Flight safety

Pilots’ contribution to Safety 2 – Can we improve their willingness to report?

Enhancing and encouraging reporting is a simple way to learn more from all operations
By Pierre Wannaz - Feb 21, 2023

Pilots' contribution to Safety 2 - Can we improve their willingness to report?

I have realized during my career that sometimes, pertinent information is kept at crew level despite having interesting content for management and flight safety.

The prime reason for not reporting is not linked to the fear of doing so but to the fact that pilots feel uncomfortable forwarding unclear, incomplete, or inaccurate information. Missing a detailed understanding of what a crew could report raises obstacles in communication.

Here is a personal example:

A few years ago, during a yearly line check, my copilot intercepted the final approach rather sportily. During this high workload situation, he made the correct procedure call-out: ” G/S * – LOC* ” indicating the capture of the final guidance.

I checked my FMA and read another indication ” G/S* – HDG “; immediately, I told the copilot to continue the intercept using raw data and rearmed the approach. I had great doubts about what I had seen because the combination of HDG and G/S mode is technically impossible.

During the debriefing, the instructor sitting on the jump seat told me he saw a strange FMA annunciation, but our rapid reaction didn’t allow him to see carefully and understand what had happened. As the event did not have any consequence and we were correctly established, for him, everything was fine.

As a crew, we have been unable to reconstruct what exactly happened, so we did not have a clear image. We were missing elements of understanding. Consequently, we didn’t know what to write and didn’t file a report!

Less than 15 days later, we had in our company, an instructor meeting. The technical pilot of the Airbus long-haul fleet warned us that a manufacturer bulletin mentioned this possibility for the installed Hardware/Software combination in our planes. An internal error could cause the LOC to be lost during capture, leading to a reversal to HDG mode but keeping the G/S engaged—a potentially dangerous combination.

After this technical explanation, a dozen colleagues in the meeting reported that they had observed such behavior.

The chief pilot was a little bit angry; he couldn’t understand why he did not receive any report on this issue. The pilots explained that there was no time available for analysis or troubleshooting during a task-intensive flight period close to the ground. After landing, pilots had doubts about what they perceived; they thought their observation was probably a misreading or misinterpretation of the FMA. Being unsure and lacking sufficient understanding, the pilots left the occurrence unreported.

Ironically, a single pilot had forwarded a report. This report did not go further, as operational engineering concluded that it must have been a pilot misinterpretation of the FMA because a combination of HDG and G/S was technically impossible, according to the books!

After this incident, when working on the replay tool CEFA AMS, I realized how useful a replay app would have been in such a case. An animation would have allowed the pilots to replay the sequence around the event, if necessary, in slow motion, all this in a realistic type-specific cockpit, showing all displayed FMA modes and indications. The animation would have immediately confirmed the erroneous flight guidance behavior.

On top of that, by having a hand tool showing pilots’ actions, the animation would also enable us to distinguish if the FMA mode change resulted from a voluntary crew action, an erroneous pilot manipulation, or if it was the result of an automation glitch.

In the company using our replay tool, the improvement of event understanding at a pilot level is definitely promoting the will to report. For example, at RYANAIR they realized an increase in pilot reporting occurrences, an example mentioned was the Flaps overspeed.

I am convinced that by reducing doubts at the crew level, the will to forward information, the degree of details and the pertinence of the reports will be greatly enhanced.

To be most effective, our replay tool is available at a very early stage, shortly after the flight, before the cognitive reconstruction mechanism occurs.

Having factual data to report is a clear benefit, but also information linked to the crew perception, so-called “soft” elements such as situational awareness, perception issues, startle effects and workload are elements not realized today by traditional FDM/FOQA data processing. Such facts only detected by human sensors are also interesting indicators to perceive the risk of potential threats.

In the previous example, the management would probably have been informed much earlier. Consequently, the aircraft manufacturer, the training, and the operations department could have quickly looked for appropriate mitigating measures.

The replay tool is an effective way to learn from all operations in an airline. It’s effective during training and regular line operation by improving the way to share information at personal, at a crew and at an organizational level.

Enhancing and encouraging reporting is a simple way to learn more from all operations.


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