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Monitoring lapses - Root causes & mitigation strategies

Condition/effect Casual factors Root cause Mitigation

Complacency Personal High level of trust 1. During LOFT

 Experience (never failed before). caused by lack of assessments
 Over familiarity/ exposure to include subtle
over reliance with  Attitude (self-satisfied). failure of high system failures that
high integrity integrated demonstrate
Psychological
systems that rarely systems. possible areas of
fail.  Trust.
weakness and
Physical encourage
 Feeling of well-
being and unaware  Lack of oxygen (hypoxia can result monitoring.
of a developing in feeling of euphoria).
situation. Aircraft
 Systems reliability.
 Long haul routes.
 Route familiarity.

Limited attentional Personal High workload is 1. The monitoring

resource  Workload pressure (time required to the most likely tasks must be
carry out tasks exceeds time root cause that prioritised and the
 Reduced capability available). reduces the lower priority
to carry out the mental capacity to monitoring tasks
monitoring tasks  Experience (novel situation to deal carry out all the need to be
required. with = higher attentional demand). monitoring tasks. shared/shed.
 Competency (limited skill in dealing 2. SOPs could identify
with situation in timely fashion the highest priority
and/or system knowledge). monitoring tasks
Psychological across the phases
 Anxiety. of flight.

 Emotional stress. 3. Exposures to high

workload situations
Physical stressors will be required to
 In general all physical stressors practice and
(temperature, noise, vibration, develop monitoring
humidity, time of day, lack of task shedding
oxygen) could result in performance strategies.
degradation and reduce capacity.
4. If non-monitoring
Aircraft task (e.g. QRH)
 System malfunction (increase takes all the
workload to deal with problem). attention then
Commercial air transport operator inform the PF
 Lack of prioritisation guidance to (ideally the PF will
deal with overload. already be aware of
the high workload
 Lack of exposure during training to situation).
task overload situations to provide
experience and hone multi-tasking
skill.
External environment
 Dealing with adversity in any
situation e.g. low visibility, high
terrain, limited navigational aids,
places high demands on both pilots
thereby reducing their spare
capacity to carry out all monitoring
tasks.

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Condition/effect Casual factors Root cause Mitigation

Confusion (loss of Physiological A monitoring 1. Training in

situational  Sleep inertia (difficulty in carrying lapse can cause metacognition
awareness) out tasks immediately after waking loss of SA (knowing what you
up). therefore to know and don’t
 Lack of address the root know and similarly
understanding of  Visual conflict. causes of the for your crew
what is going on. effect of SA on member – what
 Disorientation.
 Inability to predict monitoring lapse it he/she knows or
Personal is more likely to doesn’t know).
what is going to
happen (mode  Workload (e.g. when attention be due to
completely focused on resolving workload 2. Recognising loss of
changes, system SA and repairing it
implications, system problem). management and
crew through situation
system Psychological updates to bring
interactions,  Cultural inhibition (to request communication.
them back into the
aircraft response). information, intervene, inform). loop again.
 Inability to focus Aircraft 3. Ensuring briefings
attentions on the  Poor crew briefing (pre-flight and are adequate to
right information during flight) resulting in the reduce the
source. situation where the co-pilot is not likelihood of loss of
fully aware of the overall plan. SA.
 Lack of communication between
pilots resulting in one of the pilots
being out of the loop.
 Poor design.
Organisation
 Training (lack of knowledge).
Environment
 Unfamiliarity.
 Low visibility.

Fatigue Physical stressors The most likely 1. Acknowledge

 In general all physical stressors root cause of tiredness for crew
 Progressive (temperature, noise, vibration, tiredness will be member to self-
decline in attention. humidity, time of day, lack of related to manage rest
 Decreased levels oxygen) could result in tiredness. rostering and periods.
of consciousness. sleep
Physiological 2. Recognise and
management.
 Lack of sleep. compensate for low
Long haul flights levels of arousal
 Circadian disruption. may pose due to tiredness
 Prolonged period of wakefulness. problems due to (self and crew
multiple time member).
Psychological zones and night
 Fear. time flights. Also 3. Maintain simulation
long haul back to through passive,
 Anxiety. active periodic and
back flights may
 Motivation. result in long predictive
rosters causing monitoring.
 Emotional stress.
significant sleep 4. Schedule rosters to
Personal debt. minimise sleep
 Workload/ effort. deprivation.
Commercial air transport operator 5. Plan pre-flight rest
 Demanding schedules resulting in accordingly.
long periods of wakefulness.

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Condition/effect Casual factors Root cause Mitigation

Low arousal level Physical stressors Lack of simulation 1. Provide stimulation

 Low level of  Temperature, time of day. due to cruise through passive,
phase or over active periodic and
attention capability Physiological familiarity. predictive
normally due to
 Lack of sleep. monitoring.
task inactivity.
 Can be related to  Circadian disruption.
boredom and  Prolonged period of wakefulness.
tiredness.
Psychological
 Motivation (low).
Personal
 Workload (low).
Aircraft
 Long haul routes.
 Route familiarity.

Disorientation Physiological Eye/brain 1. Always

 Cognitive disability  Visual illusion caused by conflict interpretation of monitoring/cross
between visual, vestibular and spatial position check flight
whereby the sense instruments.
of time, direction proprioceptive mechanism.
and recognition of 2. Conduct upset
situation becomes Personal recovery and
difficult to  Principle of the moving part – a disorientation
distinguish. moving reference against a fixed training.
aircraft can cause disorientation.
Weather conditions
 Poor visibility causing loss of visual
cues/ references.

Distraction Psychological Lack of ability to 1. Discipline in

 Divided attention  Anxiety. maintain focus on prioritising task
primary task. demands.
from the current  Emotional stress.
attention focus to 2. Develop multi-
the distraction Personal tasking ability
source.  Motivation through practice
(e.g. doing drills and
 Mental distraction – System malfunction keeping an eye on
day dreaming. flight parameters) or
ATC interruption use of commercially
Cabin crew interruption available selection
of software tools
(PILAPT, ADEPT,
COMPASS).

© Global Air Training Limited 2016 1.3