Despite having the benefit of insights from 45 people of diverse expertise, the U.S. National Transportation Safety Board (NTSB) has not settled on systemic explanations for instances in which airline pilots and air traffic controllers flouted regulations and standard operating procedures (SOPs). Potential elements of safety recommendations have emerged, however.
In remarks at the NTSB’s Professionalism in Aviation Safety Forum on May 18–20 in Washington, Chairman Deborah A.P. Hersman cited seven U.S. accidents and serious incidents in 2004-2009 involving breakdowns in professionalism. The NTSB accepted public comments until June 3.
“We recognize that there are many industry professionals whose work, day-in and day-out, reflects the highest level of professionalism,” Hersman said. “While the Colgan Air [Flight 3407] accident investigation [ASW, 3/10, p. 20] was the impetus for this forum, many of the issues raised in that accident investigation were not new to the NTSB. … The evidence is clear that when pilots and controllers drift away from their training, procedures and best practices, safety margins erode and inadvertent errors go uncorrected. Things are happening in industry that have led us to this point — errors and practices that warrant closer scrutiny. … Defining professionalism and creating a culture of professionalism … is what the NTSB will be focusing on over the weeks and months to come.”
Most forum panelists offered personal views, not positions of organizations, as the NTSB asked them about opportunities to strengthen defenses against deficiencies such as lapses of discipline, distractions and deviations, including flight crews engaged in conversations and activities not pertinent to aircraft operation during critical phases of flight; lax, casual or unfocused atmosphere on the flight deck; inexplicable deviations from SOPs; self-centered behavior; substandard airmanship; loss of situational or positional awareness; reluctance of pilots to challenge each other’s deviations; and equivalent behaviors in the air traffic control (ATC) profession. Streaming videos from the forum and related documents are available at www.ntsb.gov/news/events/Pages/Professionalism_in_Aviation_Ensuring_Excellence_in_Pilot_and_Air_Traffic_Controller_Performance.aspx.
Professionalism has not been explicitly defined or mandated per se by the U.S. Federal Aviation Administration (FAA) although the concept is embodied in regulations and guidance, some panelists said, suggesting many characteristics for consideration. “The FAA’s part in professionalism is to set the standards, to set the requirements for procedures and policies, and to oversee [the industry] in a way that assures that everybody understands that we expect compliance,” said John Duncan, manager of the FAA Flight Standards Air Transportation Division. “We expect folks to ‘play by the SOPs’ every time and behave in a professional way.”
The current FAA Advisory Circular 120-51, “Crew Resource Management Training,” would be the likely starting point if the FAA decides to provide specific guidance on professionalism, he said. If government and industry “could come up with performance markers or behavioral markers — [if] we agreed by consensus, and they came out as an advisory circular — it then would be reasonable to quantitatively evaluate pilots on that,” Duncan said.
Soft skills of discipline, responsibility, judgment, emotional stability, effectiveness under pressure and leadership are “what assures us that once that cabin door is closed, that cockpit crew is acting professionally and doing what we want them to do in a safe manner,” said Randall Hamilton, a captain and director of training at Compass Airlines. “By the nature of our business, line pilots are an absentee workforce,” acknowledged Ed Sternstein, a Delta Air Lines captain and a chief line check pilot. Robert McDonnell, a captain representing the Allied Pilots Association, added, “Compliance with SOPs is the key to operating our aircraft safely and a big part of professionalism.”
In the forum’s keynote presentation, Tony Kern, CEO and senior partner of Convergent Performance, suggested that the pendulum in safety theory has swung too far in accepting human error as uncontrollable, and has diminished personal accountability. He said he typically advises airline clients to increase their emphasis on personal flight discipline and airmanship.
“If you believe the researchers, hundreds — maybe thousands — of mistakes and casual noncompliance [instances occur] without a single negative outcome,” Kern said. “Is it any wonder that we have a slight erosion [of personal responsibility] in an industry that has highly repetitive, highly automated systems where everything goes right nearly all the time, right up to the moment when it doesn’t?”
Aviation professionals have to be inspired and motivated to practice introspection, self-management and ethical behavior along with training to master technical systems, procedures, tactical skills and information, he added. “Sometimes in aviation, just to survive, we need to do things nearly perfectly,” Kern said. In light of breakdowns in professionalism cited by the NTSB, issues of behavior represent “the last big challenge in aviation safety,” he said.
Some panelists echoed the importance of intangible personal qualities. “Professionalism really starts with the pilot’s value system … early in life,” said John Rosenberg, a captain and check airman for Delta and chair of the National Professional Standards Committee of the Air Line Pilots Association, International (ALPA). “It is a dedication to striving for mastery.”
Others framed each individual’s responsibility for professionalism based on their personal experience in applying the prevailing theories of aviation human factors. “There is no perfect flight; I have never done one,” said Ben Berman, a captain-rated first officer at Continental Airlines and senior research associate in flight crew human factors and cognition at the Ames Research Center of the U.S. National Aeronautics and Space Administration (NASA), who explained that most errors can be traced to human cognitive limitations. “I always try, but I have never seen one. … Every flight has literally thousands of opportunities for flight crews to make errors in one way or another, and there is always an error that creeps in. … And so these errors are, in a sense, related to the way we are wired and not so much to the way we handle ourselves in terms of professionalism.”
Although identifying pilot intentions during line operations safety audit (LOSA) observations is difficult, for example, “it is clear that most of the deviations [seen] are not intentional and are inadvertent,” Berman said. “Even though we have the standards, we still make errors … we self-correct, accept corrections by others and always strive to improve; that is professionalism for captains and first officers.”
The First Step
A number of panelists and NTSB members concurred that careful screening and selection of ab initio students and experienced airline pilots is the foundation of safe performance and professionalism. Judy Tarver, vice president of FltOps.com, said that U.S. major airlines in the last three years have not had difficulty finding qualified pilots, but the workforce structure has become less stable with fewer military pilots available and with regional airlines — hiring pilots directly from universities and flight schools — expected to be the main pipeline of all pilots for many years.
Airlines could have more difficulty identifying personal qualities and attitudes associated with professionalism, however, if they dismantle pilot-selection programs in response to capacity fluctuations, then reactivate them when high demand resumes — especially if corporate interviewing expertise declines, selection criteria are relaxed or funding is cut so that candidate pilots are not tested in flight simulators, some panelists said.
Another challenge has been difficulty finding legal and scientifically valid selection instruments — that is, tests and interview questions that can be used to deny employment to an applicant — to deselect people. Some “personality tests” have been discarded as no longer valid in a society as diverse as that in the United States, said Diane Damos, president of Damos Aviation Services.
Attributes of professionalism must be instilled long before pilots are hired for the flight deck of an airliner, Continental’s Berman said. “There are certain aspects of people that cannot be trained, and those need to be selected out,” he said. “They cannot be allowed to join or to continue with an airline. When they [most] need to act professionally — make professional decisions to do the right thing — will be in the heat of things [an emergency].”
In Northern European countries such as The Netherlands, however, “rigid psychological testing” remains a cornerstone of screening and selecting ab initio pilot candidates from a relatively homogeneous pool of applicants. Chris Haber, training manager, KLM Flight Academy, said the academy requires constant compliance with regulations and procedures that align as closely as possible with what pilots can expect in line operations.
The academy also relies on aviation safety reports, a nonpunitive self-disclosure system. “Students, instructors and members of staff are actively encouraged to disclose anything they feel constitutes a safety issue, and then the report is handled confidentially by a dedicated safety officer,” he said. “It’s encouraged from the first day of ground school even if they have not touched an airplane yet. We debrief whoever has reported the situation. The idea is ‘If you make a mistake, you’ve made a mistake. Report it. Tell us about it so we can learn from it, and then we will retrain and move on.’ If necessary, we will change our procedures or use it as a case study for future training.”
Similarly, Lufthansa’s ab initio flight academy has “a selection process that ensures the right aptitude and personality [suitable for developing during training] … interpersonal competence consisting of [skills in] communication, leadership and teamwork, situational awareness and decision making,” added Matthias Kippenberg, president and CEO of Airline Training Center Arizona.
Evidence of “passion for what they do” has been a reliable predictor of safety commitment and professionalism, said Al Thompson, chief pilot, flight training simulators, Boeing Training and Flight Services. This factor also distinguishes the retired airline captains selected as Boeing instructors, he said.
Panelists acknowledged that fluctuations in both the level of experience of prospective candidates in the labor market and company demand for new hires sometimes create conflicts of interest that have to be reconciled safely. “We know that the economy changes,” said Compass’s Hamilton. “When you need pilots, you have to get pilots from somewhere. You have to broaden your pool as widely as possible to get the numbers with the understanding that your success rate may go down considerably because you are bringing in … folks who you still don’t want to put out onto the line until they have met your minimum standards.”
In major U.S. airlines, the likelihood of the same captain and first officer flying together more than once or twice has become remote. This makes excellent communication, trust and adherence to SOPs essential but may make mentoring socially awkward, several presenters and NTSB members agreed. One byproduct of mergers has been more first officers who are captain-rated and who have more experience than the pilot-in-command.
NTSB Member Robert Sumwalt suggested that a new defense against lapses of professionalism might be increasing the social acceptance of mentoring among pilots. Ideally, any social discomfort would not impede either pilot’s willingness to offer the other constructive input about best practices, compliance with SOPs or behavior.
“There is an opportunity, beyond licensing and beyond flight training, to develop a way to educate [first officers] about professionalism and [captains about] taking input and suggestions, but we can’t water it down to the point where it is just called crew resource management [CRM, suggesting only that] everybody is going to get along,” agreed Jamie Bosworth, a Delta captain and line check airman.
Malpractice of crew resource management (CRM) also increases risk, some panelists said. “On the line, my observations as a check airman for the most part indicate that the captain is more willing to defer to the first officer and his/her opinion instead of just making a decision as the captain,” said Molly Boss, a captain at Air Wisconsin Airlines. “There is a [CRM] need to gather all the information from all sources, but I see a lack of willingness to just make a decision.”
Sumwalt responded that retraining on CRM ought to occur in such cases. “I am disturbed that that notion is out there because … CRM is not a decision by committee,” he said. “CRM is gathering all the available information that you can, and then the pilot-in-command makes the decision.”
Metrics of Professionalism
A highly experienced pilot might fail to perform or behave as required because of diminished self-discipline, poor study habits or decline in personal motivation, said Paul Preidecker, chief instructor at Air Wisconsin. “If flight discipline and self-discipline are lacking, it will eventually show up in training,” he said. “The measuring tools that we have for [soft skills of] professionalism are … not always clear. This has caused us to think quite a great deal about the notion that just because someone has done this before, they can do it again and do it for our organization. Our experience has been that that is not always the case.”
The NTSB’s Sumwalt asked for panelists’ opinions of the feasibility of identifying specific attributes of professionalism and behavioral markers, and reaching a government-industry consensus about how to measure and apply them. “We need the industry to agree upon those attributes and then come up with the behavioral markers for the continuum — this is excellent, this is substandard,” Sumwalt said. Such an agreement would enable pilots to be objective in assessing one another and in measuring themselves, he added.
Gerda Pardatscher, rule-making officer–flight crew licensing, at the European Aviation Safety Agency (EASA), suggested that the NTSB consider existing work on airmanship — the European term most relevant to this discussion — in the European Joint Aviation Regulations on flight crew licensing. “We already have markers by which we have exactly defined in which phases of the flight the examiner has to look at [airmanship] very closely,” Pardatscher said. “It’s possible for pilots to fail a check solely because of lack of airmanship, which happens very rarely.”
Summarizing the nature of management oversight of professionalism, Delta’s Sternstein said that the company conducts scheduled line checks of entire crews at least every 24 months, and no-notice line checks for line check captains. Annually, 50 percent of captains receive a random line check. “[We also do a] line check blitz — for example, over a six-week period [in late 2009] we conducted 1,000 random line checks,” he said. “If there are procedural errors or deviations or behavior that detracts from safety, those can cause an individual pilot or the crew to be graded as unsatisfactory.”
Under Delta’s advanced qualification program (AQP), a pilot who no longer meets standards of leadership skills, risk management or situational awareness “will have difficulty with [the AQP] line operations evaluation,” a fifth type of check prompted by unsafe trends in flight operational quality assurance (FOQA) data and reports from the aviation safety action program (ASAP) and other AQP inputs, Sternstein said.
“We have a tool kit of options to remedy most procedural, policy or professional issues,” he said. “If someone’s behavior is a detractor to safety — or as the chief line check pilot, I’m not completely comfortable putting my family in his or her airplane for whatever reason — we will not sign off that pilot [to operate flights]. We ask our pilots, particularly our captains, to make decisions and say we will support them. We empower our pilots to take action if someone steps out of bounds.”
‘Pro Stan’ Successes
Professional standards programs of pilot unions — open to all members but providing services relevant to the situations of very few — help pilots face professionalism issues through peer intervention by trained volunteer counselors. “Pro stan” services facilitate confidential discussion of a professional or ethical problem of any nature, including issues of attitude, motivation or compliance with procedures. Pilots typically, but not always, overcome such problems without entering a formal company process that may lead to disciplinary action, documentation in personnel records or termination of employment, said ALPA’s Rosenberg.
Robert McDonnell, an American Airlines captain representing the Allied Pilots Association, estimated that professional standards committees of U.S. major airlines interact with fewer than 1 percent of their unions’ members. Delta’s Sternstein provided an example of intervention with a pilot whose behavior might have led to breakdown of professionalism.
“One captain mentioned that he wished he had retired,” Sternstein recalled. “He was going through bankruptcy and [loss of] pension … he was very distracted and was having difficulty compartmentalizing [that is, consciously ‘tuning out’ non-aviation mental distractions],” he said. “The chief pilot and I … explained to him that there are things that [pilots] just can’t control. Because his attitude was affecting the safety of the aircraft, he had to make a decision to move beyond this [anger] or he wasn’t going to get back into the cockpit. He did move beyond his anger at what had occurred with the bankruptcy and the loss of the pension. We put him in special training and checking, which shortened the interval in which we were going to observe him again. Other people and I have flown again with him … I consider [this] a success story.”
If the ASAP event review committee (ERC) identifies deficiencies of professionalism that should be addressed with an individual pilot, peers from the professional standards committee will be asked to talk with the pilot on behalf of the ERC, said Horizon’s Keinath. The peers typically are best equipped to handle training or take other appropriate action, making it unnecessary to involve the chief pilot’s office or the standards and training department, he said.
One serious safety issue addressed by counselors involved SOPs and compliance with the operating manual, and a pilot who repeatedly refused to respond to communication from them, McDonnell recalled. “This pilot was a little deficient, but because this was definitely a safety issue, we went to the chief pilot, who told him he was either going to be fired or retire early,” he said. “The pilot decided to retire early. Once a chief pilot … and issues that involve safety are involved, there is no recourse but to bring in the FAA for certificate action … termination or early retirement.”
Typically, some kind of interpersonal conflict at work triggers a call to the professional standards committee, Rosenberg added. “One of the best things we can do while counseling and helping to mediate conflicts is to help pilots reestablish their sense of dedication and focus on the task at hand,” he said. “We say, ‘This is what we are hearing. Here is the path that you are presently walking down in the footprints of pilots who have gone before you and are no longer here. Professionalism is an attitude — you have a choice.’”
Several pilot panelists told the NTSB that nothing has been more influential in maintaining professionalism in their own careers than flying with captains who modeled the “right” attitudes and behaviors to operate safely. Captains must continue setting the standard of professionalism to influence others, they said.
A few panelists were asked about the effect on individual performance of the airline industry’s business cycles or wider economic woes. Pilots’ skills in compartmentalizing the tasks at hand prevent significant risks, they agreed. Delta’s Sternstein, for example, responded, “People are extremely professional, I don’t see [personal economic concerns] affecting the operation of Delta. What we do see is that … some of the younger people may have the perspective that [operating airplanes] is not a career, it is a job, and that they have a Plan B just in case they get furloughed, the company is not financially successful or [other things occur] out of their control [and some] do have side businesses.” Captains have to ensure that behavior related to such outside interests does not impinge on flight operations, he said.
Horizon’s Keinath was among panelists who expressed concern that some soft skills for coping safely with the demands of airline flying may not be transmitted to a new generation of first officers and captains, given their varied backgrounds. “This generation of new [civilian] pilots, in particular, has not heard of the concept of compartmentalizing [as taught to naval aviators] and maybe we should be training that,” he said. “As one of the lessons learned from this forum, maybe we … need to come up with an industry-accepted set of [skills] that should be added to the training curriculum.”
Continental’s Berman emphasized that even a momentary lapse — such as an impulsive decision or distraction induced by personal convenience — can increase the risk of an accident as much as a prolonged lapse of professionalism. “The captain and first officer have to recognize that both crewmembers need to be engaged in monitoring and challenging each other at all times — and the channels of communication have to be open,” he said. “To address the very tiny percentage of things not being done professionally, however, we have to make sure we don’t shut down the flow of communication. … That would have more of a negative safety impact than all of the many safety threats out there that are not directly related to professionalism.”
There is some evidence that professionalism can suffer despite pilots’ efforts to use personal discipline to ward off complacency, some panelists said. “Constant monitoring of the aircraft’s position, track and trend continues to be a major challenge for crews,” said Air Wisconsin’s Boss.
A review of pilot reports to aviation safety action programs showed that roughly 20 percent involved missed crossing restrictions and 15 percent involved lateral navigation errors, she said. “Many of today’s airline pilots operate multiple flights per day, multiple days a week, between the same city pairs and within the same route structure,” Boss explained. “Though familiarity can be beneficial, the ‘been there, done that’ mentality is sometimes difficult to conquer. … Captains must strive to create a zero-tolerance atmosphere for casual noncompliance.”
One of the NTSB’s questions about the “Generation Y” flight crew demographic concerned reports that these pilots may expect others to obtain their personal agreement or “buy-in” to comply with regulations and SOPs; in particular, that some captains may not actively enforce rules they consider arbitrary. “Buy-in is … one of the essential parts of what we are trying to accomplish right now,” Boss agreed. “I think pilots are most responsive to constructive criticism from a peer as opposed to from a manager or any other source. It is going to take peer-to-peer contact … one pilot at a time.”
Such individual expectations may have a precedent in the pilot community at large, however. The concept of buy-in to SOPs perhaps has become ingrained in the self-concept of aviation professionals, some panelists’ comments indicated. In merging Northwest Airlines and Delta Air Lines, for example, flight operations specialists adapted, merged and implemented the best SOPs of both companies, said Delta’s Bosworth. “We have been at that for nearly a year … and now we have identified 350 items that line pilots have brought back to the company. They said, ‘You need to revisit these items because we are not buying in that they are the best way.’”
Air Traffic Control
In the ATC domain, FAA Air Traffic Organization (ATO) managers and National Air Traffic Controllers Association (NATCA) representatives told the NTSB that organizational change management — especially ongoing work to fully implement the Air Traffic Aviation Safety Action Program (ATSAP; ASW, 7/09, p. 9); a professional standards committee; a fatigue risk management system; and the Next Generation Air Transportation System (NextGen; ASW, 4/10, p. 30) — has a significant bearing on efforts to enhance the professionalism of controllers. The 18-month-old ATSAP, designed for voluntary nonpunitive reporting of errors and safety concerns, is becoming a vital asset in these efforts, several panelists said.
“With this change [to just culture principles] we’re going to see an opening up of information,” said Steven Wallace, a NATCA representative and controller at the FAA’s Miami Air Route Traffic Control Center. “We need to do whatever we can do to ensure ATSAP’s longevity. It is a huge cultural change [for the FAA to say] it may not have been the individual who was the problem, it may have been something in the system.” Independent experts reviewing errors likely will reach different conclusions than individual managers and “this maybe will take the personality issues out of fact finding,” he said.
Scott Proudfoot, the FAA’s ATSAP lead analyst, said that the ATSAP policy represents the “complete opposite” of automatic disciplinary action for individuals, and that the level of professionalism can be linked to morale. “We want controllers to freely report,” he said. “We want to know about safety problems that have existed for years and have not been reported for fear of reprisal. We want the information so we can identify trends — both facility-specific and in the National Airspace System [NAS] — to present those trends and problems to people who are responsible for fixing them.”
In April, teams from the FAA and NATCA began meeting to design the professional standards program. Plans call for its implementation in the third quarter of 2010 with termination in October 2012, subject afterward to collective bargaining, said Garth Koleszar, a NATCA representative and a controller at the Los Angeles Air Route Traffic Control Center. The peer counseling will be similar to programs in the airline pilot community, he said.
In late 2010, the ATO also will institute an ATC quality control program, said Michael McCormick, acting executive director of the ATO Terminal Service Unit. “It will provide an ability to take a look at the performance of individuals, the organization and individual service delivery points to ensure [that the values, mission and level of professionalism are] consistent with our expectations of the organization,” he said.
Controllers who work for the FAA or its private ATC contractors have some advantages over airline pilots in how uniformly they acquire knowledge and skills, and how consistently professionalism is instilled in them. The FAA’s screening, selection and training of controllers use structured interviews and comprehensive aptitude screening, said Kate Bleckley, a personnel research psychologist at the FAA Civil Aerospace Medical Institute. More than 90 percent of people accepted for training become certified, compared with 50 to 75 percent in the 1990s and 2000s. About 50 percent of candidates have no prior ATC training; the remainder have prior military or academic training. “Less than 0.5 percent are terminated for unprofessional behavior [during training],” added Henry Mogilka, assistant division manager, Air Traffic Training Division, FAA Academy.
Professionalism is instilled at the academy, in closely supervised initial experience in ATC facilities, and in recurrent training, said Jennifer Allen-Tallman, manager of the ATO CRM program. “We literally go through the traits of an expert controller, how these controllers conduct their team debriefs, how they work with their assist [controller], how they communicate and various attributes of operating professionally in a control room,” she said. “We also value consistency. In our workshops, we say, ‘Do the right thing at the right time every time with every aircraft … when no one is looking, as well.’ So CRM works in very well with instilling that sense of professionalism when they get to that first field facility [where] they are all working together as a team, from the manager to the developmental controller.”
As federal employees sworn to positions of public trust, controllers consent to abide by FAA ethical standards at all times, such as in obtaining adequate rest before reporting for duty, said Laurie Zugay, air traffic manager at the Tampa (Florida) International Airport.
A number of NTSB forum panelists favored the reinstatement of airline programs for controller familiarization flights in transport airplane jumpseats, which were cancelled in the wake of the 9/11 terrorist attacks. Tim Flaherty, a Northwest Airlines captain representing ALPA, and Doug Thoman, a captain and line check airman for UPS Airlines representing the Independent Pilots Association, concurred that these flights are valuable for both professions to understand pilot workload and ATC decision making. The FAA’s McCormick and Zugay responded that only preliminary discussions of the idea have occurred.