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Enhancing Flight Crew Management of Unexpected Events

Enhancing Flight Crew Management of Unexpected Events

This presentation is intended to enhance the reader's understanding, but it shall not supersede applicable regulations or airline operational documentation. Should there be any This presentation is intended to enhance the reader's understanding, but it shall not supersede applicable regulations or airline operational documentation. Should there be any

discrepancy between this presentation and the AFM/(M)MEL/FCOM/QRH/FCTM, the latter shall prevail at all times.discrepancy between this presentation and the AFM/(M)MEL/FCOM/QRH/FCTM, the latter shall prevail at all times.

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IntroductionIntroduction

The objective of this visual guide is to reinforce

the importance of being ready for and properly

handling unexpected events to avoid associated

aircraft upsets. Even though the events

described are mostly unanticipated, a flight crew

can effectively prepare to deal with them,

thereby avoiding problems. The material may be

used for self-study or as part of a formal training

presentation.

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ContentsContents

1. Defining Unexpected Events

2. Types of Unexpected Events

3. Unexpected Events and Aircraft Upsets

4. Surprise, Stress and Error

5. Preparing and Responding

6. Summary

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Unexpected Events DefinedUnexpected Events Defined

An event is unexpected if it disagrees with

expectations as determined by planning and the context

of the situation. The nature of an unexpected event may be:

– Normal

– Abnormal

– Emergency

An unexpected event may be:– Frequent

– Infrequent

– Novel or surprising

The absence of an expected event is an unexpected

event in itself.

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Types and Causes of Unexpected EventsTypes and Causes of Unexpected Events

Types of unexpected events: Events omitted from a plan Planned events that do not occur at all or at the expected time Unplanned events (e.g., abnormal events and emergencies)

even if they are included in training

Causes of unexpected events: System malfunctions Changes in flight plans while en route Weather or environmental threats Crewmember incapacitation Loss of situational awareness Failure to receive instructions when they are normally provided ATC or other crewmember communications Aerodynamic anomalies

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Aircraft Upset (Loss of Control)Aircraft Upset (Loss of Control)

The most serious consequence of an unexpected event

is aircraft upset or loss of control, defined as: Unintentional pitch > 25 degrees nose-up or 10 degrees nose-down

Bank > 45 degrees

Inappropriate airspeeds for flight conditions

Any other aircraft state not intended by the pilot

Types of Aircraft Upsets: Environmentally induced

Systems failure induced

Pilot induced

Often, loss of control is due to a fixation on the unexpected

event instead of returning to essential flight duties.

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Factors Involved in Unexpected EventsThat Lead to Aircraft Upsets

Factors Involved in Unexpected EventsThat Lead to Aircraft Upsets

Factors Leading to an Aircraft Upset

Aircraft position

Air traffic control

Other crewmember

actions

Aircraft state

System status

Automation In-flight turbulence

Low visibility

Percentage of upset events in which the factor was present*

65.8 51.1 42.3 31.7 19.3 14.9 11.6 10.0

* Percentages add to more than 100 because multiple factors can be present in a single event.

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SurpriseSurprise

All unexpected events cause at least some level of surprise. An

event causing no surprise is not an unexpected event.

Levels of surprise: Mild surprises are usually caused by unexpected events that are fairly

common or have no significant consequences.

High surprise levels are usually generated by events that are extremely

unlikely, rare or directly threaten safety.

Surprise

Finding no memory

image to fit the situation

Assessing data about

the situationAnalysis

and evaluation

Action selection

and execution

Event

The Process of SurpriseThe Process of Surprise

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•.

Surprise Can Cause Stress and ErrorSurprise Can Cause Stress and Error

Surprise may contribute to an interruption of thought

processes and motor activities that may then lead to error. The same unexpected event may induce higher stress for some pilots

than for others.

Experience level, personality, attention level and fatigue may influence

the extent of stress generated by surprises.

High levels of stress may lead to a spiraling effect in which loss of

situational awareness causes a larger number of events to be

unexpected.

Eventually, the stress from an unexpected event can lead to aircraft

upset.

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Preparing and RespondingPreparing and RespondingFlight instruction should apply realistic, scenario-based

training to teach students to: Maintain situational awareness

Recognize and respond to ill-defined events

Modify known procedures to fit novel situations

Learn problem-solving techniques to avoid becoming fixated on a

solution that is not working

Strive for optimal stress/arousal levels — neither too little

(complacency) or too much (overloaded)

Strive for a measured emotional response

– Do not completely ignore your own senses or internal dialogue

– Be sensitive to instinctive reactions and the “hair standing up on the

back of your neck”

Integrate creative thinking and emotional control with the

requisite “stick-and-rudder” skills

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Preparing and Responding (continued) Preparing and Responding (continued)

Apply proven procedures for using maximum available flight

control inputs and power — employ alternate control strategies

as required

Deliberately seek all available information during flight and as

part of preflight planning

Continually evaluate the unfolding situation

Practice monitoring thoughts and actions

Continuously ask, “What if?”

Maintain cognitive flexibility by keeping an open mind to

alternatives and possibilities at all times

Approach flying with an appropriate attitude (mental, physical

and social) so that when faced with an unexpected event the

detrimental effects of surprise are minimized

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SummarySummary There are many types of unexpected events in aviation.

Many events prompt a surprise reaction from the flight crew.

Any unexpected event can produce an undesirable outcome.

The reactions of pilots to unexpected events are major

contributors to loss of control in flight.

When pilots seek all available information in flight and during

preflight planning, fewer events will be unexpected, and

surprise will be less likely.

Flight training should integrate mental skills and emotion

management with the “stick-and-rudder” skills necessary to

promote successful perception, processing and response to

any unexpected event.