BizAv CRM Implementation & Situation Awareness

On the evening of December 20, 1995, American Airlines Flight 965 crashed into high terrain during an approach to Alfonso Bonilla Aragon International Airport, Cali, Colombia. Of the 163 people on board only four survived.

The airplane involved was equipped with cathode ray tubes (CRT) or ‘glass cockpit’ technology, including screens which displayed flight path and navigation information, engine information, and a Flight Management System (FMS). A Ground Proximity Warning System (GPWS) was also installed and functioned normally at the time of the accident, according to the FAA.

The investigation concluded that the accident was due to flight crew human error involving lapses in navigational and crew resource management.

The Importance of Pilot Situation Awareness

In this latest feature, we continue our series covering the implementation of Crew Resource Management (CRM) in Business Aviation, this time focusing on Situation Awareness, the lack of which played a part in the crash of American Airlines Flight 965.

According to Alaba Gabriel Idowu, Michael A Shogbonyo and Olurotimi Adefemi Adeyeye in a 2022 academic article entitled ‘Situational Awareness and Workload Management in Aviation: A Case Analysis of the Crash of American Airlines Flight 965’, the analysis revealed that the absence of radar services, ineffective communication, automation mismanagement, improper coordination and planning, and assumption led to the loss of situation awareness regarding vertical navigation, the airplane’s proximity to terrain, and the relative location of critical radio aids.

“These are a series of events that, if not efficiently managed, could lead to a loss of situational awareness in flight operations due to the fact that they are likely to serve as precursors to errors of commission and omission”, the analysis says.

The crash of American Airlines 965 also confirmed that poor workload management could lead to a high workload situation and eventually set the stage for accidents due to the likelihood of improper coordination and planning and a series of errors that could stem from increased mental workload, preventing flight crews from adhering to safety-related functions to ensure the safety of flight.

“In addition, an unexpected change of events could lead to ineffective workload management and eventually set the stage for an accident due to the probability of losing situational awareness. Therefore, maintaining situational awareness is hugely dependent on effective workload management,” the analysis concludes.

Improper planning and coordination could make flight crews susceptible to a series of errors leading to ineffective workload management and, eventually, loss of situational awareness, Idowu et al say. “This is because ineffective workload management takes away attention from pertinent functions in flight, such as radio communication.

“When flight crews become distracted with other flight-related functions and unable to pay attention to radio communication, assumptions may set in, making flight crews act contrary to air traffic control instructions, thereby losing situational awareness”.

According to Emilie Roth, Devorah Klein, and Katie Ernst in a 2021 report document entitled: ‘Aviation Decision Making and Situation Awareness Study: Decision Making Literature Review’, the situational awareness concept has its roots in military aviation and continues to be an important concept in both military and civilian aviation.

Identifying Situation Awareness Levels in Business Aviation

Meanwhile, according to Mica R. Endsley in a 1999 book section entitled ‘Situation awareness in aviation system’, situation awareness involves perceiving critical factors in the environment (Level 1 Situation Awareness); understanding what those factors mean, particularly when integrated in relation to the aircrew’s goals (Level 2 Situation Awareness); and understanding what will happen with the system in the near future (Level 3 Situation awareness).

The higher situation awareness levels allow pilots to function in a timely and effective manner.

Level 1 Situation Awareness: “A pilot needs to perceive important elements such as other aircraft, terrain, system status and warning lights along with their relevant characteristics,” says Endsley.

“In the cockpit, just keeping up with all of the relevant system and flight data, other aircraft and navigational data can be quite taxing.”

Level 2 Situation Awareness: “The aircrew puts together Level 1 data to form a holistic picture of the environment, including a comprehension of the significance of objects and events,” Endsley continues.

“For example, upon seeing warning lights indicating a problem during take-off, the pilot must quickly determine the seriousness of the problem in terms of the immediate airworthiness of the aircraft and combine this with knowledge on the amount of runway remaining in order to know whether it is an abort situation or not.”

Level 3 Situation Awareness: This deals with the projection of the future status, and it refers to the ability to project the future actions of the elements in the environment, at least in the short-term, according to Endsley.

“This is achieved through knowledge of the status and dynamics of the elements, and a comprehension of the situation (both Level 1 and Level 2 Situation Awareness).”

Pilot Situation Awareness Doesn’t Come by Chance!

All situation awareness levels need to be nurtured and cultivated, and there are several areas of focus for Business Aviation organizations to embed best practices.

Roth et al. observe that according to Endsley’s model, goals and objectives, information processing mechanisms and limitations, abilities, long-term knowledge based on experience and training, and non-conscious mental processes that are automatic directly influence both situation awareness and decision making.

“Similarly, system design (system capability, interface design, automation), as well as other features of the task environment (e.g., complexity, stress and workload) will influence both situation awareness and decision making”, they add.

Stay tuned as we continue our series reviewing different components that comprise effective Crew Resource Management in the Flight Department next month.

Read more articles in this series, including:

• Why Automation Should be Part of Your BizAv CRM Training
• Implementing Business Aviation Crew Resource Management