidence of incorrect or incomplete deicing;
• Cart stowage difficulty;
• Suspicious, unclaimed bag or package; and,
• Any other condition, as deemed relevant by the senior cabin crewmember (purser).
This list may need to be adjusted for local regulations or to suit each individual
company policy.
Cabin crewmembers may hesitate to report technical occurrences to the flight crew
( e.g., because of cultural aspects, company policies and / or intimidation ).
To overcome this reluctance, the implementation and interpretation of the sterile
cockpit rule should be discussed during cabin crew CRM training, and recalled by the
captain during the pre-flight briefing.
Analyses of aviation safety reports indicate that the most frequent violations of
the Sterile Cockpit Rule are caused by the following factors :
• Non-flight-related conversations;
• Distractions by cabin crewmembers;
• Non-flight-related radio calls; and/or,
• Non-essential public-address announcements.
VI Prevention Strategies and Lines-of-defense

A high level of interaction and communication between flight crewmembers, and
between flight crew and cabin crews, constitutes the first line of defense to reduce
errors.
Effective communication is a two-way transfer of information, not just a mere one-way
consultation or registration.
The foundations for an effective line of communication and interaction between all flight
crewmembers and cabin crewmembers should be embedded in :
• Company policies;
• SOPs;
• CRM training; and,
• Leadership role of the pilot-in-command.
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Strict adherence to the following operating policies provides safeguards to minimize

disruptions or to lessen their effects:
• Sterile Cockpit Rule;
• Operations Golden Rules; and,
• Standard Calls.
The following lines-of-defense address the three families of cockpit disruptions and,
thus, prevent or minimize the interference of competing or preempting tasks:
• Communications :
− brief jump-seat rider, as applicable, regarding adherence to the Sterile Cockpit
Rule;
− don headsets during critical phases of flight ( e.g. for any operations below
10,000 ft );
− plan Public Address ( PA ) announcements during low-workload periods;
− keep intra-cockpit communications brief, clear and concise; and,
− interrupt conversations when approaching the defined next target or the next
altitude restriction / constraint.
• Head-down activity ( FMS programming or chart review ) :

− define task sharing for FMS programming or reprogramming depending on
the level of automation being used and on the flight phase ( SOPs );
− plan long head-down tasks in low-workload periods; and,
− announce that you are going “ head-down ”.
• Responding to an abnormal condition or to an unanticipated situation :

− keep the AP engaged to decrease workload, unless otherwise required;
− adhere to PF / PNF task sharing for abnormal / emergency conditions
( i.e., PNF should maintain situational awareness, monitor and back-up the PF );
− give particular attention to normal checklists, because handling an abnormal
condition may disrupt the normal flow of SOPs actions;
SOPs actions and normal checklists are initiated based on events ( triggers );
in case of disruption these events may go unnoticed and the absence of
the usual trigger may be result in the omission of actions or checklists.
• Search for Traffic :

− Express a clear and loud “ I fly, you watch ” call.
The above lines of defense minimize the flight crew exposure to disruptions caused by
interruptions and distractions.
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VII Managing / Mitigating Interruptions and Distractions

Because some interruptions and distractions may be subtle and insidious, the first
priority is to recognize and identify the disruption.
The second priority is to re-establish situational awareness, as follows :
• Identify :
− What was I doing?
• Ask :
− Where was I interrupted?
• Decide/Act :
− What decision or action shall I take to get “back on track” ?
The following decision-making-process should be applied:
• Prioritize :
− Operations Golden Rules provide clear guidelines for task prioritization :
• “ Fly, Navigate, Communicate and Manage systems, in that order ”.
• Plan :
− Some actions may have to be postponed until time and conditions permit.
Asking for more time ( e.g. from the ATC or from the other crewmember )
will prevent being rushed in the accomplishment of competing actions.
In other words, take time to make time.
• Verify :
− Using SOPs techniques ( i.e., concept of next target, action blocks, event
triggers and normal checklists ), ensure that the action(s) that had been
postponed have been duly accomplished.
Finally, if the disruption interrupt the course of a normal checklist or abnormal

checklist, an explicit hold should be verbalized to mark the interruption of the checklist
and an explicit command should be used for resuming the checklist.
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VIII Summary of key points

Interruptions and distractions usually result from the following factors :
• Pilot / controller or intra-cockpit communications ( i.e., including flight crew / cabin
crew communications );
• Head-down activity;
• Responding to an abnormal condition or an unanticipated situation; or,
• Searching for traffic.
Prevention strategies and lines-of-defense should be developed to minimize

interruptions and distractions and to lessen their effects.
Strict adherence to the following standards is the most effective company prevention
strategy and personal line-of-defense:
• SOPs;
• Operations Golden Rules;
• Standard calls;
• Sterile Cockpit Rule; and,
• Recovery techniques such as :
− Identify – ask – decide – act; and,
− Prioritize – plan – verify.
IX Associated Flight Operations Briefing Notes

The following Flight Operations Briefing Notes provide expanded information to
complement the discussion of interruptions and distractions :
• Standard Calls
• Human Factors in Incidents / Accidents
• CRM Aspects in Incidents / Accidents
• Threat Management
• Error Management
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X Regulatory References
• ICAO - Preparation of an Operations Manual (Doc 9376).
• ICAO – Human Factors Digest No 8 – Human Factors in Air Traffic Control
(Circular 241).
• FAR 121.406, 121.419, 121.421 or 121.422 - CRM Training.
• FAR 121.542 – Sterile Cockpit Rule.
• JAR-OPS 1.085(d)(8) – Sterile Cockpit.
XI Industry References
• Flight Safety Foundation website – http://www.flightsafety.org
• NASA – ASRS website - http://asrs.arc.nasa.gov/main.htm
This Flight Operations Briefing Note (FOBN) has been developed by Airbus in the frame of the Approach-and-Landing
Accident Reduction (ALAR) international task force led by the Flight Safety Foundation.

FOBN Reference : FLT_OPS – HUM_PER - SEQ03 - REV03 – OCT. 2004
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Flight Operations Briefing Notes Effective Pilot / Controller Communications

Human Performance
Effective Pilot / Controller Communications
I Introduction
Until controller / pilot data link communication ( CPDLC ) comes into widespread use,
air traffic control ( ATC ) will depend upon voice communications that are affected by
various factors.
Operators and Air Traffic Management providers, like pilots and controllers, are close
partners in terms of “productivity” ( i.e., for enhancing the airport / airspace flow
capacity ); operators and ATM should be also close partners in terms of “safety”
( i.e., for risk management ).
Communications between controllers and pilots can be improved by the mutual
understanding of each other’s operating environment.
This Flight Operations Briefing Note provides an overview of various factors that may
affect pilot / controller communications.
This Briefing Note may be used to develop a company awareness program
for enhancing flight pilot / controller communications.
II Statistical Data
Incorrect or incomplete pilot / controller communications is a causal or circumstantial
factor in 80 % of incidents or accidents, as illustrated in Table 1.
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A survey of the NASA Aviation Safety Reporting System ( ASRS ) data base identifies
the following factors, affecting pilots / controllers communications :
Factor % of Reports
Incorrect Communication 80 %
Absence of Communication 33 %
Correct but late Communication 12 %
( Source – NASA – ASRS )
Table 1
Communication Factors in NASA ASRS Reports
The survey also reveals how various modes of communication are affected :
Mode of Communication % of Reports
Listening 45 %
Speaking 30 %
Reading and Writing 25 %
( Source – NASA – ASRS )
Table 2
Communication Factors in NASA ASRS Reports
Incorrect or inadequate …
• ATC instructions ( e.g., radar vectors, … );
• Weather or traffic information; and/or,
• Advice / service in case of emergency,
… are causal factors in more than 30 % of approach-and-landing accidents.
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III Remark
Although pilot / controller communications are not limited to the issuance and
acknowledgement of clearances, this Flight Operations Briefing Note primarily refers
to clearances because this provides a convenient example to illustrate this overview.
IV Pilot / Controller Responsibilities

The responsibilities of the pilot and controller intentionally overlap in many areas
to provide redundancy.
This shared responsibility is intended to compensate for communication failures that
might affect safety.
V The Pilot / Controller Communication Loop

The pilot / controller communication loop supports the safety and redundancy of pilot /
controller communications, as illustrated by Figure 1.
ATC Clearance
Acknowledge Transmit
or Correct
Listen
Controller’s Pilot’s
Hearback Readback
Listen Transmit
Figure 1
The Pilot / Controller Communication Loop
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The pilot / controller communication loop constitutes a confirmation / correction

process that ensures the integrity of communications.
Whenever adverse factors are likely to affect communications, strict adherence to
this closed loop constitutes a line-of-defense against communication errors.
Readback / hearback errors may result in one or more of the following types-of-event,
ranked by number of events observed over the period 1992-1993 ( Source – NASA –
ASRS – 1994 ) :
• Operational deviation ( non-adherence to legal requirements );
• Altitude deviation;
• Airborne conflict;
• Less than desired separation;
• Lateral deviation;
• Runway incursion;
• Ground conflict;
• Airspace penetration;
• CFIT; and,
• Near midair-collision.
VI Achieving Effective Communications - Obstacles and Lessons Learned

Pilots and controllers are involved equally in the air traffic management system.
Achieving effective radio communications involves many factors that should not be
considered in isolation.
Many factors are closely interrelated, and more than one cause usually is involved in
a breakdown of the communication loop.
The following provides an overview and discussion of factors involved in effective pilot /
controller communications.
VI.1 Human Factors Aspects In Effective Communication

Effective communication is achieved when our mental process is able to accommodate
and to interpret the information contained in a message.
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This mental process can be summarized as follows:
• How do we perceive the message ?
• How do we reconstruct the information contained in the message ?
• How do we link this information to an objective or to an expectation ?
• What bias or error is introduced in this process ?
Crew resource management ( CRM ) research highlights the relevance of the context
and expectations in this process. Nevertheless, expectations may introduce either
a positive or negative bias in the effectiveness of the communication.
Workload, fatigue, non-adherence to the sterile cockpit rule, distractions, interruptions,

conflicts and pressure are among the factors that may affect adversely pilot / controller
communications and result in :
• Incomplete communications;
• Omission of call-sign or use of an incorrect call-sign;
• Use of nonstandard phraseology;
• Failure to listen or respond; and,
• Failure to effectively implement the confirmation / correction loop.
VI.2 Language and Communication

No individual is expected to speak any language, even his/her own native language,
correctly and in a standard way. Acknowledging this fact is a first step towards
developing or enhancing communication skills.
The language of pilot / controller communications is intended to overcome this basic
shortcoming.
CRM studies show that language differences are a more fundamental obstacle to safety
in the cockpit than cultural differences.
In response to a series of accidents involving language skills as a causal factor,
an effort has been initiated to improve the English-language skills of pilots and
controllers worldwide.
Nevertheless, even pilots and controllers for whom English is the native language may
not understand all communications spoken in English, because of regional accents or
dialects.
Language differences generate significant communication difficulties worldwide.
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Controllers using both English ( for communication with international flights ) and
the country’s native language ( for communication with domestic flights ) prevent pilots
from achieving the desired level of situational awareness ( because of loss of party-line
communications ).
VI.3 Communication Techniques

The first priority of any communication is to establish an operational context, by using
markers and modifiers to define the following elements of the context :
• Purpose - clearance, instruction, conditional statement or proposal, question or

request, confirmation;
• When - immediately, anticipate / expect;
• What and how - altitude ( i.e., climb, descend, maintain ), heading ( i.e., left,
right ), airspeed; and,
• Where - ( i.e., before or at […] waypoint ).
The structure and construction of the initial and subsequent message(s) should support
this context by :
• Following the chronological order of the sequence of actions;
• Grouping instructions and numbers related to each action; and,
• Limiting the number of instructions in the transmission.
The intonation, the speed of transmission ( i.e., speech rate ) and the placement and
duration of pauses may positively or adversely affect the correct understanding of
a communication.
ICAO Annex 10 – Volume II and PANS ATM ( Doc.4444 ) provide rules and procedures
for pilot / controller communications.
ICAO guidelines and techniques for radio transmission highlight the following
objectives:
• Transmissions shall be conducted concisely in a normal conversational tone;
• Full use shall be made of standard phraseologies, whenever prescribed in ICAO

documents and procedures; and,
• Speech-transmitting techniques shall be such that the highest possible intelligibility

is incorporated in each transmission.
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To reach the above objectives, pilots and controllers should :
• Enunciate each word clearly and distinctly;
• Maintain an even rate of speech ( not exceeding – typically – 100 words per
minute );
• Make a slight pause preceding and following numerals, this makes them easier
to understand;
• Maintain the speaking volume at a constant level;
• Be familiar with the microphone operating techniques ( particularly in maintaining

a constant distance from the microphone, if the aircraft does not feature a constant-
level modulator ); and,
• Suspend speech temporarily if it becomes necessary to turn the head away from
the microphone.
VI.4 Use of Non-standard Phraseology

Use of nonstandard phraseology is a major obstacle to voice communications.
Standard phraseology is intended to be easily and quickly recognized.
Pilots and controllers expect each other to use standard phraseology.
Standard phraseology helps lessen the ambiguities of spoken language and thus
guarantees a common understanding among speakers :
• Of different native languages, or,
• Of the same native language but who use or understand words differently
( e.g., regional accents or dialects ).
Non-standard phraseology or the omission of key words may change completely

the meaning of the intended message, resulting in potential conflicts.
For example, any message containing a “number” should indicate whether the number
refers to an altitude, a heading or an airspeed. Including such key words prevents
an erroneous interpretation and allows an effective readback / hearback.
Pilots and controllers might use non-standard phraseology with good intentions;
however standard ICAO phraseology always minimizes the potential for
misunderstanding.
Use of non-standard ICAO phraseology may result from national practice.
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The most significant example is the North American phraseology “taxi into position and
hold”, that has the same meaning as the ICAO phraseology “line up [ and wait ]”,
whereas the ICAO phraseology “taxi to holding position” is a clearance to taxi to, and
hold at, a point clear of the runway ( e.g., the CAT I or CAT II / III holding point /
line ).
VI.5 Building Situational Awareness

Radio communications ( including party-line communications ) contribute to build
the pilot’s and the controller’s situational awareness.
Flight crew and controller may prevent misunderstandings by providing each other with
timely information, for better anticipation.
At all times, pilots should build and update a mental picture of the other traffic
in the vicinity of their intended flight or ground path.
VI.6 Frequency Congestion

Frequency congestion significantly affects the correct flow of communications during
critical phases such as takeoff-and-departure as well as approach-and-landing,
particularly at high-density airports, this requires enhanced vigilance by pilots and
by controllers.
VI.7 Omission of Call-sign

Omitting the call-sign or using an incorrect call-sign jeopardizes an effective readback /
hearback process.
VI.8 Lack of Readback or Incomplete Readback ( Readback Errors )

ICAO Annex 11 requires that the safety-related part(s) of any clearance or instruction
be readback to the air traffic controller.
The following parts of a clearance shall always be readback :
• ATC routes clearances;
• Clearances and instructions to enter, land on, takeoff on, hold short of, cross or
backtrack on a runway;
• Runway in use;
• Altimeter setting;
• ATC transponder ( SSR ) code;
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• Altitude of FL instructions ;
• Heading and speed instructions ; and,
• Transition levels ( whether issued by the controller or broadcasted by the ATIS ).
The pilot’s readback must be complete and clear to ensure a complete and correct
understanding by the controller.
The readback message shall always include the flight callsign.
Readback of an hold short, crossing, takeoff or landing instruction shall always include
the runway designator.
The use of the term Roger is not an acceptable readback as it does not allow
the controller to confirm or correct the clearance or instruction, thus decreasing
the pilot’s and the controller’s situational awareness :
• Pilot may use Roger to acknowledge a message containing numbers ( instead of

a normal readback ), thus preventing effective hearback and correction by
the controller; or,
• Controller may use Roger to acknowledge a message requiring a specific answer

( e.g., a positive confirmation or correction, such as acknowledging a pilot’s
statement that an altitude or a speed restriction cannot be met ).
VI.9 Failure of Correct an Erroneous Readback ( Hearback Errors )

Any readback by the pilot requires an hearback by the controller, in order to close
the communication loop.
Most pilots perceive the absence of an acknowledgement or correction following
a clearance readback as an implicit confirmation of the readback.
The lack of acknowledgement by the controller usually is the result of frequency
congestion, requiring the controller to issue clearances and instructions to several
aircraft.
Uncorrected erroneous readback ( known as hearback errors ) may cause deviations
from the assigned altitude or non-compliance with altitude restrictions or with radar
vectors.
A deviation from a clearance or instruction may not be detected until the controller
observes the deviation on his/her radar display.
Less-than-required vertical or horizontal separations, near midair collisions or runway
incursions usually are the result of hearback errors.
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VI.10 Perceiving What Was Expected or Wanted ( not what was actually said )
The bias of expectation can affect the correct understanding of communications by
pilots and controllers.
This involves perceiving what was expected or wanted and not what was actually said.
The bias of expectation can lead to:
• Transposing the numbers contained in a clearance ( e.g., an altitude or FL ) to what

was expected, based on experience or routine; or,
• Shifting a clearance or instruction from one parameter to another ( e.g., perceiving

a clearance to maintain a 280-degree heading as a clearance to climb / descend and
maintain FL 280 ).
VI.11 Failure to Seek Confirmation ( when a message is not understood )

Misunderstandings may include half-heard words or guessed-at numbers.
The potential for misunderstanding numbers increases when a given ATC clearance
contains more than two instructions.
VI.12 Failure to Request Clarification ( when in doubt )

Reluctance to seek confirmation or clarification may cause pilots to either :
• Accept an inadequate instruction ( over-reliance on ATC ); or,
• Define by themselves the most probable interpretation.
Failing to request clarification may cause flight crew to believe erroneously that they
have received the expected clearance ( e.g., clearance to cross an active runway ).
VI.13 Failure to Question an Incorrect or Inadequate ATC Instruction

Failing to question an incorrect or inadequate instruction may cause a crew to accept
an altitude clearance below the sector MSA or a heading that places the aircraft near
obstructions or on a collision course with another aircraft.
VI.14 Taking a Clearance or Instruction Issued to Another Aircraft

This usually occurs when two aircraft with similar-sounding call-signs are on the same
frequency and are likely to receive similar instructions or if the call-sign is blocked by
another transmission.
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When pilots of different aircraft with similar-sounding call-signs omit the call-sign on
readback, or when simultaneous readback are made by both pilots, the error may go
un-noticed by the pilots and the controller.
Some national authorities have instituted call-sign de-confliction programmes
( Source – Eurocontrol – Level Bust Briefing Notes ) to minimize or eliminate this
threat.
Eurocontrol recommends that all operators study their schedules and arrange call-signs
to reduce the chances of company aircraft operating in the same airspace at the same
time, having similar call-signs.
VI.15 Effective Listening - Filtering Communications

Effective communication requires active and intensive listening by all parties involved,
concentrating on each part and word in order to fully understand the whole message.
Because of other flight deck duties, pilots tend to filter communications, listening
primarily to communications that begin by their aircraft call-sign and not hearing other
communications.
For workload reasons, controllers also may filter communications ( e.g., not hearing or
responding to a pilot readback, while being engaged in issuing clearances / instructions
to other aircraft or ensuring coordination with an other ATC center ).
To maintain situational awareness, this filtering / selection process should be adapted,
according to the flight phase, for more effective listening, e.g., :
• Whenever occupying an active runway ( e.g., while back-tracking or holding into

position / being lined up and ready for takeoff ) or when conducting a final approach
to an assigned runway, pilot’s should listen and give attention to all communications
related to this runway; and,
• When operating in a congested airspace, pilots should listen and give attention to all
communications related to clearances to climb or descend to, or through, their flight
level.
VI.16 Timeliness of Communications

Deviating from an ATC clearance may be required for operational reasons
( e.g., performing a heading or altitude deviation for traffic or weather avoidance,
inability to meet a restriction, … ).
Both the pilot and the controller need time to accommodate such deviations; therefore
ATC should be notified as early as possible to obtain a timely acknowledgement.
Similarly, when about to enter a known non-radar-controlled flight information region
( FIR ), contacting the new air route traffic control center ( ARTCC ), approximately
10 minutes before reaching the FIR boundary, may prevent misunderstandings or less-
than-required separations.
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VI.17 Blocked Transmissions ( simultaneous communications )

Blocked transmissions often are the result of not immediately releasing the push-to-talk
switch after a communication.
An excessive pause in a message ( i.e., holding the push-to-talk switch while preparing
the next item of the transmission ) also may result in blocking part of the response or
part of another message.
Simultaneous transmission of communications by two stations ( i.e., two aircraft or one
aircraft and ATC ) results in one of the two ( or both ) transmissions being blocked and
unheard by the other stations ( or being heard as a buzzing sound or as a squeal ).
The absence of readback ( by the pilot ) or the absence of hearback acknowledgement
( by the controller ) should be considered as an indication of a possibly blocked
transmission and, thus, prompt a request to repeat or confirm the information.
Blocked transmissions are responsible for many altitude deviations, missed turnoffs and
takeoffs and landings without clearance.
VII Communicating with ATC on Specific Events

The following events or encounters should be reported as soon as practical to ATC,
stating the nature of the event or encounter, the actions taken and the flight crew’s
further intentions ( as applicable ) :
• TCAS / ACAS resolution advisory (RA) events;
• Severe turbulence encounter;
• Volcanic ash encounter;
• Windshear or microburst encounter; and,
• (E)GPWS / TAWS terrain avoidance maneuver.
VIII Pilot / Controller Communications in Emergency Situations

In an emergency, the flightcrew and the controller should adopt a clear and concise
communications pattern, as suggested hereafter.
VIII.1 Flight crew

In an emergency, flight crew should appreciate that the controller may not be familiar
with the aircraft and its performance capability.
The controller may not understand a message that is too technical; a simple message
should be used to inform the controller of the prevailing condition.
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In an emergency, the initial message should comply with the standard ICAO
phraseology :
Pan Pan – Pan Pan – Pan Pan; or,
Mayday – Mayday – Mayday,

… depending on the criticality of the prevailing condition, to alert the controller
to the level of urgency and trigger an appropriate response.
Then, to explain the situation, simple and short messages should be used highlighting
the operational implications of the prevailing condition.
VIII.2 Controllers
Controllers should recognize that, when faced with an emergency situation, the flight
crew’s most important needs are:
• Time;
• Airspace;
• Silence on frequency.
The controller’s response to the emergency situation could be patterned after

the ASSIST memory aid, proposed below ( Source : Amsterdam Schiphol ATC ) :
• Acknowledge :
− Ensure that the reported emergency is well understood and acknowledged.
• Separate :
− Establish and maintain separation with other traffic and/or terrain.
• Silence :
− Impose silence on your control frequency, if necessary; and,
− Do not delay or disturb urgent cockpit actions by unnecessary transmissions.
• Inform :
− Inform your supervisor and other sectors, units and airports, as appropriate.
• Support :
− Provide maximum support to the flight crew.
• Time :
− Allows flight crew sufficient time to manage the emergency situation.
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IX Awareness and Training Program

A company awareness and training program on pilot / controller communications should
involve both ATC personnel and pilots ( e.g., during meetings and simulator sessions )
to promote a mutual understanding of each other’s working environment, including :
• Modern flight decks ( e.g., FMS reprogramming );
• Modern ATC equipment ( e.g., elimination of primary returns such as weather

returns on synthetic radar displays );
• Operational requirements ( e.g., aircraft deceleration characteristics, performance,

limitations ); and,
• Procedures ( e.g., SOPs ) and practices ( e.g., CRM ).
Special emphasis should be placed on pilot / controller communications and task

management during emergency situations.
X Summary of Key Points

Achieving effective pilot / controller communications requires a holistic approach,
the importance of the following key points should be emphasized :
• Adherence to company SOP’s;
• Understanding of pilots and controllers respective working environments and

constraints;
• Disciplined use of standard phraseology;
• Strict adherence to the pilot / controller communication loop ( i.e., confirmation /

correction process );
• Alertness to request clarification or confirmation, when in doubt;
• Readiness to question an incorrect clearance or an inadequate instruction;
• Preventing simultaneous transmissions;
• Adapting listening of party-line communications as a function of the flight phase;

and,
• Adopting clear, concise and adapted communications in an emergency situation.
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In addition, Operations Manual and/or SOPs should define the following company
policies:
• Primary language for use with ATC and in the cockpit; and
• Use of headsets below 10 000 ft.
XI Associated Flight Operations Briefing Notes

The following Flight Operations Briefing Notes may be reviewed to expand
the discussion on Effective Pilot / controller Communications :
• Standard Operating Procedures ( SOPs ) – Operating Philosophy
• HF Aspect in Incidents / Accidents
• CRM Aspects in Incidents / Accidents
• Enhancing Situation(al) Awareness
• Preventing Runway Incursions
XII Regulatory References

Reference regarding pilot / controller communications can be found in many
international and national publications, such as :

Transport – Aeroplanes, Appendix 2, 5.15.
• ICAO – Procedures for Air Navigation Services – Air Traffic Management

( PANS-ATM, Doc 4444 ).
• ICAO – Procedures for Air navigation Services – Aircraft operations ( PANS-OPS,

Doc 8168 ), Volume I – Flight Procedures (Post Amendment No 11, applicable
Nov.1/2001).
• ICAO - Annex 10 – Volume II / Communication Procedures – Chapter 5 /

Aeronautical Mobile Service.
• ICAO - Manual of Radiotelephony ( Doc 9432 ).
• ICAO – Human Factors Training Manual ( Doc 9683 ).
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• ICAO – Human Factors Digest No 8 – Human Factors in Air Traffic Control

(Circular 241).
• The respective national Aeronautical Information Publications ( AIPs ).
• National publications, such as :

− the U.S. Federal Aviation Administration ( FAA ) Aeronautical Information
Manual ( AIM ) – Official guide to basic flight information and air traffic control
procedures;
− the guide of Phraseology for Radiotelephony Procedures issued by the French
Direction de la Navigation Aerienne ( DNA ); and / or,
− the Radiotelephony Manual issued by the U.K. Civil Aviation Authority
( Civil Aviation Publication - CAP 413 ).
• FAR 121.406, 121.419, 121.421 or 121.422 - CRM Training for pilots, cabin crew
and aircraft dispatchers.
• FAA AC 60-22 – Aeronautical Decision Making.
• UK CAA - CAP 710 – On the Level.
• UK CAA – Air Traffic Information Services Notice 8/2002 – Phraseology Associated

with Clearances Involving FL 100, 200, 300 and 400.
• UK CAA – Flight Operations department Communication 11/2000 – Understanding

and Interpreting Phraseology and Procedures used by Air Traffic Services Providers.
XIII Industry References and Publications
• IATA Report – English Language in Civil Aviation.
• IHS – AV-DATA website :

− http://www.ihserc.com/regulations/aviation-av-data/index.html
• GAIN – Report of Working Group E ( Flight Operations / ATC Operational Safety

Information Sharing ) – Pilot / Controller Collaboration Initiatives : Enhancing
Safety and Efficiency, available on GAIN website – http://www.gainweb.org/
• NASA – ASRS website - http://asrs.arc.nasa.gov/main.htm
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• Eurocontrol – Level Bust Tool Kit.
• Eurocontrol website – Level Bust website :

− http://www.eurocontrol.int/safety/LevelBust_LevelBust.htm
This Flight Operations Briefing Note (FOBN) has been developed by Airbus in the frame of the Approach-and-Landing
Accident Reduction (ALAR) international task force led by the Flight Safety Foundation.

FOBN Reference : FLT_OPS – HUM_PER - SEQ04 - REV03 – SEPT 2004
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Flight Operations Briefing Notes Enhancing Situational Awareness

Human Performance
Enhancing Situational Awareness
I Introduction
This Flight Operations Briefing Note presents a definition of situational awareness.
It explains the complex process of gaining and maintaining situational awareness,
focuses on how it may be lost and proposes prevention and recovery strategies.
This briefing note is intended to help the reader gain and maintain situational
awareness, to prevent falling into the traps associated with the loss of situational
awareness and to avoid the adverse effects of the loss of situational awareness on flight
safety.
II Background Information
Situational Awareness is (Source: Mica Endsley – 1988):

• The perception of the elements in the environment within a volume of time and
space
• The comprehension of their meaning
• The projection of their status in the near future.
The main components of situational awareness are:

• Environmental Awareness: Awareness of other aircraft, communications between
ATC and other aircraft, weather or terrain
• Mode Awareness: Awareness of aircraft configuration and auto flight system modes.
The latter includes such aspects as current and target speed, altitude, heading,
AP / FD armed / engaged modes and the state of flight management system
(FMS) data enties and flight planning functions
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• Spatial Orientation: Awareness of geographical position and aircraft attitude

• System Awareness: Awareness of status of aircraft systems
• Time Horizon: Awareness of time management (e.g., fuel status / monitoring, time
factor in smoke situation or emergency electrical configuration).
III Statistical Data

Situational awareness is not just a theoretical notion and is pertinent to most accident
or incident cases. It is real, and its absence causes accidents. Research from
the Australian Transportation Safety Board (ATSB) indicates that human factors is
a contributing cause in around 70 percent of all incidents and accidents. Approximately
85 percent of incident reports include a mention of loss of situational awareness.
Degraded situational awareness can lead to inadequate decision making and
inappropriate actions. This is illustrated in Table 1, which identifies causal factors
involved in approach and landing accidents.
Factor % of Events
Inadequate decision making 74%
Omission of action or inappropriate action 72%
Non-adherence to criteria for stabilized approach 66%
Inadequate crew coordination, cross-check and back-up 63%
Insufficient horizontal or vertical Situational Awareness 52%
Inadequate or insufficient understanding of prevailing conditions 48%
Slow or delayed action 45%
Flight handling difficulties 45%
Deliberate non-adherence to procedures 40%
Inadequate training 37%
Incorrect or incomplete pilot/controller communication 33%
Interaction with automation 20%
Source: Flight Safety Foundation - Flight Safety Digest Volume 17 & 18 – November 1998 / February 1999
Table 1
Causal Factors in Approach and Landing Accidents
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IV Gaining and Maintaining Situational Awareness
Situational awareness is having an accurate understanding of what is happening around

you and what is likely to happen in the near future. As shown in Figure 1, situational
awareness includes three processes:
• The perception of what is happening (Level 1)
• The understanding of what has been perceived (Level 2)
• The use of what is understood to think ahead (Level 3).
Source: Adapted from Endsley’s definition
Figure 1
Gaining and Maintaining Situational Awareness
Level 1 — Perception: scanning, gathering data

To build a mental model of the environment, it is necessary to gather sufficient and
useful data by using our senses of vision, hearing and touch to scan
the environment. We must direct our attention to the most important and relevant
aspects of our surroundings and then compare what we sense with experience and
knowledge in our memory.
It is an active process that requires significant discipline, as well as knowing what to
look for, when to look for it and why.
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e.g., Gather flight plan data: Available routes, Available altitudes, Planned flight path, Dispatcher's
concurrence with plan, Fuel reserve requirement, Arrival fuel requirement, Assigned runway, Planned
climb profile, Planned airspeed profile …
Level 2 — Representation: understanding, creating our mental model

Our understanding is built by combining observations from the real world with
knowledge and experience recalled from memory. If we successfully match
observations with knowledge and experience, as shown in Figure 2, we have
developed an accurate mental model of our environment. This mental model has to be
kept updated with inputs from the real world by paying attention to a wide range of
information.
Mental
Model
Figure 2
Understanding the Situation by Matching Mental Model and Real World
e.g. Understand flight plan data: Deviation between plan and optimal profile, Safety/legal
requirements, Aircraft capabilities and ATC requirements, Fuel reserves , Schedule deviation, Heading
deviation, Altitude deviation, Airspeed deviation …
Level 3 — Projection: Thinking Ahead, Updating the Model

Our understanding enables us to think ahead and project the future state of
our environment. This step is crucial in the pilot’s decision making process and requires
that our understanding, based on careful data gathering, is as accurate as possible.
It simply is “ Flying ahead of the aircraft”.
e.g. Project flight plan data: Projected taxi time, Projected schedule deviation, Estimated time of
arrival, Predicted fuel usage, Predicted fuel burn rate, Projected time available on current fuel,
Predicted time to destination …
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V Situational Awareness and Decision Making Process

Situational awareness is strongly related to the decision making process. Figure 3
shows a simple model of the tight coupling between situational awareness and decision
making. Situational awareness must precede decision-making because the operator has
to perceive a situation in order to have a goal.
Source: Endsley, 1995
Figure 3
Situational Awareness and Decision Making
Our actions are driven by goals. To help us act to achieve our goals, we use our mental
models to anticipate the outcome of our action. This can be thought of as
a feed-forward process.
The more we anticipate accurately, the more efficient we become in our tasks,
the more energy we save, and the more we can preserve resources for unexpected
situations.
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Conversely, by comparing the results of our actions with set goals, we can modify
our actions or, if necessary, our goals. This feedback is vital to the success of
the process.
Feedback and anticipation help keep our mental picture of the world aligned with
the real world.
A major loss of situational awareness occurs when inappropriate mental representations
are activated in spite of real world evidence. People then act “in the wrong scene” and
seek cues confirming their expectations, a behavior known as confirmation bias.
In other words, situational awareness influences our decision making and allows us
to stay ahead of the aircraft:
• It helps us develop a mental picture of the world around us and use that mental
picture to anticipate the future, to feed-forward
• Because of the close coupling of real-world feedback, mental anticipation and
adaptation of actions, we adjust our mental picture and modify our actions.
If what we expect to happen and what is really happening does not coincide,
we may even adjust our goals. This is often coupled with a feeling that we have lost
“control”.
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VI Losing Situational Awareness

Many factors can cause a loss of situational awareness. Errors can occur at each level of
the process previously described. Table 2 lists a non-exhaustive series of factors
related to loss of situational awareness and conditions contributing to these errors.
Level 1: Perception
• Data is not observed, either because it is difficult to observe or because the observer’s
scanning is deficient due to:
− Tunnel vision
− Passive, complacent behavior
− High workload
− Distractions and interruptions
• Visual Illusions
E.g. Focusing on recapturing the LOC and not monitoring the G/S.
Level 2: Understanding
• Use of a poor or incomplete mental model due to:

− Deficient observations (Level 1 problem)
− Poor knowledge / experience.
• Use of a wrong or inappropriate mental model
• Confirmation bias: perceived information is misunderstood. Expecting to observe
something and focusing our attention on this belief can cause seeing what you
expect rather than what is actually happening.
E.g. Applying a fuel imbalance procedure without realizing it is an engine fuel leak.
Level 3: Thinking Ahead
• Over-reliance on the mental model and failing to recognize that the mental model
needs to change.
E.g. Expecting an approach on a particular runway afther having received ATIS

information and being surprised to be vectored for another runway.
Table 2
Typical Factors Involved in Loss of Situational Awareness
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VII Best Practices, Prevention Strategies and Lines-of-Defense
Build Situational Awareness :
• Set specific objectives

− Define flight targets and data gathering
• Set priorities
− Follow SOPs
• Prepare for anomalies

− Consider visual illusions, missing information, etc.
• Make risk assessments

− Ask, “what if?”
• Manage workload
− Shift tasks away from busy times, delegate, anticipate.
Maintain Situational Awareness :
• Communicate
− Keep all crewmembers and external participants (e.g., company flight dispatch /
flight watch office) in the loop
• Manage attention
− Set priorities, avoid distraction, adjust monitoring to flight phase urgency
• Seek information
− Use your senses
− Know WHAT is important, WHEN to seek for and WHERE to find it
− Validate your data
• Cross-check – Use multiple sources of information when available
• Use rules of thumb when data are not available.
• Check your understanding

− Check for contradictory elements in the real world
− Apply experience and lessons learned.
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• Think ahead
− Brief others on what you expect
− Compare projected state with objectives
− Set markers for confirmation and information ( define “next targets” at each
point of the whole flight and “approach gates” during descent / approach )
− Compare actual state with expectations and objectives
− Readjust your plan if required.
Detect Loss of Situational Awareness :

• Look for clues of degraded situational awareness
− Ambiguity – Unclear flight plans or ATC instructions
− Fixation – Focusing on one thing to the exclusion of everything else
− Confusion – Uncertainty or misunderstanding a situation or information
− Preoccupation – Everyone focusing on non-flying activities; nobody
flying the aircraft
− Unresolved discrepancies – Contradictory data or personal conflicts
− Expected checkpoints not met – Flight plan, profile, time, fuel burn
− Poor communications – Vague or incomplete statements
− Broken rules – Limitations, minimums, regulatory requirements, failure
to follow SOPs
− No time – Falling behind the aircraft.
Recover Situational Awareness :

• Go to the nearest STABLE, SIMPLE and SAFE situation
− Follow rules, procedures and SOPs
− Change automation level (user a lower level of automation or revert to hand-
flying)
− Buy time (request delaying radar vectors, a hold or an extended downwind leg).
• Communicate – Asking for help is not a sign of weakness
• Recover the big picture

− Go back to the last thing you were sure of
− Assess the situation from different perspectives, with different sources
− Expand your focus to avoid fixation and tunnel vision
− Manage stress and distraction
− Take time to think / Use that time / Be willing to delay flight progress.
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VIII Summary of Key Points
• Situational awareness is essential for flight safety and its influence and impact are
pervasive
• Situational awareness is gained by using the senses to scan the environment and
compare the results with mental models
• Planning, communication and coordination for upcoming flight phases, goal setting
and feedback are essential ingredients of Situational Awareness and decision-
making
• Inattention, distraction and high workload threatens situational awareness
• To prevent the loss of situational awareness :

− Implement proven best practices: sterile flight deck, standard calls, CRM, golden
rules, instrument scan, …
− Follow strictly company SOPs.
IX Associated Flight Operations Briefing Notes

The following Flight Operations Briefing Notes should be reviewed along with the above
information:
• Human Factors Aspects in Incidents and Accidents
• CRM Aspects in Incidents and Accidents
• Error Management
• Effective Pilot / Controller communications
• Optimum Use of Automation
• Standard Calls
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X Additional Reading Material / Websites References

• Enhanced Safety through Situation Awareness Integration in training (ESSAI); Air
Transport Portal of the European Commission – Research – 5TH Framework
Programme: http://ec.europa.eu/transport/air_portal/index_en.htm
• Guidelines for Situation Awareness Training; Air Transportation Division – Branches
- Air Carrier Training Branch – Training Aids:
http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/afs/
• Situation Awareness Information Requirements for Commercial Airline Pilots; MIT /
International Center for Air Transportation – Research – 1998:
http://web.mit.edu/aeroastro/www/labs/ICAT/
All uses shall credit Airbus.

Flight Operations Support and Services
FOBN Reference : FLT_OPS – HUM_PERF – SEQ 06 – REV 01 – JUL. 2007
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Flight Operations Briefing Notes Error Management

Human Performance
Error Management
I Introduction
With the achieved high reliability of modern aircraft systems, human performance has
become a key focus area for flight safety. Various types of human error are often
quoted as contributing factors to incidents and accidents.
Safety officers at airlines observe human errors and even violations when they monitor
the safety performance of their airline through safety reports and Flight Data
Monitoring.
Information or training alone cannot immunize a person or an organization against
error. Improvement is only achieved through concrete improvements that make errors
less probable and their consequences less severe.
The objectives of this Flight Operations Briefing Note are:

• To familiarize the reader with the key concepts of human error and violation
• To guide the reader towards productive solutions in error and violation
management.
The perspective of this Briefing Note is at the organizational level. In other words,
the aim is to help Safety Managers, Training Managers and other similar people to
apply the most effective systemic solutions for managing errors and violations in their
organization. Even if the Briefing Note certainly gives ideas for Error Management also
at the individual level, it is not the primary aim here to give pilots new Threat and Error
Management techniques, but rather to try reduce the number and gravity of Threats
they face in the operation.
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II Defining Human Error and Violation
II.1 Errors and Violations

In everyday language, the term “error” is used in a very broad sense. For a more
detailed discussion of the topic, more precise definitions are needed. The classification
used here is in line with James Reason’s definitions.
Errors are intentional (in)actions, which fail to achieve their intended outcomes.
Errors can only be associated with actions with a clear intention to achieve a specific
intended outcome. Therefore, uncontrolled movements, e.g. reflexes are not considered
errors. The error itself by definition is not intentional, but the original planned action
has to be intentional. Furthermore, it is assumed in the above definition that
the outcome is not determined by factors outside the control of the actor.
Violations are intentional (in)actions, which violate known rules, procedures or norms.
The fundamental difference between errors and violations is that violations are
deliberate, whereas errors are not. In other words, commiting a violation is a conscious
decision, whereas errors occur irrespective of one’s will to avoid them. Cases of
intentional sabotage and theoretical cases of unintentional violation (breaking a rule
because the person is not aware of the rule) are outside the scope of this Flight
Operations Briefing Note.
Therefore, it is important to realize that within the scope of our discussion a person
committing a violation does not intend the dramatic negative consequences which
sometimes follow a violation - usually it is belived bona fide that the situation remains
under control despite the violation.
It is worth noting that many sources, even in the domain of aviation safety, use
the term “error” in a wider sense, covering both errors (as defined here) and violations.
Errors can further be divided into the two following categories:
• Slips and lapses are failures in the execution of the intended action.
Slips are actions that do not go as planned, while lapses are memory failures.
For example, operating the flap lever instead of the (intended) gear lever is a slip.
Forgetting a checklist item is a lapse.
• Mistakes are failures in the plan of action. Even if execution of the plan was
correct, it would not be possible to achieve the intended outcome.
Plans that lead to mistakes can be deficient (not good for anything), inappropriate
good plans (good for another situation), clumsy (with side-effects) or dangerous
(with increased risks).
Figure 1 summarizes the defined concepts.
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Human Performance
Unintentional Slips and lapses

Plan is good
Action is not according to the plan
Slip (incorrect action), lapse (action forgotten)
Mistake
Plan is not correct for reaching the goal
Deficient, wrong, clumsy or dangerous plans
Intentional
Violation
Deliberate violation of a rule, procedure or norm
Routine, situational and exceptional violations
Figure 1
Summary of Errors and Violations
II.2 Performance Levels

Different error types are often associated with so-called performance levels. At any
point in time, a person usually performs several tasks simultaneously. For example,
a pilot may be flying the aircraft manually (reading instruments, analyzing the situation
and giving inputs to flight controls), going through the checklist read by the PNF and
remaining vigilant for any radio traffic. In order to be capable of such multi-tasking,
despite limited attentional resources, the human cognition is able to perform familiar
tasks with minimal attention and the most familiar tasks automatically.
This capability can be modeled with Rasmussen’s skill-based, rule-based, knowledge-
based presentation of performance levels. Rasmussen’s model is briefly introduced
below.
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Applying learned routine skills in normal well-known situations is skill-based

performance.
Example – Skill-based Performance

When flying the aircraft manually, an experienced pilot does not need to focus
the attention on the physical routines of moving the sidestick and operating the thrust
levers. Such routines have become automatic “programs” that can be run while
the pilot allocates the conscious attention on something else – typically on where (s)he
wants to fly the aircraft.
In the hierarchy of performance levels, the next level is rule-based performance. In

rule-based performance the person is confronted with a situation where attention must
be focused on making a decision or creating a solution. However, the situation is a well-
known one, for which the person has been trained. Therefore, as soon as the situation
has been identified, the person can easily apply a known solution and carry on with
the original activity, often returning to the skill-based level. The name “rule-based”
reflects the existence of learned solutions providing IF-THEN “rules” that can be applied
to the situation – not necessarily rules in the classical sense, i.e. regulations or norms.
Example – Rule-based Performance

The automatic routine of taxiing on an empty straight taxiway may be interrupted by
the observation of an animal running in front of the aircraft, requiring momentary
attention, diagnosis of the situation and a decision on the action to take. What is
the animal? How far is it and where is it going? Is there a risk the aircraft will be
damaged? Should the aircraft be slowed down, stopped or can taxiing continue
normally?
Training and experience allows a person to construct a collection of rules, to know when
to apply these rules and to know which clues to use to identify a situation correctly. For
instance, at the time when windshear and microburst phenomena were still not well
known within the aviation community, many flight crews found themselves in a
surprising situation where it was difficult to understand what was happening, and
without any effective solutions to apply. Sometimes the consequences were disastrous.
Since these phenomena have been better known, crews have been trained to identify
the situation rapidly and correctly, and to apply the correct flying techniques.
The most attention-consuming performance level is the knowledge-based level.

In a completely new situation, without the help of any existing solutions, the person is
forced to face the painful task of trying to find an on-the-spot solution, based solely on
the knowledge of the system. When such a situation emerges in the context of
a complex system and under time pressure, the analytical capacity of the human
cognition is quickly surpassed, and the chances for a successful outcome are seriously
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compromized. Preventing crew members from getting into such situations is one of
the self-evident guiding principles in aviation.
Example – Knowledge-based Performance

Two cases that involved a total loss of hydraulics, the DC-10 at Sioux City 1989
(uncontained engine failure) and the A300 in Baghdad 2001 (hit by a missile), serve as
rare examples where the flight crew were successful in the almost impossible task of
learning to fly a damaged aircraft with engine power only, and landing it. In these cases
the flight crew could only rely on the on-the-spot reasoning, experimenting and overall
knowledge of the aircraft and flying.
Errors and violations have different forms at different performance levels.

Slips and lapses typically emerge at the skill-based level. There are several known
mechanisms behind slips and lapses. It is known, for example, that mental “programs”
which are most commonly used, may take over from very similar programs, which are
less frequent or exceptional.
Example – Lapse at the skill-based level

The captain learns that a structural repair has been performed on his aircraft prior to
the flight due to an earlier ground damage, and decides to take a look at it during
the walkaround. However, when he later starts the walkaround check, he quickly falls
into the normal routine “program” of performing the walkaround, completely forgetting
his exceptional intention to check the damage repair. He realizes his lapse only once
back in the cockpit.
Violations at the skill-based level are routine violations: violations that have become
part of the persons automated routines, like routinely exceeding the speed limit slightly
when driving.
Mistakes are results of conscious decision making, so they occur at rule and knowledge-
based performance levels. In both cases, the two typical problem areas are:
• Identifying the situation correctly
• Knowing the correct solution (“rule”) to apply.
At the knowledge-based level the challenge is to process an overflowing quantity of

information and to understand it in such a way as to be able to make correct diagnosis
and decisions. In contrast, at the rule-based level the flow of information may be well
within the processing limits, but the partially unconscious process of situation diagnosis
and the quality of previously learned solutions (“rules”) become critical.
Violations at the rule-based level are usually situational: the person performs
the corner-cutting he judges necessary or useful to get the job done. Violations at
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the knowledge-based level are usually so-called exceptional violations, and sometimes
quite serious in their nature.
Figure 2 illustrates the three performance levels.
Control Modes
Conscious
Mainly conscious and automatic Mainly automatic
Situations
Routine, Skill-based
expected
performance
Slips & lapses

Familiar or Rule-based Routine violations
trained- for
performance
problems
Mistakes: applying incorrect rules
Situational violations
Novel, difficult Knowledge

or dangerous -based
problems performance Mistakes: overflow of cognitive capacity
Exceptional violations
Figure 2
Performance Levels and Main Error and Violation Types
(adapted from Rasmussen and Reason)
II.3 Consequences of Errors and Violations

Errors and violations together form the unreliable part of human performance. It is
often stated that 70-90% of current aviation disasters are “due to human factors”.
While the reality is somewhat more complex, it is true that current accidents usually
contain important human performance elements. Errors and violations contribute to
accidents both directly and by making the consequences of other problems more
serious.
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In a complex (at least a priori) high-risk system – like commercial aviation – there are
multiple layers of defenses against known types of accidents. Therefore, an accident
involves several contributing factors, some usually being quite visible, and others being
more distant in time and place from the actual accident. It is important to realize, that
in such a system, the consequences of an error depend more on other factors than
the apparent gravity of the error itself. In other words, it is wrong to think that a big
catastrophe must have been preceded by an equally serious error. It is more
the number of errors and the capability of the system to contain the errors, that
determine the outcomes.
Examples – Consequences of errors

Error (lapse): Setting the flaps correctly for takeoff is forgotten.
Factors influencing the consequences:
• Aircraft type and performance
• Actual takeoff weight
• Runway length and obstructions ahead
• Functioning of the takeoff configuration warning.
Error (mistake): Navigation error.

Factors influencing the consequences:
• Other aircraft nearby
• High terrain nearby at same or higher altitude as the aircraft
• Functioning of the Traffic Alert and Collision Avoidance System (TCAS)
• Warnings from Air Traffic Control (ATC)
• Functioning of the Enhanced Ground Proximity Warning System (EGPWS).
As these examples portray, the very same error can have completely different
consequences, depending on the factors involved.
Some error types tend to have more serious consequences than other:
• Slips are usually easy to detect quickly and do not have immediate serious
consequences due to in-built system protections.
• Lapses may be more difficult to detect, and therefore may also be more likely to
have consequences.
• Mistakes are even more dangerous, because the person committing the mistake
believes that (s)he is doing the correct thing and thus carries on with the action
often despite a growing number of signs showing that things are not going right.
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• Violations are similar to mistakes but with an increased potential to deviate to an

abnormal type of operation – with increased risks. Many violations are tempting
because often they bring benefits without any visible drawbacks. The embedded
dangers may not be obvious, and people have few chances to learn to appreciate
them because violations are forbidden and thus a taboo subject. For example,
the violator usually assumes the remainder of the system to be nominal (i.e. no
other errors or violations). Ironically, Line Operations Safety Audit (LOSA) data has
shown that a violation almost doubles the chances of committing a further error or
violation during the remaining flight.
One common false assumption is that errors and violations are limited to incidents and
accidents. Recent data from Flight Operations Monitoring (e.g. LOSA) indicate that
errors and violations are quite common in flight operations. According to the University
of Texas LOSA database, in around 60% of the flights at least one error or violation was
observed, the average per flight being 1.5.
A quarter of the errors and violations were mismanaged or had consequences (an
undesired aircraft state or an additional error). The study also indicated that a third of
the errors were detected and corrected by the flight crew, 4% were detected but made
worse, and over 60% of errors remained undetected. This data should underline the
fact that errors are normal in flight operations and that, as such, they are usually not
immediately dangerous.
Overall, when an error has serious consequences in a highly safety-protected system, it
usually tells more about the operational system than about the error itself. Safe
systems (like aviation) are supposed to be engineered to manage errors in different
ways in order to avoid serious consequences. This is the topic of the next chapter.
III Error Management

People in management positions often find it difficult to deal with human errors. Simple
reactions like asking people to be “more careful” very rarely bring any improvement.
The seemingly easy solution to add warnings in documentation usually turns out to
have a very limited effect. Another natural reaction is to try to train people more,
hoping errors would then be avoided. Whereas different technical and non-technical
skills can be improved by training, therefore having a positive impact on certain types
of mistakes, training does very little in preventing slips and lapses.
Therefore, one must accept the fact that errors cannot be completely prevented no
matter how much people are trained and how many warnings are put in the operational
documentation.
The first step in successful error management is to understand the nature of
the experienced errors and the mechanisms behind them.
Real solutions for human error require systemic improvements in the operation. One
way consists of improving working conditions, procedures, and knowledge, in order to
reduce the likelihood of error and to improve error detection. Another way is to build
more error tolerance into the system, i.e. limit the consequences of errors.
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Achieving such systemic solutions requires first adopting an organizational focus to

error management, instead of focusing on the individuals committing the errors.
Preventing errors is usually not possible. Therefore the correct term to use is Error
Management. This chapter focuses first on the known error management strategies in
general, and then goes on to discuss the specifics of managing slips, lapses and
mistakes.
III.1 Error Management Strategies

• Error Prevention aims at avoiding the error all-together. This is possible only in
some specific cases and, almost without exception, requires design-based solutions.
• Error Reduction aims at minimizing both the likelihood and the magnitude of
the error.
• Error Detection aims at making errors apparent as fast and as clearly as possible,
and therefore enabling recovery. An error can be:
− Detected by the person that committed the error (self-monitoring), or
− Cued by the environment, or
− Detected by another person.
• Error Recovery aims at making it easy to rapidly recover the system to its safe state
after an error has been committed.
• Error Tolerance aims at making the system as tolerant as possible towards error,
i.e. minimizing the consequences of errors.
Example – Error prevention

A classic manual engine start routine introduces the potential for engine damage
through human error – e.g. by wrong timing of initiation and cutting off the fuel flow.
The automatic engine start sequence on FADEC equipped aircraft prevents these errors
by precise monitoring of the key engine parameters, correct timing of each step in
the sequence and automatic shut-down if anything abnormal occurs during the engine
start.
Example – Error reduction

Applying good ergonomics to the cockpit design reduces errors. Shaping the flap,
spoiler and landing gear levers to symbolize their functions produces both visual and
tactile cues and reduces slips involving the use of the wrong lever. The clear and logical
visual design of instruments and displays, like the presentation of speed and altitude on
the Primary Flight Display, reduces errors in reading them.
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Examples – Error detection

• Performance calculation software can warn the flight crew when some input values
are outside the reasonable range, making the error immediately visible (cued by
the environment).
• Red-flags on the pins can help detect pins that have been left in position: they can
be seen in the wrong place (still at landing gear during taxiing) or their absence in
the correct place can alert the crew.
• Crosschecking is a way to apply error detection as an error management strategy
(facilitating detection by another person).
• So-called forcing functions are design features, that force a person to detect and
correct an error before continuing the task, e.g. the refuel panel of the Hawk-trainer
– it cannot be closed if the fuel switch underneath is left in the “ground” position.
Examples – Error recovery

• The undo-function in computer software is perhaps the best-known application of an
error recovery feature.
• The possibility to introduce an automatic pull-up function as an extension of
the EGPWS has sometimes been discussed. Such a function would introduce forced
error recovery.
Example – Error tolerance

Conservative operational margins in performance models ensure that reasonably small
errors in aircraft loading and Weight & Balance calculations do not endanger the flight
in its critical phases, such as takeoff.
III.2 Managing Slips and Lapses.

Slips and lapses are very much the drawback of the useful human capability to perform
actions “automatically”, without full attention. The mechanisms causing them function
at an unconscious level. Therefore, even if slips and lapses can be reduced through
good design of the working interfaces, procedures and environments, it is impossible to
prevent all of them.
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Examples - Reduction of slips and lapses

• Controlling factors that are known to contribute to errors, like distractions. Among
other things, the sterile cockpit principle aims at reducing distractions.
• Standardized procedures reinforce the correct sequences of actions, and thus have
a positive impact on both slips and lapses.
• Levers designed with good tactile feedback reduce the risk of slips.
• Use of checklists reduces the risk of lapses.
• An airline was worried about several cases of omitted takeoff flap settings, that
were only detected by the takeoff configuration warning. The checklists were
changed to include the flap item before the taxi phase, that was considered to be
too prone to lapses due to distractions.
The last example also illustrates the already stated fact that effective solutions usually
require operational changes at the organizational level.
Due to the somewhat unpredictable nature of slips and lapses, the key management
strategies are detection, recovery and tolerance. Fortunately, most slips and lapses are
detected, and most often by the actor. As soon as the error is detected, slips and
lapses are usually easy to recover.
Examples - Detection, recovery and tolerance of slips and lapses

• To facilitate detection, it is crucial that the aircraft provides the flight crew with
immediate good-quality feedback on their actions and that flight crew members are
trained to use that feedback systematically to validate that their commands
(e.g. autopilot mode changes) are taken into account and implemented correctly.
• The PNF has an important error detection role. In order to truly fulfill the monitoring
role, the PNF must know how to monitor the flight effectively in different flight
phases.
• The unlocking movements needed to operate flap and spoiler levers may delay
the execution of a slipped action in such a way as to facilitate detection either by
the actor themselves or by another person.
• Erroneously retracting the flaps at too low a speed or too high an angle of attack
causes an Airbus aircraft to activate protections in order to minimize excursions
from the desired flight profile. Depending on the situation, slats will remain
extended and TOGA thrust may be applied. Thus the error is tolerated.
• Not having retracted the flaps and approaching the speed limit for the configuration
will activate the overspeed protections. In this case error detection (overspeed
warning) and tolerance (automatic flap retraction) together provide the opportunity
for successful error recovery.
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III.3 Managing Mistakes

As stated earlier, mistakes are deficient solutions or decisions, often caused by failed
situational diagnosis or poor quality of learned solutions.
If a crew found themselves in a knowledge-based problem-solving situation, their
chances of success would rely on their basic knowledge of the key phenomena, and
the use of skills promoted through CRM training, such as the ability to stay calm,
communicate and cooperate. Because mistakes at the knowledge-based level are
practically inevitable and difficult to recover, instead of trying to develop related error
management strategies, the principle in aviation is simply to prevent crews from
getting into such situations. The whole aviation system has been built accordingly.
Scientific data suggests that the probability of correctly recovering from a skill-based
slip is double compared to a rule-based mistake, and three times higher than for
a knowledge-based mistake. The remainder of this chapter concentrates on rule-based
mistakes.
The usable strategies are mistake reduction, detection and recovery. Success in these
will be mainly determined by three areas: knowledge, attentional and strategic factors:
• Knowledge is reflected both in how well situations are diagnosed and the quality of
the chosen solutions. Adequate knowledge relies on training, experience and
availability of updated situational information, like weather and runway conditions.
• Attentional factors determine how easily the relevant information is available. In an

ideal case, the attention of the crew is guided to the contextually most relevant and
reliable source of information, and the presentation of the information is such that it
enables the crew to construct a complete situational understanding rapidly.
Information overload, distractions and noise should be avoided. When the available
information corresponds to attentional resources and informational needs, diagnosis
is easier and potential mistakes are more easily detected. Attentional factors are
particularly important in view of the biases and heuristics that often distort
the diagnostic process.
Note:
Heuristics are simple mental rules of thumb which the human mind uses to solve
problems and make decision efficiently, especially when facing complex problems or
incomplete information. These rules work well under most circumstances, but
sometimes lead to systematic misjudgments.
• Strategic factors determine the difficulty of the situation in terms of multiple goals,
some of which are often partly in conflict. Usually, some goals are obvious and
official, while it is possible that others are hidden, personal or even unconscious
goals. Strategic factors become most visible in decision-making situations.
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Example – Strategic factors

Following a system failure, the flight crew hesitates between: 1) Landing at the nearest
airport that has a short runway and limited landing aids, and, 2) Continuing to
the original destination, that is also the airline’s base with maintenance facilities and a
good runway. Safety, operational and passenger comfort goals all mix together.
The flight crew may have their own emotional preference for continuing to the home
base, because it also means getting home. There may also be fear of retribution by
the company’s management, if the flight crew takes the aircraft to an unplanned
destination “without real need”.
It is clear that while some strategic factors originate from the flight crew, many of them
are imposed by the organization and external agents. Obviously, the organization
should try to ensure that serious goal conflicts are avoided and that when they arise,
safety is not compromised.
A significant proportion of mistakes are caused by incorrect situation diagnosis, which is
a particularly problematic task for the human cognition. This is mainly due to the biases
and heuristics used by the human cognition in an attempt to process large amounts of
information rapidly.
Examples - Biases and heuristics:

• Expectation bias helps to fill in the blanks in communications and understand
incomplete messages, but can also make the person hear what he expects to hear
instead of what was actually said. Expectation bias is hard to counteract. It is
important to stress the importance of read-backs and trying to really listen.
• Availability heuristic helps to collect information rapidly, but puts more emphasis
on the most easily available information sources rather than the most reliable and
relevant sources. Availability heuristic can be counteracted through good design of
instruments and procedures, and training that teaches the flight crew to focus on
the contextually most relevant information sources, and underlines
the limitations of the sources.
• Confirmation bias helps create a hypothetical diagnosis about the situation
rapidly, but the hypothesis is based only on a subset of available information and
may lead to fixation, where an incorrect diagnosis is maintained despite
an increasing quantity of counter-evidence. This underlines the value of “fresh eyes”
making an independent diagnosis.
IV Violation Management
In simple terms, violation management consists of understanding the reasons for
violations and then trying to remove these reasons. In an ideal situation,
the organization facilitates learning from difficulties in the operations, and fixing them
before people need to “fill the gaps” by violating.
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There are known factors that increase the probability of committing violations:
• Expectation that rules will have to be bent to get the work done
• Powerfulness: Feeling that skills and experience justify deviating from the standard
procedures
• Opportunities for short cuts and other ways of doing things in a seemingly better
way
• Poor planning and preparation, putting the person in situations where it is necessary
to improvise and solve problems “on the fly” as they arise.
This set of factors is sometimes called “the lethal cocktail”.

Often the conditions that induce violations are created, because the organization cannot
adapt fast enough to new circumstances. The violator may be a very motivated person,
trying to do things “better” for the company. This explains why management pilots are
often more likely to violate, especially in small companies where business pressures are
strongly felt due to very limited operational flexibility.
Examples - Violations
• The CEO of a small helicopter operator, who was also flying as a Captain, flew
scheduled passenger flights without the required co-pilot, sometimes making a non-
qualified pilot sit in the co-pilot seat to mask the violation. This exceptional and
completely unacceptable behavior probably reflects operational pressures, a high
motivation to perform, and a sense of powerfulness.
• Arrival of new aircraft and a growing route network without increasing resources
accordingly create a lack of pilots. This, in turn, creates the pressure for some
management pilots to “push the duty time limits”.
• Over-motivation to bring the aircraft to the scheduled destination, combined with
high regard of one’s own flying skills, may encourage a pilot to try to “push through
the minima” and land.
As with errors, it is important to look for the root causes of violations in

the organization. Therefore, the solutions must also be implemented at that level. This
also explains why violations are not necessarily always punishable.
It is in no way the intention to undermine the importance of individual responsibility for
one’s own actions. Dangerous and reckless behavior should never be tolerated.
However, some routine or situational violations may have been imposed on
the individual by deficient organization or planning, and any individual put in the same
situation might find it difficult not to violate.
Acceptance of a non-compliant way of doing the job may have become part of the local
working culture, which also means that the whole group – including management - is
responsible for the violation, not only the individual actually carrying it out.
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The ultimate goal is to establish a working culture, where violations are not an
acceptable option. Like all cultural issues, this can take considerable time and effort.
Chances for success are greatly enhanced if the employees themselves are involved in
setting the limits of what is acceptable in their own work. The limits must then be
clearly communicated and imposed.
On a continuous basis, violation management can take four different forms:
• Establish channels for people to communicate difficulties and to discuss solutions.

This facilitates learning about problems and adjusting planning accordingly to avoid
strains, which could lead to violations.
• Analyze existing violations and assess current violation potential. Try to understand
the background of current violations. Use the above list of violation inducing factors
to assess potential for future violations.
• Try to ensure that management reduces violations through good leadership and
planning.
• Ensure that both management and employees are aware of their responsibilities and
key risks related to their work and understand how violations reduce vital safety
margins.
V Summary of Key Points

• Errors and violations are more common in flight operations than one would expect.
They have the potential to affect safety, although usually the robustness of
the aviation system is high enough to contain errors and violations without
significant consequences.
• The first step in error and violation management is to understand the mechanics
behind them. This Flight Operations Briefing Note has aimed at providing the basic
information on the subject.
• Successful management of errors and violations requires continuous application of
systemic improvements at the organizational level. Ultimately, violation-free
operations should become a natural part of the corporate culture.
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VI Associated Flight Operations Briefing Notes
The following Flight Operations Briefing Notes handle topics related to this Briefing
Note:
• Threat Management
• Effective Pilot/Controller Communications
• CRM Aspects in Incidents and Accidents
• HF Aspects in Incidents and Accidents
VII Additional Reading Materials

• James Reason (1990) Human Error, Cambridge University Press, Cambridge, UK
• David D. Woods et al (1994) Behind Human Error: Cognitive Systems, Computers,
and Hindsight, CSERIAC State-of-the-Art Report, Wright-Patterson Air Force Base,
Ohio, US
• Patrick Hudson, University of Leiden (2000) Non-Adherence to Procedures:
Distinguishing Errors and Violations, presentation given to the 11th Airbus Human
Factors Symposium, Melbourne, Australia (available at www.airbusworld.com /
Secure Area / Flight Operations Community / Products and Services / Conferences).
All uses shall credit Airbus.

FOBN Reference : FLT_OPS – HUM_PER – SEQ 07 – REV 01 – DEC. 2005
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Flight Operations Briefing Notes Visual Illusions Awareness

Human Performance
Visual Illusions Awareness
I Introduction
Visual illusions take place when conditions modify the pilot’s perception of
the environment relative to his / her expectations.
Visual illusions may result in landing short of the runway, hard landing or runway
overrun, but may also cause spatial disorientation and loss of control.
This Flight Operations Briefing Note provides an overview of:

• Factors and conditions that may cause visual illusions;
• How visual illusions affect the pilot’s perception of the airport / runway environment
and runway; and,
• How to reduce the effects of visual illusions by implementing related prevention
strategies and lines-of-defense in training and line operation.
II Statistical Data
30 % of approach-and-landing accidents occur during the conduct of visual approaches

or during the visual segment of an instrument approach.
Visual approaches at night present a greater exposure because of reduced visual cues,
increased likelihood of visual illusions and risk of spatial disorientation.
Low visibility and/or precipitations are a circumstantial factor in more than 70 % of
approach-and-landing accidents, including those involving CFIT.
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“ Visual ” Factors % of Events
Night time 75 %
Low visibility 70 %
IMC 59 %
Darkness or twilight 53 %
Non-ILS approach 53 %
Precipitation (rain or snow) 50 %
Visual approach 30 %
Visual illusions or spatial disorientation 21 %
Absence of :
- letdown navaid
21 %
- approach / runway lighting
- VASI / PAPI
( Source – Flight Safety Foundation 1998 – 2000 )
Table 1
“ Visual ” Factors in Approach-and-Landing Events
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III Visual Illusions – Factors and Conditions
The following factors and conditions affect the flight crew ability to accurately perceive
the environment, resulting in visual illusions.
III.1 Airport Environment
• Ground texture and features;

• Off-airport light patterns such as brightly lighted parking lots or streets;
• “Black hole” along the final approach flight path; and/or,
• Uphill or downhill sloping terrain before the runway threshold or in the approach
path environment.
III.2 Runway Environment
• Runway dimensions (aspect ratio);

• Runway uphill or downhill slope;
• Terrain drop-off at the approach end of the runway;
• Approach and runway lighting; and/or,
• Runway condition (e.g., wet runway).
III.3 Weather Conditions
• Ceiling;
• Visibility (i.e., vertical visibility, slant visibility and horizontal visibility); and/or,
• Cloudiness (e.g., rain, fog or fog patches, haze, mist, smoke, snow, whiteout
effect).
IV How do Visual Illusions Affect the Pilot’s Perception ?
Visual illusions result from the absence of or the alteration of visual references that
modifies the pilot perception of his / her position relative to the runway threshold.
Visual illusions affect perception of heights, distances and/or intercept angles.
Visual illusions are most critical when transitioning from IMC and instrument references
to VMC and visual references.
Visual illusions (such as the black-hole effect) affect the flight crew vertical and
horizontal situational awareness, particularly during the base leg and when turning final
(as applicable) and during the final approach.
Visual illusions usually induce crew inputs (corrections) that cause the aircraft to
deviate from the original and intended vertical or lateral flight path.
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Visual illusions can affect the decision about when and how fast to descend from
the MDA(H).
The following paragraph provides an expanded overview of all the factors and
conditions creating visual illusions to discuss how each factor or condition may affect
the pilot perception of:
• The airport and runway environment;
• The terrain separation; and,
• The aircraft vertical or lateral deviation from the intended flight-path.
Usually, more than one factor is involved in a given approach, compounding

the individual effects.
IV.1 Airport Environment
• “Black hole” along the final approach flight path:

− In case of approach over water or with an unlighted area on the approach path,
the absence of visible ground features reduces the crew ability to perceive
the aircraft lateral and vertical position relative to the intended flight path.
• Uphill or downhill terrain before the runway threshold:

− An uphill slope in the approach zone or a drop-off of terrain at the approach end
of the runway creates an illusion of being too high (i.e., impression of a steep
glide path, as shown on Figure 1), thus:
• Possibly inducing a correction (increasing the rate of descent) that places

the aircraft below the intended glide path; or,
• Preventing the flight crew from detecting a too shallow flight path.
Perceived Glide Path

Actual Glide Path
Figure 1
Effect of Terrain Up-hill Slope on Flight Path Perception
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− A downhill slope in the approach zone creates an illusion of being too low
(i.e., impression of a shallow glide path, as shown on Figure 2), thus:
• Possibly inducing a correction placing the aircraft above the intended glide
path ; or,
• Preventing the flight crew from detecting a too steep flight path.
Perceived Glide Path

Actual Glide Path
( Photo No.1 : 12 NM from touchdown – Photo No.2 : 2 NM from touchdown, on PAPI glide path )
Figure 2
Effect of Terrain Down-hill Slope on Flight Path Perception
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IV.2 Runway Environment
• Runway dimensions / aspect ratio (Figure 3):

− The runway aspect ratio (i.e., its length relative to its width) affects the crew
visual perspective view of the runway:
• A wide or short runway (low aspect ratio) creates an impression of being too
low; and,
• A narrow or long runway (high aspect ratio) creates an impression of being

too high.
Figure 3
Center Photo : LFBO 14 R (3500 m x 45 m) / 3-degree glide slope / 200 ft RA
• Runway uphill or downhill slope:

− An uphill slope creates an illusion of being too high (impression of a steep glide
path); and,
− A downhill slope creates an illusion of being too low (impression of a shallow
glide path).
• Approach and runway lighting:

− The approach and runway lighting (including the touchdown zone lighting)
affects the dept perception as a function of:
• The lighting intensity;
• The daytime or night time conditions; and,
• The weather conditions.
− Bright runway-lights create the impression of being closer to the runway (hence
on a steeper glide path);
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− Low intensity lights create the impression of being farther away (hence on
a shallower glide path);
− A non-standard spacing of runway lights also modifies the pilot’s perception of

the runway distance and glide path; and,
− If runway lighting is partially visible (e.g., during the downwind leg or during
the base leg of a visual or circling approach), the runway may appear being
farther away or at a different angle (i.e., the intercept angle is perceived as
smaller than actual).
IV.3 Runway Approach Aids
The following runway approach-aids and conditions may increase the crew exposure to
visual illusions:
• Glide slope beam being unusable beyond a specific point because of terrain or below
a specific altitude/height because of approach over water;
• Offset localizer course; and/or,
• 2-bar VASI, if used below 300 ft height above touchdown (HAT) for glide path
corrections.
IV.4 Weather Conditions
The following weather conditions may cause visual illusions:

• Precipitation’s (e.g., rain, fog, snow):
− Flying in light rain, fog , haze, mist, smoke, dust, glare or darkness usually
create an illusion of being too high;
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− Flying in haze creates the impression that the runway is farther away, inducing
a tendency to shallow the glide path and land long;
− Shallow fog (i.e., fog layer not exceeding 300 ft in thickness) results in a low
obscuration but also in low horizontal visibility:
• When on top of a shallow fog layer, the ground (or airport and runway,
if flying overhead) can be seen, but when entering the fog layer the forward
and slant visibility usually are lost;
• Entering a fog layer also creates the perception of a pitch up, thus inducing a
tendency to push over and place the aircraft below the desired glide path
and in a steeper-than-desired attitude;
− In light rain or moderate rain, the runway may also appear fuzzy because of rain
halo effect, increasing the risk of not perceiving a vertical deviation or lateral
deviation during the visual segment.
The visual segment is defined as the segment flown after full transition from
instruments to visual references;
− Heavy rain affects depth perception and distance perception:
• Rain on windshields creates a refraction and the perception of being too

high, thus inducing a nose down correction that places the aircraft below
the desired flight path;
• In daylight conditions, rain diminishes the apparent intensity of

the approach lighting system (ALS) resulting in the runway appearing to be
farther away. As a result of this illusion, the flight crew tends to shallow
the flight path resulting in a long landing;
• In night time conditions, rain increases the apparent brilliance of the ALS,
making the runway appears to be closer, inducing a pitch down input and the
risk of landing short of the runway threshold.
− When breaking out of the overcast at both ceiling and visibility minimums (DH
and RVR), the slant visibility may not allow sight of the farther bar(s) of
the VASI/PAPI, thus reducing the available visual clues for the visual segment in
reduced visibility;
− A snow-covered terrain together with a clouds overcast create a phenomenon
called “white-out” that eliminate perception of terrain features (slope) and
height above terrain.
• Crosswind:
− In crosswind conditions, the runway lights and environment will be angled with
the aircraft heading; flight crew should maintain the drift correction and resist
the tendency to align the aircraft heading with the runway centerline.
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• Runway surface condition (e.g., wet runway):

− A wet runway does not reflect light, thus affecting depth perception by
appearing to be farther away.
This visual effect usually results in a late flare and in a firm touchdown.
When landing on a wet runway, peripheral vision of runway edge lights should
be used to increase the depth perception and determine the flare point.
V Typical Crew Actions and Results
The following crew actions and their consequences often are cited in the analysis
of approach-and-landing incidents or accident resulting from visual illusions:
• Unconscious modification of the aircraft trajectory to keep a constant perception

of visual references;
• Natural tendency to descend below the glide slope or the initial glide path
(i.e., “ducking under”);
• Inability to arrest the rate of descent after descending below the intended glide path
(i.e., late recognition of the flattening of runway and runway environment);
• Absence of reference to instruments to support the visual segment;
• Failure to detect the deterioration of visual references; and,
• Failure to monitor the instruments and the flight path, while both crew members are
involved in the identification of visual references.
The following table provides a summary of the various factors and conditions together
with their effects on the pilot’s perception and unintended actions that may result in
a hazardous situation:
Condition Perception Unintended Action Result
Narrow / long runway Being too high Push Land short / Land hard
Wide or short runway Being too low Pull Land long / overrun
Runway or terrain
Being too high Push Land short / Land hard
uphill slope
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Condition Perception Unintended Action Result
Runway or terrain
Being too low Pull Land long / overrun
downhill slope
Being too close

Bright runway lighting Push Land short / Land hard
(too steep)
Being farther away

Low intensity lighting Pull Land long / Overrun
(too shallow)
Light rain, fog, haze,

Being too high Push over Land short / Land hard
mist smoke, dust
Heavy rain Being too close Push over Land short / Land hard
Entering fog
Increasing pitch Push over Steep glide path / CFIT
(shallow layer)
Being farther away

Flying in haze Pull up Land long / Overrun
(too shallow)
Drifting rain,
Aircraft drifting sideways Undue drift correction Off-runway landing
snow or sand
Being farther away

Wet Runway Late flare Hard landing
(too high)
Being angled with Drifting off track /

Crosswind Cancel drift correction
runway off runway centerline
Table 1
Effects of Visual Illusions on Pilot’s Perception and Actions
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Human Performance
VI Prevention Strategies to Reduce the Effects of Visual Illusions
To lessen the effects of visual illusions, prevention strategies and lines-of-defense

should be developed and implemented based on the following recommendations.
VI.1 Hazard Awareness
Operators should assess their exposure to visual illusions in their operating

environment (i.e., over the entire route network).
Flight crews should be educated and trained on the factors and conditions creating
visual illusions and their effects on the perception of the environment and aircraft
position:
• Perception of heights / depth, distances, and angles;
• Assessment of aircraft lateral position and glide path.
The awareness of visual illusions can be supported by an identification of all hazard-

airports and/or hazard-runways (in the operator’s network) as a function of
the available navaids, visual aids and prevailing hazards.
VI.2 Hazard Assessment
Approach hazards – and any combination thereof - should be assessed for each
individual approach, during the approach and go-around briefing, by reviewing
the following elements:
• Ceiling and visibility conditions;
• Weather:
− Wind, turbulence;
− Rain showers;
− Fog or smoke patches;
− Drifting snow or sand;
− Snow-covered terrain / runway (white-out phenomenon); and/or,
− Sun height over horizon;
• Crew experience with airport and airport environment:

− Surrounding terrain (i.e., texture); and/or,
− Specific airport and runway hazards (runway condition, obstructions, black-hole,
off-airport light patterns, …);
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Human Performance
• Runway approach and visual aids:

− Type of approach;
− Availability and location of DME with respect to runway threshold;
− Let-down aid restriction, if any, such as glide slope unusable beyond a specific
point or below a specific altitude;
− Type of approach lighting system; and,
− VASI or PAPI availability.
VI.3 Terrain Awareness
When requesting or accepting a visual approach, flight crew should be aware of the
surrounding terrain features and man-made obstacles.
At night, an unlighted hillside between a lighted area and the runway threshold may
prevent the flight crew from correctly perceiving the rising terrain.
VI.4 Flying Techniques
Type of approach
At night, when an instrument approach is available, prefer this approach to a visual

approach to reduce the risk of accident caused by visual illusions:
• ILS approach, with use of VASI / PAPI (as available) for the visual segment; or,
• Non-precision approach, supported by a VASI / PAPI (as available).
If / when performing a step-down (i.e., dive-and-drive) non-precision approach, do not

descend below the MDA(H) before reaching the visual descent / decision point (VDP) -
if defined - even if adequate visual references have been acquired before reaching
the VDP.
To prevent going too early to visual references and descending prematurely below
the MDA(H), the PF should maintain reference to instruments until reaching the VDP.
This provides further protection against visual illusions in hazard conditions.
During a visual or circling approach, if the VASI / PAPI indicates below glide slope level
off or climb until the VASI/PAPI shows on-glide-path.
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Human Performance
Flight path monitoring
Resist the tendency to pitch down and “duck under”; this is the greatest challenge
during the visual segment of the approach, this includes:
• Pitching down into the approach light in an attempt to see the runway during
a precision approach; or,
• Ducking under because of the impression of being too high when affected by visual
illusions.
Maintain a combination of visual flying supported by monitoring of instruments

(including the glide slope deviation during the visual segment of an ILS approach).
Monitor the VASI/PAPI, whenever available; this provides additional visual cues to
resist the tendency to increase or decrease the rate of descent.
On runways equipped with an ALSF-II approach lighting system, be aware of the two
rows of red lights aligned with the touchdown zone lights as an additional safeguard
against “ducking under”.
The following provides a summary of the techniques available to counter visual illusions
(and prevent from ducking under):
• Maintain instruments scan down to touchdown;
• Cross-check instrument indications against outside visual cues to confirm glide

path;
• Use an ILS approach, whenever available;
• If no ILS approach is available, fly a constant-angle non-precision approach

(CANPA) supported by the use of the Flight Path Vector / Flight Path Target
(Director) or use the FMS FINAL APPR mode (as available);
• Use available references and indications such as the ND extended runway

centerline, the ILS-DME (or VOR-DME) distance – or the FMS track distance to
runway threshold - and the altitude above airfield elevation to confirm the glide
path (based on a typically 300 ft-per-nm approach gradient); and,
• Use VASI / PAPI, if available, down to runway threshold (only when using
a 3-bar VASI or a PAPI).
In summary, the main line-of-defense against visual illusions and disorientation is to

use and rely on flight instruments.
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Human Performance
VI.5 Coordination
The defined task sharing ensures a continued monitoring of visual and instrument
references, throughout the transition to visual references and thereafter (i.e., during
a visual approach or during the visual segment of an instrument approach).
In known or anticipated hazard conditions, the PNF should reinforce his / her
monitoring of instrument references and of flight progress, for an effective cross-check
and back-up of the PF.
Altitude and excessive-parameter-deviation callouts should be the same for instrument
approaches and visual approaches, and should be continued during the visual segment
(i.e., including glide slope deviation during an ILS approach or vertical speed deviation
during a non-precision approach).
In case of a go-around, specific excessive-parameter-deviation callouts should be
considered (as indicated in SOPs).
VII Summary of Key Points
The following critical keypoints need to be emphasized:

• Awareness of weather factors;
• Awareness of surrounding terrain and obstacles;
• Awareness and assessment of approach hazards (i.e., conditions that may result in
visual illusions, such as “black hole”);
• Adherence to defined PF/PNF task sharing for acquisition of visual references and
for flying the visual segment; this includes:
− Monitoring by PF of outside visual cues while transiently referring to instruments
to support and monitor the flight path during the visual segment; and,
− Monitoring by PNF of head-down cues for effective cross-check and back-up
(i.e., for calling any excessive-parameter-deviation).
VIII Associated Briefing Notes
The following Briefing Notes complement the above discussion on the acquisition of
visual references and on visual illusions:
• Standard Operating Procedures
• Enhancing Terrain Awareness
• Acquisition of Visual References
• Flying Visual Approaches
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Human Performance
IX Regulatory References
• ICAO – Preparation of an Operations Manual (Doc 9376).
• FAR 91.175 – Takeoff and landing under IFR – Paragraph (b), Loss of visual
references.
• JAR-OPS 1 – Subpart E – All Weather Operations - 1.1430 – Aerodrome Operating

Minima.
• JAR-OPS 1 – Subpart E – All Weather Operations - 1.435 - Terminology.
X Additional Reading Material
• FAA brochure on Spatial Disorientation :

− “ Seeing is not Believing ”, available from:
http://www.cami.jccbi.gov/aam-400A/Brochures/SpatialD.htm
This Flight Operations Briefing Note (FOBN) has been adapted from the corresponding ALAR Briefing Note developed by
Airbus in the frame of the Approach-and-Landing Accident Reduction (ALAR) international task force led by the Flight Safety
Foundation.

1 Rond Point Maurice Bellonte - 31707 BLAGNAC CEDEX France
FOBN Reference : FLT_OPS – HUM_PER – SEQ 11 – REV 02 – SEP. 2005
Page 15 of 15

Human Performance

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What are some of the main human factors issues identified in incidents and accidents?

What are some of the main human factors issues identified in incidents and accidents?

What percentage of incidents originate from the pre-flight phase according to a NASA study?

What percentage of incidents originate from the pre-flight phase according to a NASA study?

Human Performance

Flight Operations Briefing Notes Human Factors Aspects in Incidents / Accidents

Flight Operations Briefing Notes

Ultimately, human factors are involved in all incidents and accidents.

II Background Information - Statistical Data

III Human Factors Issues in Operational Events

III.1 Operational and Human Factors Markers :

• Situation recognition and crew diagnosis :

• Operating environment and circumstances :

The observation of individual factors or patterns of factors involved in operational

III.2 Standard Operating Procedures (SOPs) :

• Insufficient emphasis on strict adherence to SOPs during transition training and

III.3 Use of automation :

In a nutshell, briefings should attract the attention of the PNF.

• Share a common action plan; and,

• Set priorities and task sharing.

III.5 Pilot / Controller Communications :

This mental process can be summarized as follows:

The following factors may affect the correct understanding of communications:

This may result in :

III.6 PF / PNF Communications :

III.7 Altimeter Setting and Altitude Deviation Issues :

Strict adherence to the defined task sharing (for normal or abnormal/emergency

III.8 Rushed and Unstabilized Approaches :

• Pressure of flight schedule (e.g., making up for takeoff delay);

• Insufficient ATC awareness of crew or aircraft capability to accommodate

III.9 Runway Excursions and Overruns :

• Incorrect assessment of crosswind limit for prevailing runway conditions;

III.10 Adverse Wind / Crosswind Landing :

IV Summary of Key Points

V Associated Briefing Notes

• Operations Golden Rules

• Conducting Effective Briefings

• CRM Issues in Incidents / Accidents

• Effective Pilot / Controller Communications

• Managing Interruptions and Distractions

• Altimeter Setting - Use of Radio Altimeter

• Flying Stabilized Approaches

• Preventing Runway Excursions and Overruns

• ICAO – Annex 6 – Operation of Aircraft, Part I – International Commercial Air

• ICAO – Accident Prevention Manual (Doc 9422).

• ICAO – Human Factors Training Manual (Doc 9683).

• JAR-OPS 1.945, 1.955 or 1.965 - CRM Training.

Airbus Customer Services

Flight Operations Briefing Notes

III Company Culture and Policies

• Facilitate the mitigation of organizational factors; and,

• Identify and address precursors of potential incidents or accidents.

IV International Cultural Factors

• Highlighting the importance of cultural and national sensitivities; and,

• Promoting the use of standard phraseology as a common working language.

• Advocacy / inquiry; and,

• Crew coordination, mutual monitoring and backup; and,

• Human relations (e.g., effective intra-crew communications).

• Mutual cross-check and back-up;

VIII Inquiry and Advocacy