Human Factor

Pilot monitoring my Superhero, did his job but couldn’t save FlyDubai @Rostov


Most accident investigation reports are oriented towards the actions/inaction, errors/mistakes of the pilot flying or the Captain if he is flying. The crucial role of the supporting crew or the other pilot in the cockpit who is monitoring the flight progress (PM) is not examined so critically. The PM might have the powers to save the day when things don’t go as planned.

The co-pilot of the ill-fated FlyDubai B-737 did perform his job(considering his experience)as the pilot monitoring when he gave vital inputs to the Captain for maintaining the reference pitch angle during the second go-around. Unfortunately, the inputs were not enough to prevent the accident.

Research published by the BEA (French accident investigation agency) states that “Key finding relating to Pilot Monitoring: The survey indicates that many pilot monitoring (PM’s) do not know where and when to look during a go-around.

In the Rostov accident, the PM knew where to look at, the PITCH but did not monitor the STAB TRIM and the engine THRUST. What if he had monitored?

What could the PM have done in addition to calling the pitch angle required to be maintained? Do airlines have a “practical” policy which clearly delineates the PM function especially during a go-around?Lets examine the industry recommendations.

AirlinePlace of accidentPitch downTrim/ThrustSpeed
EthiopianBeirut63 degNose DN/High407 kts
Lion AirJakarta45 degNose DN/High450kts
TatarstanKazan75degNose DN/High391kts
EthiopianAddis Ababa45degNose DN/High458kts
Fly DubaiRostov50degNose DN/High340kts

IATA guidance material for improving flight crew monitoring


Monitoring is an overarching process requiring knowledge, skills and attitudes that enables flight crews to perform safely, effectively and efficiently. Monitoring includes the process of observing and creating a mental model, by seeking out available information to compare actual and expected aircraft state.

Scope of monitoring

Monitoring is not done in isolation; it must be performed concurrently while performing other required tasks, including operating aircraft controls, making data entries and communicating with others. “Good monitoring relies upon effective task management and making time for monitoring”.

The primary job of the flight crew is the flight path management, including managing the energy state of the aircraft at all times.

Secondly, the flight crew is also required to monitor all operational tasks not directly related to the flight path. These include monitoring of aircraft systems, destination and en-route weather, operational factors, observing other flight crew members, cabin crew, dispatcher functions, etc.

 Monitoring requires a combination of cognitive resource allocation such as attention, and a link to previously acquired knowledges (scripts and scenarios), which allow a pilot to detect, understand, project into the future, and then take the right decision/action.

Example of monitoring

Takeoff, Climb, Descent and Landing

During these phases of the flight, workload is high. The flight crew should focus all their attention to flight path monitoring. The flight crew should delay actioning any task that is not related to the flight path. If the task is a time critical one, then the distribution of workload is very important before one of the flight crew members performs the assigned task. For example, if a technical malfunction is detected by the aircraft systems or by the flight crew, performing the abnormal checklist will be the responsibility of the Pilot Monitoring.

Extract from the IATA document giving an example of a policy

While all the text above is good for a read, practically do you get a clear guidance of what to do and where to look especially in a tightly coupled high stress situation?

Research on how did the crew manage Go-Around Execution during the experiment?

Frédéric Dehais, Julia Behrend, Vsevolod Peysakhovich, Mickaël Causse & Christopher D. Wickens (2017) Pilot Flying and Pilot Monitoring’s Aircraft State Awareness During Go-Around Execution in Aviation: A Behavioral and Eye Tracking Study, The International Journal of Aerospace Psychology, 27:1-2, 15-28

The analysis of pilot performance revealed that all flight crews managed to stabilize the aircraft in accordance with ATC clearances. However, debriefing results indicated that the execution of the maneuver was particularly demanding. During the debriefing session, all PMs—except one—highlighted the complexity of the procedure and reported difficulties. In particular, they felt overwhelmed by the PF’s callouts, ATC particular instructions, and the numerous actions to be performed during a short period of time. As stated by one pilot, “The diverse nature of the tasks and the speed at which they must be performed generate stress, notably when the startle effect is also included in the situation. Since stress reduces our ability to cope with complex actions, performance levels drop during go-arounds.

The eye-tracking measurements emphasized the essential role of the PM in the detection of flight-parameter deviations. The PM’s numerous tasks (e.g., interaction with ATC, FCU settings, and flaps management) can leave this pilot ill equipped to face the sudden onsets of these actions and to monitor the flight path in the meantime.

mindFly analysis

The crew gets so overwhelmed by a go-around or an unexpected situation that their instrument scanning pattern changes and becomes even more unpredictable. What would happen if there is a failure coupled with the situation.

There is no clear cut precise guidance or task sharing for the pilot monitoring. The PM is expected to shadow fly the pilot flying (PF) in addition to own task sharing and the ability to read the PF’s mind in order to form the perfect mental image of the scenario.

The PM is mostly heads down and the range of tasks involve monitoring instruments, review documents, communicate with ATC, perform actions relating to checklists (normal/abnormal) and on top of it keep a check on the physiological/psychological state of the PF/Captain. Considering the low experience and age of an average copilot, isn’t this the job of a super hero?

Flight Safety Foundation guide to Flight Path Monitoring