Flight Safety Article FLT LT Soumitra

CHANCE TAKERS ARE ACCIDENT MAKERS
SITUATIONAL AWARENESS
Preface
1. The two military jets are flying low level to Mt Isa. After more than an hour
over the featureless countryside, getting low on fuel, and thinking they ought to be
there by now, the wingman radios, “Where are we, Ron?” There’s no answer, so he
tries again, a petulant edge to his voice, “Where are we, Ron?” A well-modulated,
airline-pilot-type, voice comes up, “Go on Ron, tell him”. “I don’t (expletive) know”,
says Ron.
2. Situation awareness is knowing where you are and what’s going on. It’s “the
big picture” and one of the very foundations of pilot competence. Breakdown of
situation awareness is the root cause of so many aircraft incidents that eliminating it
would dramatically reduce the accident rate and hence flight safety can’t be denied
due to losing situational awareness.
Lose of Situational Awareness

3. Ambiguous problems often cause pilots the most difficulty, mainly because
there is no clear-cut course of action. Serious in-flight emergencies, such as an
engine failure, tend to be managed more effectively because established procedures
take the place of the time and effort needed to solve the problem.
4. There are a number of factors that may increase your risk of losing situation
awareness. The most obvious is stress, which can result in a pilot being less
attentive or making a decision without considering all the information available.
Under stress, a narrowing of attention, or tunnel vision, may make your method of
gathering information (scanning) scattered and poorly organized. Too much work
(over load) or too little (under load) is also bad for situation awareness.
5. If there is a great deal of information that needs to be prioritized quickly, your
situation awareness will ultimately suffer. Under periods of low workload, such as in
long-haul flying, vigilance problems may affect your motivation to actively find out
what is going on around you.
Scan Pattern
6. Situation awareness can be seen as maintaining control over a range of
information sources. You do that by looking at each source through a “scan” pattern
that you control. Time is the critical variable. You need time to get a reading from an
instrument, time to look at places of interest, time to build the picture. Just like fuel,
time is a resource. Sensible rationing of your time resource can represent the
difference between “losing the plot” and staying with it.
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Time Management
7. When you want information, you look at each source for a finite length of time.
But some “readings” take longer than others. Controlling where you look – the
situation management or “control” function – also takes finite allocations of time.
8. So you can begin to see how you can make your situation awareness scan
more efficient. Minimize the amount of time you spend looking at each information
source to just that amount needed to get the reading (heading), or complete the task
(radio call), no more. You know from experience that you may need to look at an
instrument, say, for longer than you might wish to get a confident reading. A series of
glances can be used to “accumulate” readings from multiple sources when you need
to keep track of many issues.
Active Management
9. Another way of saying the same thing is that you must learn to “actively
manage” your situation awareness scan. In fact, you probably do that a lot, already.
Every time you run through a checklist, you are positively controlling where you
direct your attention, when you look at something, and when you move on. What
checklists get you to do is to manage time as a resource. The better you have
learned your checks, the less time you use in “running” them.
How Do You Know if You’ve Lost It

10. The following are common events identified in accidents that have involved a
loss of situation awareness. If you answer yes to more than 4 items on the checklist,
you could be losing situation awareness.
a. Ambiguous information. Do you have information from two or more
sources that do not agree?
b. Confusion. Are you uncertain or uneasy about a situation?
c. Primary duties. Are all crew focused on non-flying duties?
d. See and avoid. Is there too much heads-down time with nobody
looking outside for conflicting traffic?
e. Compliance. Is there non-compliance with aircraft performance

limitations, minima etc?
f. Standard Operating Procedures (SOPs). Are established SOPs
not being followed by everyone?
g. Fixation. Are you focused on any one task to the exclusion of

others?
2
h. Communication. Have you heard or made any vague or incomplete
statements?
j. Contradictions. Have you failed to resolve any discrepancies or

contradictory information?
k. Navigation. Have you failed to meet an expected checkpoint on the
flight plan?
Case Study
11. Sometimes the outcome of loss of situation awareness can be tragic, such as
in the case of ZK-NEY, a de Havilland DHC-8 aircraft, which on June 9, 1995
crashed at Palmerstone North, New Zealand while conducting an instrument
approach. As the aircraft approached 12 DME the captain called “gear down”. The
landing gear didn’t lock. The Captain instructed the first officer to look in the quick
reference handbook to locate the “landing gear malfunction, alternate gear
extension” checklist. As the first officer went through the checklist, the captain
questioned an item, and became distracted from his primary task of flying the aircraft
safely. The Ground Proximity Warning System (GPWS) audio alarm sounded. The
aircraft collided with terrain 4.6 seconds later, killing 1 crew member and 3
passengers.
12. This accident highlights the need for pilots to always monitor the position of
their aircraft in relation to the ground and other traffic, regardless of any system
problem. It also suggests that distractions are the main cause of loss of situation
awareness. Because problems in the air are not always neatly labelled, and may
have begun well before the aircraft took-off, it is easy for pilots to get distracted with
minor problems at the cost of maintaining situation awareness
Ways to Improve Situation Awareness

13. Following ways can be mimicked to improve situational awareness. These are
as follows:
a. Plan ahead and predetermine crew roles for phases of flight that have
high levels of workload. Assign responsibilities for handling problems or
unexpected distractions.
b. Be aware of all the services available to you, then use them. For airline
pilots this may require getting input from all crew members, including cabin
crew. For single pilots, be proactive in sourcing input from ATC, maintenance,
dispatch, etc.
c. Avoid fixating on a problem. Direct your attention systematically to the
aircraft, the flight path and finally to the people around you. Repeat this
attention pattern over and over again.
3
d. Monitor and critically evaluate your current performance (flight path,
fuel estimation) based upon your pre-flight plan.
e. Anticipate by considering the “what ifs”. That is, project ahead and
design contingencies to avoid being taken by surprise.
f. While it is important to focus on the details, don’t forget to scan the big
picture.
g. Tasks that take time or are subject to interruptions from ATC or other
crew are less likely to be done right. Therefore, create visual and/or aural
reminders of interrupted tasks. For example, some pilots use the technique of
selecting the audio for the outer marker when they have been instructed to
contact the tower at the outer marker early in their approach. This aural
reminder means that they don’t have to remember to look during a busy
phase of flight.
h. Use the checklist on page 16 to watch for clues of degraded situation
awareness.
j. If you observe any obvious signs in words or actions that indicate
situation awareness is breaking down, speak up.
Take Away Message

14. Managing situation awareness is about avoiding being caught off guard or
being unprepared. It involves making the effort to stay ahead of a situation. Having
good situation awareness is like sitting on the jump seat of your own flight. In other
words, it is important to regularly take a giant step back to review your situation.
15. By mentally stepping back from your situation, you can become more aware
of where your attention is, and where it is not. Achieving and maintaining a high level
situation of awareness does not come naturally. But being aware of the traps, and
using a checklist tailored to your own flying, can help you learn to see and think
about where you are and what’s going on around you. This may certainly increase
flight safety.

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CHANCE TAKERS ARE ACCIDENT MAKERS

Lose of Situational Awareness

How Do You Know if You’ve Lost It

c. Primary duties. Are all crew focused on non-flying duties?

e. Compliance. Is there non-compliance with aircraft performance

g. Fixation. Are you focused on any one task to the exclusion of

j. Contradictions. Have you failed to resolve any discrepancies or

Ways to Improve Situation Awareness

Take Away Message

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