See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/316734587

Manual Flying Skills - Airline Procedures and their Effect on Pilot Proficiency

Thesis · April 2017

DOI: 10.13140/RG.2.2.17886.23362

CITATIONS READS

0 2,959

1 author:

Moritz Hanusch
City, University of London
4 PUBLICATIONS   0 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Manual Flying Skills - Airline Procedures and their Effect on Pilot Proficiency View project

Decision-Making and Situational Awareness of Airline Pilots in Flight Path Monitoring on highly automated Flight Decks View project

All content following this page was uploaded by Moritz Hanusch on 07 May 2017.

The user has requested enhancement of the downloaded file.

 Moritz Hanusch

„Manual Flying Skills – Airline Procedures and their Effect

on Pilot Proficiency”

Final Project

Submitted as part of the requirement for the award of MSc in Air Safety Management
at City University of London

I certify that this project is either my own work,

or appropriately referenced where sourced from other data.

This project complies with the Project Regulations and Guidelines in effect at August 2015.

Signed: …….........................
Supervisor: Giancarlo Buono
Word Count (excluding Appendices, Tables, and References): 14,879
February 2017
Unrestricted Circulation
 The safety systems that the industry has developed and implemented
over the last twenty years are based on the assumption of
two fully trained, capable and experienced pilots in the cockpit,
with each pilot able to be the absolute master of the aircraft
in every possible situation at every moment.

Chesley B. Sullenberger III,

Testimony before the Senate Subcommittee on Aviation Operations, Safety, and Security
28th April, 2015

ii
Executive Summary

Technological development and the automation of aircraft systems have undoubtedly contributed to the
present, high level of commercial flight safety. Nevertheless, pilots are still a central element of the
aviation safety net, and human perception, cognition, and creativity are crucial in dealing with
ambiguous or abnormal situations. Pilots must carefully choose an adequate level of automation to
maintain situational awareness and to operate their aircraft safely. However, there are ongoing
discussions if increased automation contributes to pilots’ over-reliance and manual flying deficiencies.
If prescribed automation policies and Standard Operational Procedures (SOP) further restrict manual
flying opportunities, the proficiency of pilots might not be sufficient to cope with situations necessitating
basic “pitch & power” aircraft control.

This paper investigates the influence of different procedural environments on pilots’ manual flying
proficiency. Beyond a comprehensive theoretical background on the topics of manual flying skills,
automation, and flight deck procedures, it provides evidence on the impact of deficient manual flying
skills on flight safety, especially concerning Loss of Control In-flight (LOC-I) accidents. Moreover, the
results of a related quantitative survey conducted among more than 1,500 pilots world-wide are
discussed against the backdrop of latest research and industry initiatives. Based on some alarming
results, especially concerning pilots in rather rigid procedural environments, restrictive company
cultures and/or long-haul or enlarged crew operations, recommendations to further promote flight safety
are presented. By means of an integrated approach, adequate and balanced SOPs can support pilots’
opportunities to acquire and maintain resilient manual flying skills, not least during line operations.

iii
Table of Contents
Page
Front Page i
Executive Summary iii
Table of Contents iv
List of Abbreviations & Acronyms vii
List of Figures & Tables x

1 Introduction 1

2 Objectives & Research Method 3

2.1 Objectives 3
2.2 Method 4

3 Background 5

3.1 Automation in Aviation 5

3.1.1 The Early Years 5
3.1.2 Advanced Cockpit Automation 6

3.2 Levels of Automation 9

3.3 Physiological Background 11

3.3.1 Required Pilot Skills 11
3.3.2 Acquisition and Retention of Skills 12

3.4 Human-Automation Interaction – Ergonomics – Flight Deck Design 12

3.5 Advantages and Disadvantages of Flight Deck Automation 13

3.5.1 Overview 13
3.5.2 System Accuracy 14
3.5.3 Workload Management 16
3.5.4 Complexity – Mode Confusion – Mode Error 16
3.5.5 Effects of Trust – Automation Over-Reliance – Pilot Complacency 18
3.5.6 Automation Surprise 19
3.5.7 Degradation of Manual Flying Skills 20

iv
 3.6 Procedural Framework in the Flight Deck 22
3.6.1 Standard Operating Procedures (SOP) 22
3.6.2 Automation Policies and “Freedom of Manoeuvre” 23
3.6.3 A Matter of Culture 24

4 The Impact of Manual Flying Deficiencies on Aviation Safety 26

4.1 Manual Flying Issues in Flight Safety Analysis 26

4.1.1 Statistical Evidence 26
4.1.2 A Focus on Loss of Control In-Flight 27

4.2 Safety Initiatives addressing Manual Flying Skills 29

4.2.1 Manual Flying Opportunities in Line Operations 29
4.2.2 Upset Prevention and Recovery Training (UPRT) 30

5 Manual Flying Skills Online Survey 32

5.1 Survey Method & Objectives 32

5.2 Survey Results 32

5.2.1 General Observations 32
5.2.2 Manual Flying in Daily Operations 33
5.2.3 Manual Flying and Simulator Training 34
5.2.4 Manual Flying Opportunities 34
5.2.5 The Influence of the Procedural Environment 37

5.3 Limitations of the Survey 40

6 Discussion & Recommendations 41

7 Further Research 44

8 Conclusion 46

References 47

v
Appendix A: Terminology

Appendix B: Practical Examples of Automation Issues

Detail 1: Fly-By-Wire and Envelope Protection Issues
Detail 2: The Normal Go-Around – A Complex, High-Workload Situation
Detail 3: Qantas 32 – Complexity of Alerts and Warnings
Detail 4: Hapag-Lloyd 3378 – Over-Reliance on FMS Calculations
Detail 5: Automation Complexity, Mode Confusion, and Task Saturation
Detail 6: Asiana 214 – Automation Over-Reliance and a Silent Mode Transition

Appendix C: Background on the Manual Flying Skills Online Survey

Appendix D: Manual Flying Skills Online Survey Questionnaire

Appendix E: Aircraft Categories used for Survey Analysis

Appendix F: Proposed Automation Policy

vi
List of Abbreviations & Acronyms

AAP = Accident Analysis & Prevention

AC = Advisory Circular
ADS-B = Automatic Dependent Surveillance Broadcast
AFCS = Automatic Flight Control System
ALPA = Air Line Pilots Association
ASAP = Aviation Safety Action Program
ASRS = Aviation Safety Reporting System
ATPL = Airline Transport Pilot Licence
ATSB = Australian Transport Safety Bureau
BEA = Bureau d’Enquetes et d’Analyses pour la securité de l’aviation civile
BFU = Bundesstelle für Flugunfalluntersuchung
CAA = Civil Aviation Authority
CAST = Commercial Aviation Safety Team
CAT = Commercial Air Transport
CDU = Control Display Unit
CFIT = Controlled Flight into Terrain
CRM = Crew Resource Management
CRT = Cathode Ray Tube
DoT = Department of Transport
EASA = European Aviation Safety Agency
ECAM = Electronic Centralized Aircraft Monitoring
EFIS = Electronic Flight Instrument System
EICAS = Engine Indicating and Crew Alerting System
FAA = Federal Aviation Administration
FBW = Fly-by-Wire
FCC = Flight Control Computer
FDM = Flight Data Monitoring
FMA = Flight Mode Annunciator
FMC = Flight Management Computer
FMGS = Flight Management and Guidance System
FMS = Flight Management System

vii
GCAA = General Civil Aviation Authority
HAI = Human-Automation Interaction
HFE = Human Factors Engineering
HUD = Head-up Display
HUPER = Human Performance
IASS = International Air Safety Summit
IATA = International Air Transport Association
ICAO = International Civil Aviation Organization
ICATEE = International Committee for Aviation Training in Extended Envelopes
IFALPA = International Federation of Air Line Pilots’ Associations
ILS = Instrument Landing System
LCD = Liquid Crystal Display
LNAV = Lateral Navigation
LOC = Loss of Control
LOC-I = Loss of Control In-Flight
LOSA = Line Operations Safety Audit
MCP = Mode Control Panel
MPL = Multi-Crew Pilot Licence
NASA = National Aeronautics and Space Administration
ND = Navigation Display
NTSB = National Transport Safety Board
PBN = Performance-based Navigation
PF = Pilot Flying
PFD = Primary Flight Display
PM = Pilot Monitoring
PNF = Pilot non-Flying
RNAV = Area Navigation
RVSM = Reduced Vertical Separation Minima
SAFO = Safety Alert for Operators
SESAR = Single European Sky ATM Research
SIB = Safety Information Bulletin
SID = Standard Instrument Departure
SOP = Standard Operating Procedures

viii
STAR = Standard Arrival
SUPRA = Simulation of UPset Recovery in Aviation
SUST = Schweizerische Sicherheitsuntersuchungsstelle
TOGA = Take-Off/Go-Around
UPRT = Upset Prevention and Recovery Training
US = United States
VC = Vereinigung Cockpit
VNAV = Vertical Navigation

ix
List of Figures & Tables

Figure Page
1 Accident Rates and Onboard Fatalities per Year (Boeing 2016a) 1
2 Douglas DC-4 Flight Deck (Wikimedia Commons) 5
3 Airbus A310 Flight Deck (Wikimedia Commons) 6
4 Boeing 727 Flight Deck (Wikimedia Commons) 7
5 Boeing 787 Head-up Display (Wikimedia Commons) 7
6 Airbus A380 Flight Deck (Wikimedia Commons) 8
7 Levels of Automation of Decision and Action Selection (Parasuraman et al 2000) 9
8 Levels of Flight Deck Automation (Department of Transport 2016) 10
9 Example of Complex RNAV Standard Arrivals (LIDO/mPilot) 14
10 Example of Advanced Flight Procedures (Department of Transport 2016) 15
11 Flight Control System Automation Overview (Flight Safety Foundation 2008) 17
12 Accident Category Frequency and Mortality Risk (2011-2015) – Fatal Accidents 28
(IATA 2016)
13 LOC Accident Sequences Initiated by Inappropriate Crew Input 29
(Belcastro & Foster 2010)
14 Central Part of an Embraer 195 Flight Deck (Wikimedia Commons) Appendix B, p. 2
15 Boeing 737-500 Flight Deck (Wikimedia Commons) Appendix E, p. 2
16 Boeing 737-800 Flight Deck (Wikimedia Commons) Appendix E, p. 2

Table Page
1 Pilot Preferences concerning Manual Flying Opportunities 35
(different Comparison Groups)
2 Pilot Preferences concerning Manual Flying Opportunities 36
(different Comparison Groups) (continued)
3 Differences between Pilots’ Procedural Environments – Answers to Key Questions 38
4 Differences between Pilots’ Procedural Environments – Answers to Key Questions 39
(continued)

x
1 Introduction

During the last decades, commercial aviation has grown dynamically. The number of flight hours of the
commercial western-built jet fleet alone has doubled between 1996 and 2015 (Boeing 2016a).
Concurrently, flight safety has reached new heights, and flying is by far the safest means of
transportation world-wide: according to the International Air Transport Association (IATA), only 1.61
airliner accidents per million flights were recorded in 2016 (IATA 2017). Figure 1 displays an overview
of accident rates and onboard fatalities from 1959 to 2015 (Boeing 2016a).

Figure 1: Accident Rates and Onboard Fatalities per Year (Boeing 2016a)

However, severe accidents continue to occur. Especially if a large loss of life is involved, public
attention and media coverage are considerable (García-Gavilanes et al 2016). The ramifications of such
an event can even threaten the economic viability of entire companies. Due to the complexity of the
aviation system, many factors contribute to system breakdowns such as accidents or incidents (Dekker
et al 2011) – often involving human error on side of the involved pilots (cf. CAA 2013a).

After cockpit automation was initially intended to relief pilots physically, further development aimed at
higher system accuracy and reliability, reduced workload, and a mitigation of pilot error. This approach
was widely successful, however at the price of creating new issues: humans have difficulties to
continuously monitor automated systems that barely fail (Bainbridge 1983) and can thus become
complacent (Parasuraman & Manzey 2010). Moreover, there are several issues around system
complexity, and pilots often fail to effectively interact with inscrutable systems that can increase
workload instead of reducing it (Mosier 2010). When automated systems suddenly fail or disconnect –

1
so-called “automation surprise” situations – pilots often struggle to take over aircraft control, especially
if the aircraft is technically degraded (Sherry & Mauro 2014).

Although many aircraft systems, functions and tasks have been partly or wholly automated, pilots are
still a central element of the aviation safety net: “The safety and effectiveness of the civil aviation system
rely on the risk mitigation done by well trained and qualified pilots (and other humans) on a regular
basis” (Flight Deck Automation Working Group 2013, p. 29). No matter how sophisticated the
technology is, human perception, cognition, and creativity are crucial in dealing with ambiguous or
abnormal situations. Pilots must carefully choose an adequate level of automation to maintain situational
awareness and to operate their aircraft safely. These levels range from manual, “pitch & power” aircraft
control up to the use of highly-integrated autoflight systems.

Standard Operating Procedures (SOP) provide the framework for a seamless interaction within the flight
crew and with the automated systems of the aircraft (Degani & Wiener 1994). Within the procedural
concept of the SOPs, however, a flight crew’s “freedom of manoeuvre” (see chapter 3.6.2) can be
defined in quite different ways. SOPs or overlying automation policies can be defined in a way that
flight crews can decide how to fill the procedural framework with an adequate use of automation.
Otherwise, SOPs or automation policies can be prescribed in a rather narrow way precisely specifying
which level of automation or even which autopilot mode flight crews must use. In this case, pilots’
freedom of manoeuvre is rather restricted, and little room is left within the procedural framework for
so-called techniques (Degani & Wiener 1997). For example, manual flying opportunities can be
diminished if pilots are obliged to use the autopilot as soon as possible after take-off and as long as
possible before landing; some airlines even demand to perform an automatic landing wherever
practicable. Therefore, a pilot’s actual manual flying time can be limited to just minutes over weeks or
months, especially in long-haul operations. A study performed in a large international airline revealed
that maximum automation was used during 99.6% of all analysed flights (Landry 2017). Thereby
deprived of manual flying opportunities, pilots can sustain a certain degree of “skill rusting”, and there
is a considerable body of evidence on retarding manual flying skills (Ebbatson et al 2010; Casner et al
2014; Haslbeck & Hoermann 2016). Several official publications addressed this issue (EASA 2013a;
FAA 2013a; Transport Canada 2015) as the safety implications of pilots’ deficient manual flying skills
are significant, especially concerning Loss of Control In-flight (LOC-I) (IATA 2015a).

However, research has paid little attention to these issues so far, and presently, there is no study available
evaluating the effects of restrictive SOPs on pilots’ manual flying skills, especially considering
decreasing manual flying opportunities many pilots face. This paper intends to fill this gap by addressing
the issue of pilots’ manual flying proficiency under the influence of different procedural environments,
with the aim to positively contribute to airlines’ safety management (ICAO 2013). Chapter 2 will
provide more details on the objectives and research method of this paper.

2
2 Objectives & Research Method

2.1 Objectives

This paper has the following main objective:

- To analyse the effects automation policies or related Standard Operating Procedures (SOP) have
on the ability of pilots to acquire and maintain sufficient manual flying skills, and therefore to
develop a better understanding of the influence different SOPs have on pilot proficiency.

Furthermore, this paper has the following secondary objectives:

- To find out how pilots perceive their respective automation policy and SOPs (or their company
culture) in relation to automation and manual flying skills: do they feel empowered to achieve
and maintain adequate manual flying skills, or do they feel restricted?

- To investigate if different aircraft types and their automation design influence pilots’ manual
flying skills;

- To find out if pilots consider simulator training adequate to (partly) replace sufficient time in
manual control of the real airplane;

- To investigate the role of experience in pilots’ perceived ability to maintain flying skills;

- To analyse if there is a need to reconsider present automation policies, as automation becomes

more complex while many pilots’ manual flying opportunities tend to decrease.

This paper intends to contribute to flight safety and efficient safety management by means of the
following practical implications:

- To enable aircraft operators to obtain a better understanding of the correlation between

automation policies or related SOPs and pilots’ manual flying skills, thus enhancing the safety
management of pilot proficiency issues;

- To encourage operators to adapt or adjust their automation policy and/or SOPs in such a way
that their pilots have better opportunities to acquire and maintain resilient manual flying skills
without compromising flight safety, efficient flight operations, and/or passenger comfort.

3
2.2 Method

This paper is based on two parts. Initially, an overview concerning automation in aviation, required pilot
skills, and flight deck design aspects will be given, and advantages and disadvantages of automation
will be presented. An emphasis will be laid on issues around deficient manual flying skills of pilots, and
reference to related accidents or incidents will be given. The topic of Standard Operating Procedures
(SOP) will be explained, with an emphasis on different automation policies and pilots’ “freedom of
manoeuvre.” Statistical evidence for the impact of manual flying deficiencies on commercial flight
safety will be presented, especially considering Loss of Control In-flight (LOC-I) accidents. Related
safety initiatives published by different legislative entities will complete the first part of this paper. For
all these topics, a thorough review of literature was performed, including latest research publications.

In a second step, the results of a quantitative evaluation of pilots’ perspectives obtained through an
online survey will be presented. More than 1,500 commercial pilots world-wide participated in the
survey and gave valuable insights into the topics of SOPs regarding automation and their effects on
manual flying. Finally, the research background as well as the end-user perspective obtained from the
online survey will be discussed, and recommendations to further enhance flight safety will be given.

For this paper, the author complied with the ethical guidelines of City University of London as well as
the European Commission’s “Ethics for Researchers” document (European Commission 2013).
Appendix A provides a detailed overview of the terminology used in this paper.

4
3 Background

3.1 Automation in Aviation

3.1.1 The Early Years

In the early years of aviation, flying was nearly exclusively based on a pilot’s physical control skills,
visual perception, and judgment. Visual reference to the ground was required to safely navigate the
aircraft – until 1929, when James H. Doolittle performed the first-ever flight solely based on flight deck
instruments. However, manual control of the aircraft was still required. This changed when the first
triaxial “automatic pilot”, “Sperry”, was introduced in 1932; especially concerning long-haul flights,
autopilots became a standard soon “(…) alleviating fatigue and freeing pilots from the burden of
constant manual control of the aircraft” (Billings 1991, p. 262). Instruments such as artificial horizons
or attitude indicators reduced pilots’ dependency on cues outside the aircraft – and helped to overcome
human limitations concerning perception and recognition, night vision, information processing, or
attention. Flight decks developed during that time (see figure 2) were characterised by separate round-
dial gauges indicating data received from one single source each.

Figure 2: Douglas DC-4 Flight Deck (Wikimedia Commons)

With the advent of the jet age, control forces became too large for pilots, so hydraulic or pneumatic
actuators were developed to amplify pilot inputs. Thus, it was necessary to review the technological
advances from an ergonomics perspective, as pilots were used to have a certain “control feel” during
manual aircraft control (Langewiesche 1944; Dunlap 1948).

The “electric automation” of the 1950s and 1960s further revolutionised the flight deck: autothrottle
systems were installed, flight directors provided command information, and autopilots could be coupled
to different modes, e.g. capturing Instrument Landing System (ILS) localisers and glideslopes; even

5
automatic landings were possible from the 1970s on (Billings 1991). However, navigation was still
performed relative to ground-based stations.

In the face of advancing automation, pilots were increasingly performing monitoring duties and
therefore no longer directly involved in the control loop (Mouloua et al 2010). Concerns were expressed
that pilots were “losing sight of the raw data” (Billings 1991, p. 263) behind the automation’s rationale,
an aspect that is still discussed regarding today’s advanced cockpit automation.

3.1.2 Advanced Cockpit Automation

Around the year 1980, the “electronic automation” era began, and aircraft with integrated Flight
Management Systems (FMS) and early “glass cockpits” were introduced (Billings 1991). Instead of
several analogue, round-dial gauges, cathode ray tubes (CRT) were used to present information from
multiple sources in few centralised Electronic Flight Instrument System (EFIS) displays. The “map
display” was introduced to improve pilot situational awareness and to show information sourced from
the FMS, such as aircraft present position and planned route. Lateral navigation (LNAV) autopilot
modes allowed to follow routes along coordinate-based waypoints saved in the FMS (Abbott 2001).
With the introduction of the glass cockpit, the two-man cockpit became an industry standard as the tasks
of the flight engineer were either assumed by the aircraft’s automated systems or distributed among the
two remaining pilots, a major change for cockpit teamwork (Hoeft et al 2006). Figure 3 shows the flight
deck of an Airbus A310, a typical EFIS cockpit with a combination of round-dial instruments and CRTs.
As a comparison, figure 4 displays the “classic” flight deck of a Boeing 727 including the flight engineer
station.

Figure 3: Airbus A310 Flight Deck (Wikimedia Commons)

6
Figure 4: Boeing 727 Flight Deck (Wikimedia Commons)

FMS capability increased considerably with the integration of vertical navigation (VNAV) functions,
e.g. allowing the use of optimum descent profiles. Head-up Displays (HUD, see figure 5) were
introduced enabling pilots to have essential flight information available within their line of sight. Liquid
Crystal Displays (LCD) replaced the CRTs used in earlier glass cockpit designs, and caution and
warning systems or electronic checklists were integrated in centralised displays.

Figure 5: Boeing 787 Head-up Display (Wikimedia Commons)

7
The Airbus A320, first flown in 1987, introduced the second generation of glass cockpits offering
several new design features, e.g. sidesticks for aircraft control (cf. figure 6, Airbus A380 flight deck).
Digital Fly-by-Wire (FBW) flight control technology (Traverse et al 2006, Airbus 2017a) replaced
traditional cable transfer and allowed the integration of computer-enhanced algorithms to refine (or
restrict) pilot input. Tailored control laws streamline the control characteristics of different aircraft
models enabling pilots to have a similar control feel (Airbus 2017b). However, sidesticks do not offer
tactile feedback (cf. Sklar & Sarter 1999); as they are not interconnected, they do not move according
to the inputs of the other pilot (as control columns normally do), an aspect that has played a role in the
sequence of events in different incidents and accidents (BEA 2012; Komite Nasional Keselamatan
Transportasi 2015; SUST 2016). Correspondingly, thrust levers on modern Airbus aircraft are normally
arrested in designated detents while the autothrust system regulates engine thrust. Thus, normal “pitch
& power” feel and tactile feedback are massively reduced on aircraft constructed along this design
philosophy, and pilots are forced to rely more on other, mostly visual cues – and the automated systems
alerting and protecting them, e.g. by means of envelope protection. While Boeing and Embraer have
implemented rather “soft” envelope protection logics where pilots will only meet increasing resistance
to control inputs when approaching design limits, Airbus has implemented “hard” limits where the
airplane will not accept control inputs that would result in exceedances of prescribed aircraft states
(Abbott 2001). More aspects on Fly-by-Wire and envelope protection issues can be found in Appendix
B, Detail 1.

Figure 6: Airbus A380 Flight Deck (Wikimedia Commons)

8
Each aircraft manufacturer has an individual design policy regarding integration and use of automation.
According to Luchtvaartveiten.nl (2016, p. 6), Airbus’ philosophy is that “Automation should lead the
aircraft through a normal and safe flight envelope and must not work against the operator’s inputs,
except when absolutely necessary for safety.” Boeing’s philosophy leaves more sovereignty to the pilot:
“The pilot is the final authority for the operation of the airplane. Only apply automation as a tool to aid
the pilot and not to replace the pilot” (Luchtvaartveiten.nl 2016, p. 6). With the words of Abbott (2001,
p. 6), “different philosophies can be effective if each is consistently applied in design, training, and
operations, and if each supports flight crew members in flying their aircraft safely” – and if crews are
aware of their respective aircraft’s design philosophy, its functions, and limitations.

With automation and system sophistication moving on, handling patterns that have become common
and usual for decades are underlying further change. Automation policies, SOPs, and company cultures
strongly influence pilots’ ability to deliberately use all available levels of automation, from manual
control up to highly integrated automated modes.

3.2 Levels of Automation

Levels of automation are used to categorise different degrees of automation authority and autonomy in
human-automation interaction. Parasuraman et al (2000) defined ten different levels, ranging from full
manual control up to autonomous computer control (see figure 7).

Figure 7: Levels of Automation of Decision and Action Selection (Parasuraman et al 2000)

9
However, in modern flight decks, these levels can be hard to operationalise (Abbott 2015), as a multitude
of different systems and sub-systems with different autonomy, but without linear mode hierarchy
interact with the pilots. However, concerning aircraft control, this interaction can be narrowed down to
four levels, ranging from “full manual” (“raw data”) up to “full autoflight” (see figure 8).

Figure 8: Levels of Flight Deck Automation (Department of Transport 2016)

Burian et al (2005, p. 7) addressed pilots’ difficulties to determine an adequate level of automation,

especially concerning non-normal and emergency situations: “In some cases, automation can help
reduce the workload that crews face as they both continue to fly the aircraft and respond to a problem.
In other cases, (…) attempting to use some aspects of automation can impair a crew’s ability to respond
appropriately to an emergency or abnormal situation”. The United States’ Commercial Aviation Safety
Team (CAST) distinguished between “tactical” and “strategic” automation and emphasised an adequate
utilisation of automation levels (CAST 2008). The United States’ Department of Transport (DoT)
underlined the importance of flexible automation use: “While no single level of automation is
appropriate for all flight environments, it is important that pilots have a good understanding of the
system and make the appropriate decisions when encountering unusual situations, such as when
automation fails or there is an emergency” (Department of Transport 2016, p. 4). Thus, it is crucial that
pilots can perform their duties in a procedural environment that offers an adequate “freedom of
manoeuvre”, thus enabling a deliberate use of all levels of automation (see chapter 3.6.2).

10
3.3 Physiological Background

3.3.1 Required Pilot Skills

In the early years of aviation, aircraft control used to be a rather “physical- and sensory-oriented task”
(Mosier 2010, p. 148), as first generation aircraft were aerodynamically unstable requiring nearly
constant “stick and rudder” control inputs. During all phases of flight, it was crucial for pilots to perform
an accurate judgment of their environment and to derive an equally accurate response from it. Increased
experience resulted in a more accurate perception that in turn promoted more accurate responses.

Nowadays, highly autonomous automated aircraft systems have altered the skillset required for aircraft
control. Except for very short times during takeoff and landing, it is no longer required to determine an
aircraft’s position in space by means of outside cues. Cockpit displays offer a multitude of information,
often visualised in a way to simplify pilot identification and awareness. The primary task of a pilot in
the electronic cockpit environment is to analyse the information available, and to monitor and supervise
system performance. Mosier (2010, p. 158) stated that “the importance of handling skills has been
replaced by an expectation of management skills requiring rule-based and knowledge-based cognitive
control.” An intuitive handling of electronic “raw data” information using mental shortcuts or
recognition processes is not advisable, and a structured, analytical approach is required.

Moreover, new cognitive demands evolve with every technological step, often involving monitoring
tasks. As humans are not perfectly suited for extended times of monitoring (Abbott et al 1996; Ferris et
al 2010), pilots often struggle to remain vigilant continuously monitoring an automated system (Warm
et al 2008; CAA 2013b), especially if errors occur only rarely (Casner et al 2014). Correspondingly,
Sarter et al (2007, p. 347) described that “(…) monitoring failures are one major contributor to
breakdowns in pilot-automation interaction.” The United States’ Federal Aviation Administration
(FAA) stated that “lapses in monitoring performance during lower workload periods [are] often
associated with boredom and/or complacency” (FAA 2003, Appendix 19, p. 1). Casner & Schooler
(2014) addressed the related issue of task-unrelated thought of pilots. Tiredness and fatigue (Mallis et
al 2010; Williamson et al 2011) are among the performance shaping factors that are most closely
interrelated with monitoring issues. Coherence errors are much more likely to occur, errors where pilots
are subject to “(…) failures to note and process relevant data or detect something in the electronic ‘story’
that is not consistent with the rest of the picture” (Mosier 2010, p. 160). To counteract human
shortcomings in constant monitoring and vigilance, Sumwalt et al (2002) have proposed more active
automation monitoring practices. It remains crucial for pilots to interact consciously and vigilantly with
their aircraft’s automated systems within the respective Standard Operating Procedures (SOP).

11
3.3.2 Acquisition and Retention of Skills

Different skills exhibit different patterns of acquisition, remembrance and forgetting. Although the
technological evolution of aviation has shifted required pilot skills from psychomotor towards cognitive
skills, the “hybrid ecology of the flight deck” (Mosier 2010) still requires competence in both areas. The
FAA’s Flight Deck Automation Working Group (2013, p. 70) stated: “Many pilot skills are developed
over time and, as with any skills, they need to be practiced to be maintained at the appropriate level of
expertise. Intervals of practice to maintain skills are dependent on initial skill level and type of skill (e.g.
visual flying skills are more durable than instrument flying skills) (…).” Casner et al (2014, p. 1515)
added:

Hand-eye skills (instrument scanning and manual control), if initially well learned, are
reasonably well retained after prolonged use of automation. Cognitive skills, such as
navigation and failure recognition and diagnosis, are prone to forgetting and may depend
on the extent to which pilots follow along when automation is used to fly the aircraft.

Although cognitive skills demonstrated to be rather susceptible to skill fading, Casner et al (2014)
remarked that psychomotor skills were still subject to atrophy. Thus, it is important that the mentioned
initial skill level is sufficient to form a robust foundation, and there is enough opportunity to keep the
skills on a level that gives the operator competence and confidence to solve even unusual, dynamic, and
critical situations (see chapter 3.5.7).

Automation policies and related SOPs play a key role here: by providing flight crews a “freedom of
manoeuvre” (see chapter 3.6.2) which is adequate to the respective operational environment as well as
to the pilots’ needs to keep their “skills sharp”, much can be done here to facilitate flight safety.

3.4 Human-Automation Interaction – Ergonomics – Flight Deck Design

Since the very beginning of aviation, flight deck design directly affected the ability of pilots to safely
control their aircraft. Dunlap (1948) described aspects such as human reaction time, equipment design
and placement, as well as ergonomic aspects such as required control forces and system feedback.
Nowadays, pilots control various systems providing different degrees of automation, from manual
control up to highly complex autoflight modes offering a multitude of inherent functions. The modern
cockpit represents a “(...) sociotechnical distributed system with humans and automation providing
complementary contributions (…)”, Ferris et al (2010, p. 484) described, and flight deck design largely
influences the achievable safety and efficiency of the resulting human-automation interaction (HAI).

Today’s flight decks have a multitude of information available, and this information is accessible in
many ways. While some information is easily interpretable, other information must be retrieved from

12
complex sequential sub-menus – or cannot be accessed at all. Mosier (2010, p. 167) described: “(…) as
the aircraft cockpit has evolved, much of the systems information has either been altered in format, not
presented at all, or buried below surface displays.” New components were often added to existing
designs in an incremental way leading to an incoherent distribution of information sources across the
cockpit. This “fragmentation of feedback” (Ferris et al 2010, p. 489) can severely hamper efficient
information management, especially when it comes to error avoidance, detection, and recovery. Mosier
(2010, p. 166) warned that “(…) displays also foster intuitive rather than analytical cognition, and in
doing so set up the expectation that the cockpit can be managed in an intuitive fashion. This is an
erroneous assumption.”

Balanced information management is difficult: too much information harbours the risk of mental
overload (Burian et al 2005). However, if insufficient information is available (so-called “system
opaqueness”, Mosier 2010, p. 167), system relationships and interdependencies can be inscrutable from
pilot’s perspective. The same difficulty applies to the salience of cues: a low salience might have the
effect that relevant information goes unnoticed possibly causing automation surprises (see chapter
3.5.6), while a high salience can impede a thorough analysis of available information, so-called
“automation bias” (Mosier et al 2007; see chapter 3.5.5).

Thus, crew station design and integration (Baxter et al 2007; Jacobsen et al 2010), display array, layout,
and size (Curtis et al 2010), and an adequate salience of cues are crucial for pilots to build an accurate
mental model. In contrast to technology-driven strategies, one approach to seamless human-automation
interaction is a flight deck design philosophy along the principles of “Human-Centered Automation”
(Billings 1991; 1996). Human Factors Engineering (HFE) (Abbott 2001) integrates flight deck design
and procedure design, as a safe and effective system does not depend on the user interface alone.
Concerning automation and manual flight, the importance of balanced and adequate SOPs as part of an
integrated HFE approach becomes evident.

3.5 Advantages and Disadvantages of Flight Deck Automation

3.5.1 Overview

Beyond clear advantages of automation such as system accuracy, reliability and workload relief, this
chapter will discuss issues such as limited mode awareness or mode errors, automation dependency,
pilots’ over-reliance on automation, or complacency. An emphasis will be put on those aspects that
evidently relate to the issues of SOPs and manual flying skills.

13
3.5.2 System Accuracy

A major advantage of automation in aviation is its accuracy and reliability. Sensor technology has
become extremely precise, and continuous efforts are undertaken to improve automation logics and
functions (Ferris et al 2010). Automation can contribute considerably to fuel efficiency, e.g. by means
of a smooth and precise flight control or by calculating an ideal idle power descent path. However, this
calculated path still depends on the accuracy of data (e.g. estimated track distance) entered by the crew
– a perfect example where pilot experience and judgement are crucial for a useful automation
functionality.

Figure 9: Example of Complex RNAV Standard Arrivals (LIDO/mPilot)

14
Congested airspaces call for other solutions that can be addressed by means of sophisticated automation
(Department of Transport 2016). The implementation of Reduced Vertical Separation Minima (RVSM)
(ICAO 2010) allowed to considerably increase traffic volume in cruise flight above 28,000 ft, however
requiring a higher precision of aircraft systems – and a mandatory use of autopilots in RVSM airspace.
Moreover, Area Navigation (RNAV) Standard Arrivals (STAR) and Standard Instrument Departures
(SID) have replaced many conventional procedures at airports world-wide (Department of Transport
2016). Due to the complexity of many RNAV routes (see figure 9), the dense traffic situation in terminal
areas, and strict noise abatement procedures requiring precise navigation, manual flight often represents
an unfavourable option, at least from a workload management perspective.

Further technological innovations include Automatic Dependent Surveillance Broadcast (ADS-B)

(ICAO 2011a) or Performance-based Navigation (PBN) (ICAO 2016a), integral elements of future
airspace utilisation projects such as NextGen (FAA 2017) or Single European Sky (European
Commission 2017). The required high accuracy mandates the use of high levels of automation; manual
flying can thus be prohibited for nearly entire flights (cf. figure 10). Especially if pilots do not thoroughly
understand system capabilities and limitations, these innovations can contribute to future automation
over-reliance (Ferris et al 2010). The Flight Deck Automation Working Group (2013, p. 33) pointed out
that although “(…) future operations are expected to involve increased number and types of automated
systems, (…) the need for reversion to manual flight operations will still exist.”

Figure 10: Example of Advanced Flight Procedures (Department of Transport 2016)

15
3.5.3 Workload Management

One of the main goals of automation in aviation is a “reduction of physical and cognitive workload”
(Ferris et al 2010, p. 492). Consequently, monitoring duties gradually replaced “stick and rudder” control
during most parts of a flight (Mosier 2010; see chapter 3.2.1). Ferris et al (2010, p. 492) described
potentially paradoxical effects of automation as follows:

However, (…) the overall amount of workload was not affected as much as it was re-
distributed over crewmembers and over time. “Clumsy” automation (…) led to a further
reduction in workload when it was already low (…), while during periods of high tempo
and workload (…), the need for instructing and monitoring the automation actually
increased workload in some cases.

While it was relatively easy to prioritise the tasks along the “Aviate, Navigate, Communicate” principle
when only the outside view or a few analogue instruments had to be supervised, it has become “(…)
harder to operationalize these concepts when there are many tasks within each area, and tasks often
overlap or are left awaiting a further trigger for completion or continuation” (Flight Deck Automation
Working Group 2013, p. 58). Highly sophisticated automation, however useful and relieving it might
be during normal operations, can prove to be highly complex and inscrutable from a pilot’s perspective,
especially if many tasks must be performed within a limited timeframe, as in non-standard or high
workload situations: “When overloaded, the pilots shed tasks based on their own experience, skill, and
risk management of the situation” the Flight Deck Automation Working Group (2013, p. 58) described.
Pilots can struggle to slow things down and become task saturated. When a multitude of tasks compete
for pilots’ attention, inadequate monitoring, communication breakdowns, or procedural errors are more
likely to occur – and can quickly lead to adverse consequences as high workload phases often take place
in proximity to the ground. More details on this issue can be found in Appendix B, Detail 2.

By granting pilots a “freedom of manoeuvre” to deliberately use their automated systems, automation
policies or related SOPs can directly contribute to an optimum workload for pilots.

3.5.4 Automation Complexity – Mode Confusion – Mode Error

While it is undisputed that automated systems have clear advantages due to their enormous capability
to quickly and accurately perform numerous parallel calculations, the nearly unlimited number of
algorithms can have downsides as well. Complexity and impenetrability from the operator’s perspective
are among the biggest issues concerning automation in aviation: “One major concern with cockpit
automation has been its low observability (…) in combination with its high degree of complexity and
authority”, Ferris et al (2010, p. 485) pointed out. The complexity of alerts and warnings can increase

16
workload especially in non-normal situations (Burian et al 2005). The severe incident of Qantas 32
represented an exemplary case for this issue (see Appendix B, Detail 3). Figure 11 gives a schematic
overview of flight control system automation and its inherent complexity.

Figure 11: Flight Control System Automation Overview (Flight Safety Foundation 2008)

Pilots are trained to think ahead and “stay in front of the airplane.” However, system complexity and
low observability can result in deficient or lost mode awareness or situational awareness (Dekker 2015).
If they are unsure about the automated systems’ behaviour, pilots cannot anticipate related performance
changes or even the future trajectory of the aircraft. Reduced mode awareness or mode confusion can in
turn result in mode errors, either errors of commission that occur “(…) when a pilot executes an action
that is appropriate for the assumed but not the actual current mode of the system” (Ferris et al 2010, p.
486), or errors of omission when a pilot does not react adequately (or not at all) to a changed situation
or a system irregularity (Sarter & Woods 1995a). Moreover, limited mode awareness or mode errors
often contribute to automation surprises (see chapter 3.5.6).

The scope of automation policies or related SOPs can contribute considerably to a susceptibility to mode
errors. For example, some airlines tend to prescribe their crews exact modes for each flight phase
(Degani & Wiener 1994; see chapter 3.6.2). For example, if VNAV modes are the only accepted descent
modes, crews will frequently find themselves in situations where other modes would be more adequate
– or even safer. However, reluctance of pilots can exist due to strict SOP adherence, especially in
punitive company cultures (see chapter 3.6.3).

17
3.5.5 Effects of Trust – Automation Over-Reliance – Pilot Complacency

System reliability, operator trust and reliance play crucial roles regarding automation in aviation
(Dzindolet et al 2003). As malfunctions occur even in highly reliable systems, “(…) the perceived
reliability of a system has a strong influence on the amount of trust operators put in it, and consequently,
the likelihood of its use”, Ferris et al (2010, p. 493) described. Thus, pilots’ trust in automated systems
can be “miscalibrated”. Inappropriate distrust can lead to an inefficient use of automation or “automation
disuse” (Parasuraman & Riley 1997). The so-called “crying wolf effect” (Ferris et al 2010) occurs when
pilots ignore cautions or warnings generated by automated systems as they received nuisance warnings
in the past. An example for such a distrust in automation was the crash of a Sukhoi Superjet in Indonesia
(National Transportation Safety Committee 2012) where the pilots outspokenly ignored several terrain
warnings before impact.

In contrast, “automation misuse” (Parasuraman & Riley 1997) describes an inappropriately high trust in
automation. The Flight Deck Automation Working Group (2013, p. 67) described that the “long term
use of FMS-derived flight path trajectory without the need to critically assess or intervene may atrophy
the skills needed to anticipate, monitor and react.” While conventional navigation used to be a
continuous process, the pre-programming of routes in the FMS might facilitate the assumption that
navigation is a “once-and-done programming exercise” (Casner et al 2014, p. 1508). Pilots often over-
rely on automated systems or delegate more authority to these systems in situations where less
automation might be required – even after the automation malfunctions or has proven unreliable (Ferris
et al 2010). This so-called “complacency” (Campbell & Bagshaw 2002, p. 156) can also impair the
cross-verification process required within Standard Operating Procedures. Casner et al (2014) described
the difficulty of pilots to maintain their thoughts focused on automated systems that rarely fail, leading
to an atrophy in pilots’ ability to handle abnormal events. An exemplary case where a flight crew
excessively relied on the FMS’ calculations can be found in Appendix B, Detail 4.

Automation bias represents another common issue concerning trust in automation (Mosier et al 1998;
Mosier & Skitka 1999). Instead of vigilantly seeking for correct information, pilots trust in saliently
displayed automated information on a heuristic basis. Especially if systems are degraded, pilots that
have not carefully monitored the state of the automated systems might be overwhelmed when an
intervention becomes necessary: “Major problems may be raised for an operator who is highly practised
at using computer generated displays if these are no longer available in an emergency”, Bainbridge
(1983, p. 776) wrote. Related aspects played a key role in the crash of an Air France Airbus A330 in
2009 (BEA 2012).

Pilot over-reliance on automation can be fostered by automation policies or SOPs directing flight crews
to generally use automation and to refrain from manual flying wherever possible. The Flight Deck

18
Automation Working Group (2013, p. 37) warned that “(…) this may lead to an erosion of manual flying
skills and a subsequent over-reliance on automation.” Casner et al (2014) assisted that an atrophy of
skills might be the result if pilots rely – or must rely – on automation alone. A strict prescription of
automation use, called “automation abuse” by Parasuraman & Riley (1997), leaves a diminished
“freedom of manoeuvre” for pilots and might contribute to automation over-reliance or automation
dependency in turn. A vicious circle between automation dependency and manual flying skills can
evolve, as pilots with marginal opportunities to hand fly can have a reduced confidence in their own
skills and might therefore feel more comfortable with the autoflight systems engaged. As FMS-based
details are usually displayed in magenta on aircraft screens, the term “Children of Magenta” is
sometimes used for pilots overly relying on automation (Reinig 2014).

3.5.6 Automation Surprise

As pilots often struggle to remain vigilant during periods of extended monitoring (cf. chapter 3.3.1),
mode errors (see chapter 3.5.4) or erroneous system behaviour often go unnoticed if the related
information is only available from the aircraft’s displays (Sarter et al 2007). One reason can be that
“most annunciations associated with mode states and transitions tend to be cryptic alphanumeric
indications that are too subtle to capture pilots’ attention when the flight crew is busy performing other
tasks or not expecting, and therefore not looking for, a change”, Ferris et al (2010, p. 485) explained.
Instead, pilots tend to rely more on actual changes in airplane behaviour, and can thus be faced with an
automation surprise situation. The “startle effect” can adversely affect recognition, decision-making and
aircraft control (FAA 2015; Martin et al 2015). Ferris et al (2010, p. 492) described that “(…) in those
rare circumstances when pilots need to intervene and manually control the airplane, they may struggle,
especially since they are now required to manually control a system that is not functioning properly.”

Automation surprise situations can lead to a spontaneous, often uncoordinated manual takeover of the
aircraft by its pilots, either inadvertently (e.g. due to system failure) or deliberately. In the sequence of
events leading to the 2009 Colgan Air crash in Buffalo (NTSB 2010a), the autopilot disconnected as the
aircraft approached an aerodynamic stall – surprising for the crew, but according to system design. In
other cases, pilots switch the autopilot off as the automated systems “do something weird” thereby
possibly compromising a situation already entailing a high level of workload, especially if complex
navigation procedures, adverse weather, tiredness or fatigue play a role. Thus, pilots can become task
saturated, being unable to plan ahead any more (see Appendix B, Detail 5 for more information). In the
case of Asiana 214 (NTSB 2014), possible over-reliance on automation and a silent mode transition
contributed to an automation surprise of the flight crew (see Appendix B, Detail 6).

19
Especially if a pilot with little manual flying proficiency or a certain degree of “skill rusting” is
confronted with an automation surprise situation, the spontaneous manual takeover of the aircraft can
have adverse consequences. Pilots often fail to transit from mostly cognitive monitoring tasks to
cognitive and psychomotor tasks required for manual flight (cf. chapter 3.3) under high workload or
task saturation. It becomes evident that it has a completely different effect on the safety of a flight if an
automation surprise happens to a manually proficient flight crew compared to a flight crew with manual
flying deficiencies.

3.5.7 Degradation of Manual Flying Skills

As laid out in chapter 3.3, different skills are required for instrument flying, skills that underlie different
patterns of remembrance and forgetting. With the words of Haslbeck and Hoermann (2016, p. 533),
“hard and continuous drill is indispensable for pilots to acquire and maintain the adequate touch and feel
essential to manually control the aircraft in any conceivable maneuver.” However, sophisticated
technology often reduces pilots’ opportunities to maintain their manual flying proficiency. Ferris et al
(2010, p. 493) described this possible “deskilling” as follows:

(…) Over time, continued and extensive use of automation can lead to overreliance on
technological assistance and the loss of psychomotor and cognitive skills required for
manual flight (…). Deskilling can lead to a “vicious cycle” of performance degradation
when pilots’ realization of their own skill loss leads to even heavier reliance on automation.

During the 1980s, marked by the introduction of “3rd generation” aircraft (Airbus 2015) such as the
Boeing 757/767 or the Airbus A300-600, research focused on the transition of pilots from conventional,
analogue cockpits to (then) modern EFIS cockpits (Wiener & Curry 1980; Childs & Spears 1986;
Wiener et al 1991; Veillette 1995). The introduction of “4th generation” aircraft including Fly-by-Wire
(FBW) flight controls (see chapter 3.1.2) instigated research investigating pilots’ interaction with these
sophisticated systems (Sarter & Woods 1995b; Sarter & Woods 1997; Young et al 2006). Today, more
than 10.000 aircraft incorporating Fly-by-Wire technology are in service world-wide (FlightGlobal
2016), and entire generations of pilots have been trained towards “4th generation” aircraft from the very
beginning of their career (Gillen 2010).

Although the effects of increased automation on deficient manual flying skills were discussed widely, a
lack of scientific evidence was occasionally criticised (CAA 2004). However, recent research on manual
flying skills, including the works of Gillen (2008), Ebbatson (2009), Ebbatson et al (2010), Casner et al
(2014), and Haslbeck & Hoermann (2016), changed the picture. The Flight Deck Automation Working
Group (2013) report on the Operational Use of Flight Path Management Systems contains additional
in-depth insights into the correlation of automation use and manual flying skills.

20
Ebbatson (2009) performed a simulator study among 15 cadet pilots. He revealed that the individual
manual flying ability of pilots varies considerably, as “the level of recent exposure to manual flight may
be dependent upon the pilot’s attitude to risk, how they perceive the benefits of manual flight and
whether they take or seek opportunities to disengage the automatics” (Ebbatson 2009, p. 116).

The innovative aspect of Ebbatson (2009) and Ebbatson et al (2010) was the measurement of “outer-
loop” (the aircraft’s trajectory) and “inner-loop” (the pilot’s control intention) parameters. Control input
frequency and amplitude were used to measure inner-loop parameters. Thus, factors that might impede
a coherent analysis of pilot control, such as inertia, aerodynamical stability, or transport delays, could
be mitigated. Ebbatson (2009, p. 84) discovered that “pilots with more manual handling experience
generally use less control input power to achieve equal levels of tracking performance.” These results
support regular manual flying practice: proficient pilots need less effort to control their aircraft and to
keep it within prescribed parameters. However, many pilots in Ebbatson’s (2009) study perceived
manual flying as a dilemma, as it can result in an increased workload and a higher risk of flight path
deviations, while automated flight might contribute to a decay of manual flying skills.

In the simulator study of Ebbatson et al (2010), 66 Boeing 737 pilots were evaluated in a single engine,
“raw data” tracking task. To evaluate the influence of recent flying on pilots’ manual flying
performance, the sectors flown in the previous week were considered. Ebbatson et al (2010) determined
four main correlations between recent sectors flown and pilots’ manual flying accuracy, thus confirming
the effect of “skill fading” due to a lack of recent manual flying practice.

Casner et al (2014) performed a simulator study involving Boeing 747 pilots. Hand-eye skills were
analysed by scenarios evaluating instrument scanning and manual aircraft control, while cognitive skills
were analysed in a navigational task. The study revealed deficiencies around cognitive skills required
for instrument flying in manual control, including shortcomings regarding position awareness and
recognition of instrument system failures. The authors confirmed that pilots would benefit from
additional opportunities to train their manual flying skills.

The latest high-level study on the topic was recently published by Haslbeck and Hoermann (2016). 126
Airbus A320 and A340 pilots were evaluated in a “raw data” simulator assessment. As all significant
exceedances observed in the study involved A340 crews, Haslbeck and Hoermann (2016, p. 533)
concluded that a “lack of practice on long-haul fleets” expedites the erosion of pilots’ manual flying
skills. All results of the study confirmed that fine-motor manual flying performance was much more
correlated with recent flight practice than time elapsed since flight training, total experience, or
experience on type. In line with recent aviation authority initiatives (see chapter 4.2.1), Haslbeck and
Hoermann (2016, p. 544) urged that “more manual flight practice could also be derived by changing
companies’ automation policies to encourage pilots to fly manually if the situation permits.”

21
3.6 Procedural Framework in the Flight Deck

3.6.1 Standard Operating Procedures (SOP)

Standard Operating Procedures (SOP) are a crucial element of the coordinated interaction between
crewmembers: “Safety in commercial aviation continues to depend on good crew performance. Good
crew performance, in turn, is founded on standard operating procedures that are clear, comprehensive,
and readily available to the flightcrew”, the FAA (2003, p. 12) stated. SOPs are a form of written and
standardised guidance prescribing sequential actions and callouts for the involved team members to
ensure that all upcoming tasks can be performed in “(…) a manner that is efficient, logical, and also
error resistant” (Degani & Wiener 1994, p. 5). By facilitating “(…) teamwork, communication, division
of labor, and clear specifications of ‘who does what’” (Degani & Wiener 1994, p. 29), SOPs enable a
flight crew that is unfamiliar with each other’s capabilities and experience to cooperate in a seamless
and predictable way, and to jointly build a common mental picture of the present and future state of their
flight. Thereby, SOPs are an essential contributor to situational awareness, effective crew coordination
and enhanced team performance, core elements of successful Crew Resource Management (CRM)
(Helmreich 2010).

SOPs require a clear distribution of roles, responsibilities, and tasks; in modern flight decks, these roles
are Pilot Flying (PF) and Pilot Monitoring (PM, formerly Pilot Non-Flying, PNF). The PM has a crucial
role monitoring the PF’s actions, the performance of aircraft systems, the resulting flight path, and the
own performance. During flight with autopilot engaged, beyond controlling the aircraft’s trajectory
using the Mode Control Panel (MCP) or the FMS, the PF performs monitoring functions as well.

Procedures must be designed carefully and with due consideration for the human operator and the
respective operational environment, especially concerning automation: “(…) many tasks that involve
the use of automation are too complex and interactive to allow a stringent set of SOPs to be mandated”,
Degani & Wiener (1994, p. 23) stated. SOPs should be appropriate for the situation, practical to use,
and comprehensible by crewmembers (FAA 2003). A procedure that is too prescriptive or proves to be
illogical, inconsistent, or inadequate (e.g. by unduly increasing workload) will hardly be accepted – and
can even lead to a general distrust towards procedures and procedural non-adherence in other areas.
Crews’ SOP non-adherence, individual workarounds, or abbreviations of mandatory cross-verifications
have been a factor in many incidents and accidents (Flight Deck Automation Working Group 2013).
Therefore, the FAA (2003) emphasised the importance of a buy-in from all stakeholders (especially the
end-users) in the SOP design process.

Degani & Wiener (1994, p. 6) formulated the integrated “Four P” procedure design, consisting of general
philosophy, policies, specific procedures, and practices. Practices represent the “system outcome”,

22
based on procedure adherence, procedure deviation, procedure omission, or the use of techniques.
Ideally, procedures and practices are identical.

Techniques can be defined as an individual method to perform tasks. Degani & Wiener (1994, p. 13)
described that “every pilot carries with him a virtual catalog of techniques. They are often fine points
which pilots have discovered for themselves, experimented with, or learned from other pilots.” They are
usually too fine-grained to be prescribed to all crewmembers as SOPs, and procedure design should not
attempt to write “a procedure for everything”, Degani & Wiener (1994, p. 24) stated.

3.6.2 Automation Policies and “Freedom of Manoeuvre”

By defining an overarching “way how to do things”, automation policies directly influence pilots’
opportunities to acquire and maintain their proficiency. While some operator’s policy allows pilots to
use a considerable “freedom of manoeuvre”, others rigidly restrict pilots in that regard. The European
Aviation Safety Agency (EASA) observed that “(…) operators’ automation policies, which include
provisions for manual flying, vary significantly (…), spanning from mandating the use of full
automation at all times, except take-off and landing (when not required by operations), to encouraging
disconnecting the automation whenever possible, below a certain altitude/flight level” (EASA 2013a, p.
1). Even if manual flying is allowed in “low-threat environments”, this can be interpreted as a strict
limitation in certain company cultures. The Flight Deck Automation Working Group (2013, p. 38)
pointed out that “such policies are said to be preferred by some operators because the automated systems
can perform more precisely while reducing pilot workload. However, this may lead to an erosion of
manual flying skills and a subsequent over-reliance on automation” (cf. chapter 3.5). Thus, “if
operational requirements and policies do not support manual flying, pilots may have difficulty
maintaining the skills needed to handle non-routine situations”, the Department of Transport (2016, p.
12) warned.

Especially in case of so-called “automation exceptions” (Landry 2006) or whenever there is unclarity
about the behaviour of the automated systems, it seems to be highly advisable to “(…) go one step down
in the level of automation”, Degani & Wiener (1994, p. 23) advised. However, the Flight Deck
Automation Working Group (2013, p. 55) clearly stated that “there may not be a single, simple answer
for all cases”; therefore, automation should be used flexibly and deliberately depending on the situation.

In sophisticated automated aircraft, the multitude of options available to accomplish tasks result in
numerous techniques pilots can apply (e.g. the use of different autopilot modes). These techniques play
a key role in pilots’ adaptability and flexibility, and should be accepted if they are consistent with

23
company policies and procedures. However, caution should be exercised, as a technique might be more
comfortable or easier for pilots, but not necessarily safer (Tullo 2010).

There are several official publications addressing the issue of adequate automation policies. Whatever
the used level of automation is, EASA (2015, p. 2) stated that “a core philosophy of ‘fly the airplane’
should permeate the automation policy prepared by air operators.” The Flight Deck Automation
Working Group (2013, p. 8) recommended to “focus the policy on flight path management” rather than
emphasising simple procedural execution of autoflight modes. Transport Canada (2015, p. 4) added that
“operators should carefully consider whether their automation policies provide for sufficient manual
operation of the aircraft during routine operations to ensure that their pilots maintain a high level of
proficiency in manual flying skills.” There is clear evidence on the crucial role of automation policies
and SOPs that should leave an adequate “freedom of manoeuvre”, thus enabling pilots to safely control
their aircraft across all levels of automation.

3.6.3 A Matter of Culture

Although the scope of this paper lies on the respective procedural environment in which pilots perform
their duties, the topic of culture cannot be underestimated. A certain culture and its inherent practices
can be described as “how it’s really done around here” (Tullo 2010, p. 72) – based on shared values,
attitudes, behaviours, or customs (Sherman et al 1997).

Beyond cultures based on a geographical, religious, or ethnical background, distinctive separate cultures
can exist even within or between company’s departments, small groups, or teams. Such sub-cultures can
exist in alignment with the entire organisation’s company culture – or in contrast to it. A crucial aspect
here is a company’s safety culture (Patankar et al 2012; Noort et al 2016; Reader et al 2016). Reckless
behaviour, SOP non-adherence or deficiencies in Crew Resource Management (CRM) can result from
a rejection of company culture or the establishment of a sub-culture.

Concerning automation and manual flying skills, cultural differences are manifold as well, often based
on an airline’s company culture or operational environment. Sherman et al (1997) conducted a survey
among more than 5,000 pilots in 12 countries to analyse the effects of national culture on attitudes
towards flight deck automation. The study revealed that pilots from rather individualistic, egalitarian
societies had rather sceptical attitudes towards automation: a majority considered the FMS as a tool, not
the primary means to control an aircraft. In contrast, pilots from rather hierarchical cultures with a
preference for rules and procedures preferred higher degrees of automation.

The operational environment strongly influences local cultures as well: one of the pilots participating in
the Manual Flying Skills Online Survey (cf. chapter 5) commented that manual flying would be

24
appreciated at one of his airline’s homebases, while another homebase’s local culture would not allow
for too much manual flying. While the first airport is surrounded by large areas of wilderness where
bush flying is quite common, the latter is a large hub in congested airspace – aspects certainly
influencing the respective local culture.

Pilots flying for an airline in the Middle East reported that while their automation policy allows manual
flying below 10,000 ft. altitude, their management deals with even minor deviations in a rather strict
and punitive way. Thus, many pilots in this company avoid flying manually, mostly to avert disciplinary
measures due to a flight path deviation which might be more likely during manual flight. IATA (2016,
p. 127) mentioned this aspect in its latest safety report: “(…) there are other cultures where the punitive
approach is taken too often. This results in airlines and crews pushing the envelope so as to avoid the
punitive culture.”

25
4 The Impact of Manual Flying Deficiencies on Aviation Safety

4.1 Manual Flying Issues in Flight Safety Analysis

4.1.1 Statistical Evidence

Deficiencies in manual flying and their impact on flight safety can hardly be analysed in a generalised
way. Beyond the inherent complexity of the cognitive and psychomotor skills required for aircraft
control (see chapter 3.3), the difference between pilot intention (“inner loop”) and aircraft trajectory
(“outer loop”) makes it difficult to differentiate between intent and outcome. Usually, several factors
contribute to a related incident or accident (Dekker et al 2011). Moreover, pilots’ manual flying
deficiencies do not automatically lead to incidents or accidents, and many related occurrences may go
unnoticed. If the respective airlines’ Flight Data Monitoring (FDM) does not capture an event, an
analysis of pilots’ control cannot be conducted, and no lesson learned can be shared. Otherwise, not
every Loss of Control In-flight (LOC-I) occurrence is the result of erroneous aircraft handling, although
manual flying deficiencies often contribute to such cases (see chapter 4.1.2).

Several entities regularly publish safety statistics (Airbus 2015; Boeing 2016a; EASA 2016a, ICAO
2016b). Although different taxonomies are used, most of these publications provide valuable
information on the impact of manual flying deficiencies on aviation safety. This chapter evaluates three
of the most tangible analyses available to specify the impact of manual handling deficiencies on flight
safety in commercial aviation.

The Safety Report annually published by IATA presents in-depth accident analyses for the last calendar
year and the last five years, respectively. According to the “Report Findings and IATA Prevention
Strategies” presented by IATA (2016, p. 113), “manual handling/flight controls” is the top “flight crew
error.” In further analysis of these flight crew errors, “manual handling/flight controls” is among the
“top contributing factors”, as it was involved in 34% of all accidents in 2015, 30% of all accidents and
26% of all fatal accidents between 2011 and 2015. Concerning different accident “end states”, “manual
handling/flight controls” has contributed to 19% of Controlled Flight into Terrain (CFIT) accidents,
73% of tailstrikes, 50% of undershoots, 74% of hard landings, and 38% of LOC-I accidents.

The British Civil Aviation Authority (CAA) regularly presents a Global Fatal Accident Review covering
a timeframe of ten years. Different to the taxonomy used by IATA, the CAA distinguishes between
primary causal factors, other causal factors, circumstantial factors, and consequences. The category
“flight handling” in the CAA’s (2013a, p. 2) analysis “(…) generally related to events in which the
aircraft was controllable (…), however the flight crew’s mishandling of the aircraft or poor manual
flying skills led to the catastrophic outcome.” In detail, “flight handling” represents the top primary

26
causal factor responsible for 19% of all analysed fatal passenger aircraft accidents. It was among all
causal factors in 34% of these accidents accounting for 34% of all fatalities.

The Flight Deck Automation Working Group (2013) performed an extensive analysis of flight path
management issues. Various data sources were used, such as published accident and major incident
reports, Aviation Safety Reporting System (ASRS) (NASA 2017) and Aviation Safety Action Program
(ASAP) (FAA 2013b) reports, and Line Operations Safety Audit (LOSA) (ICAO 2002) narratives.
Several findings related to manual aircraft handling were presented, and the report represents a valuable
source for central aspects of this paper, especially concerning the link to operational policies and
procedures. The report identified several vulnerabilities in pilot knowledge and skills for manual flight
operations, such as the prevention, recognition and recovery from unusual attitudes, upset conditions,
or stalls (see chapter 4.2.2); manual aircraft control after transition from automated systems; crew
coordination, especially concerning aircraft control; and finally, the development and retention of
manual flying skills. The report discovered that flight crews’ manual handling errors alone contributed
to more than 60% of all accidents analysed, and revealed significant shortcomings concerning pilots’
manual flying skills in many operational situations, such as visual approaches or crosswind landings.

The Flight Deck Automation Working Group (2013, p. 65) raised severe concerns over an “(...) erosion
in basic knowledge (…) i.e., knowledge of the power plus attitude equals performance relationship
across a wide range of flight scenarios and configurations (…)”, often combined with an insufficient
situational awareness. Such deficiencies in basic “pitch & power” aircraft handling contributed to
several accidents over the last years, among them prominent cases such as the crash of an Air France
Airbus A330 (BEA 2012), the Asiana crash landing in San Francisco (NTSB 2014) or the crash of a
Turkish Airlines Boeing 737-800 approaching Amsterdam (Dutch Safety Board 2010).

4.1.2 A Focus on Loss of Control In-Flight (LOC-I)

According to IATA (2015a, p. 1), “LOC-I refers to accidents in which the flight crew was unable to
maintain control of the aircraft in flight, resulting in an unrecoverable deviation from the intended flight
path.” LOC-I often coincides with aerodynamic stalls, and it is “(…) one of the most complex accident
categories, involving numerous contributing factors that act individually or, more often, in combination”
(IATA 2015a, p. 1). Most LOC-I situations develop within under 10 seconds (Wilborn & Foster 2004).

Whatever the statistical source is, LOC-I is regarded to as one of the accident categories posing the
highest threat to commercial aviation safety. EASA (2016a, p. 18) has identified “Aircraft Upset in
Flight (LOC)” as the “most frequent fatal accident type during the last 10 years” accounting for 64% of
Commercial Air Transport (CAT) aeroplane accidents in Europe. Therefore, EASA considers it as one

27
of its “key risk areas”. The British CAA (2013a) distinguished between LOC-I accidents following non-
technical failure (accounting for more than 50% of analysed LOC-I accidents), technical failure, icing,
or due to unknown reasons. Flight crew related causal factors contributed to 75%, the “top causal factor”
“flight crew handling” alone to 50% of all LOC-I accidents following non-technical failure. Following
a technical failure, a flight crew related causal factor was assigned in 63% of all cases. Therefore, the
CAA (2013a, p. 61) listed LOC-I as one of its “Significant Seven” accident categories, as “nearly 40%
of all fatal accidents involved some kind of loss of control, making this the most frequent type of
accident.”

IATA (2015a, p. 6) has published a dedicated Loss of Control In-Flight Accident Analysis Report, as
“LOC-I accidents are almost always catastrophic; 97 percent of LOC-I accidents between 2010 and
2014 involved fatalities to passengers and/or flight crew.” While only 9.3% of all accidents in the
mentioned timeframe were categorised as LOC-I accidents, they were responsible for 49% of all
accident fatalities. Concerning fatal accidents between 2011 and 2015, IATA (2016) revealed that LOC-
I is on the top end of both accident frequency and mortality risk statistics (see figure 12).

Figure 12: Accident Category Frequency and Mortality Risk (2011-2015) - Fatal Accidents (IATA 2016)

Analysing LOC-I accidents, IATA (2015a, p. 30) discovered many issues discussed in this paper:
“Human performance deficiencies, including improper, inadequate or absent training, automation and
flight mode confusion, distraction, the ‘startle’ factor and loss of situational awareness frequently
compounded the initial upset and precluded an effective recovery until it was too late.” Belcastro and

28
Foster (2010) analysed 124 LOC-I accidents between 1979 and 2009 and discovered 18 accidents where
inappropriate crew inputs initiated the accident sequence (see figure 13).

Figure 13: LOC Accident Sequences Initiated by Inappropriate Crew Input (Belcastro & Foster 2010)

Deficiencies in manual flying and/or pilot-automation interaction play a crucial role in most LOC-I
accidents. As LOC-I represents the biggest threat to commercial aviation safety even in comparably safe
times, the impact of degraded manual flying skills on flight safety becomes evident.

4.2 Safety Initiatives addressing Manual Flying Skills

4.2.1 Manual Flying Opportunities in Line Operations

Different regulatory bodies recently addressed the issue of pilots’ manual flying opportunities. The FAA
(2011, p. 32) identified “having and taking the opportunity to maintain manual flying skills” as an “air
carrier industry best practice” urging airlines to embed related opportunities in their respective policies.
Following the alarming results of the Flight Deck Automation Working Group (2013) (see chapter
4.1.1), the FAA (2013a) issued a Safety Alert for Operators (SAFO). As the “(…) continuous use of
autoflight systems could lead to degradation of the pilot’s ability to quickly recover the aircraft from an
undesired state”, the FAA (2013a, p. 1) promoted an integrated approach covering initial and recurrent
training as well as line operations. Operational policies should provide appropriate opportunities for
pilots to fly their aircraft manually, e.g. in non-RVSM airspace and under low workload conditions.

29
EASA (2013a, p. 2) issued a Safety Information Bulletin (SIB) mandating airlines to “(…) identify
appropriate opportunities for pilots to practice their manual flying skills.” Different factors influencing
the adequacy of manual flying during line operations were listed, among them workload aspects, traffic
density, meteorological conditions, and pilot experience. In the European Aviation Safety Plan 2013-
2016, EASA (2013b, p. 18) announced to “improve basic airmanship and manual flying skills of pilots”
as first of its “core action proposals”. Airbus emphasises manual flying in its Airbus A350 training
concept (Christiansen 2015).

Transport Canada (2015) published an Advisory Circular (AC) addressing the mentioned issues,
however in greater detail. For example, the AC addressed the issue of pilots’ confidence in their own
skills: “Pilots need to maintain manual flying skills to a high degree of proficiency and must develop
confidence in their ability to do so” (Transport Canada 2015, p. 3). Pilots should be able to reduce the
level of automation or revert to manual flying if the automation does not perform as expected. Moreover,
the AC mentioned augmented crew operations where pilots might have very limited manual flying
opportunities. To build a strong skill foundation, an emphasis was put on initial type training where
pilots “(…) should have ample opportunity to fly the aircraft manually (without automation), in all
phases of flight” (Transport Canada 2015, p. 5). The AC explicitly mentioned “raw data” flying, e.g. by
removing flight director guidance during visual approaches.

Recently, the inspector general of the United States’ Department of Transport (2016) published an audit
report addressing several issues regarding FAA oversight. A main point of criticism was that the FAA
has no process to ensure that pilots are trained adequately to use and monitor automated systems and to
maintain manual flying proficiency. Moreover, following the publication of SAFO 13002 (FAA 2013a),
no measures were taken to determine if airlines have facilitated increased manual flying opportunities
for their flight crews. Consequently, the report criticised that it will take until 2019 to implement new
simulator training requirements concerning manual flying (FAA 2013c). The report (Department of
Transport 2016, p. 12) clearly emphasised that “(…) using hand-flying skills is a best practice for pilots
to maintain manual flying proficiency.”

4.2.2 Upset Prevention and Recovery Training (UPRT)

Given the prevalence of Loss of Control In-flight (LOC-I) in fatal accident statistics (see chapter 4.1.2),
industry-wide efforts have been initiated to address this issue. While manual aircraft handling skills,
especially “pitch & power” skills, undoubtedly contribute to a pilot’s ability to cope with inflight upset
situations, there are limited opportunities to train such scenarios in line operations (Kochan et al 2005).
Therefore, Upset Prevention and Recovery Training (UPRT) is performed primarily in simulators.

30
The FAA (2011, p. 29) has promoted UPRT as an “air carrier industry best practice”, in an effort “(…)
to better equip pilots with the knowledge and psychomotor skills necessary to handle these events.”
EASA (2013c; 2016b) addressed UPRT as well. IATA requires UPRT for Multi-Crew Pilot Licence
(MPL) training (IATA 2015b). However, the accident investigation following the crash of an AirAsia
Airbus A320 (Komite Nasional Keselamatan Transportasi 2015) revealed that Airbus did not require
pilots to undergo UPRT as the aircraft’s envelope protection would prevent pilots from entering upset
situations. This accident as well as others (BEA 2012) have demonstrated the limitations of such a
protection in case of system failures. Since, it has become industry standard to provide pilots with UPRT
(IATA 2015c).

However, simulators still have limitations concerning realistic “feel”, especially in edge-of-the-envelope
scenarios: “Simulators cannot induce the forces, particularly the vertical g, encountered in upset
conditions, nor can they easily create the sudden startle that occurs when a pilot discovers he may have
very little time to apply life-saving control actions” (ICATEE 2017). Projects such as SUPRA
(Simulation of UPset Recovery in Aviation) (TNO 2017) intend to more accurately reproduce aircraft
behaviour to provide pilots with a realistic feel of the forces present in upset situations.

31
5 Manual Flying Skills Online Survey

5.1 Survey Method & Objectives

In line with the objectives of this paper, the Manual Flying Skills Online Survey was created to capture
a comprehensive picture of the participating pilots’ perspective regarding automation and manual flying
under the influence of different automation policies or related Standard Operating Procedures (SOP).
Part I of the survey consisted of 10 questions on the respective aeronautical background. These questions
were used to create different comparison groups for analysis of the succeeding questions. Part II
consisted of 16 questions concerning the participants’ individual use of automation, manual and “raw
data” flying during different phases of flight. Key questions asked if the survey’s participants perceive
to have sufficient opportunities to hand fly, and if they would prefer more opportunities, either in line
operations or simulator training. Comprehensive background information on the survey can be found in
Appendix C.

In the following chapters, key results from the Manual Flying Skills Online Survey will be presented.
The complete questionnaire is available in Appendix D.

5.2 Survey Results

5.2.1 General Observations

In total, 1,529 commercial pilots participated in the survey. 1,493 of these participants completed the
survey (97.6%); only completed surveys were analysed.

47.0% of the participants were captains (n=701), 49.4% first officers (n=738), 0.7% cruise relief pilots
(n=11), and 2.9% management pilots with more than 50% office duties (n=43). 40.6% indicated to fly
mostly short-haul (n=606), 25.8% medium-haul (n=386), and 33.6% long-haul (n=501).

Asked for their company policy regarding automation and manual flying, 1.3% of the participants
indicated that their procedures strictly limit their manual flying (n=19); 5.4% indicated that manual
flying is allowed within certain limits, however, the use of flight director is mandatory (n=80); 77.7%
indicated that manual flying is supported within certain limits, and flight crews can decide about desired
levels of automation (n=1,160); 12.4% indicated that manual flying is accepted or supported without
restriction (n=185); 2.8% indicated to have no detailed regulation (n=41), while 0.5% had no idea about
their regulations (n=8). To enable a better overview, the first two categories will be referred to as
“restrictive procedural environment” in this paper; the third and fourth categories will be referred to as
“supportive procedural environment.” The last two categories will only be referred to in exceptional
cases, as they are rarely significant for the objectives of this paper,

32
Moreover, pilots were asked if they had spent a prolonged time in a commercial environment where
manual flying was more common even if their present company limits manual flying. 36.7% indicated
that they don’t feel restricted concerning manual flying (n=547). While 32.9% stated to be restricted,
however building on a background where manual flying was more common (n=491), 30.4%, nearly half
of those who feel restricted in their present company, replied negatively (n=453).

Asked if manual flying practice becomes less important with increasing experience, only 4.6% of the
participants gave positive replies (n=68). Additionally, asked if they think that their manual flying skills
help them to be better pilots, 33.6% (n=501) agreed, and 62.9% (n=939) strongly agreed.

5.2.2 Manual Flying in Daily Operations

Noteworthy differences were found concerning autopilot use. While 69.3% of the participants indicated
to switch the autopilot on above 3,000 ft after take-off, only 36.8% indicated to switch the autopilot off
above 3,000 ft prior landing. In contrast, the answers regarding “raw data” flying revealed a completely
different picture. While 45.3% indicated to never fly raw data departures, only 8.0% indicated to never
fly raw data approaches; only 9.9% indicated to frequently fly raw data departures, and 33.2% indicated
to frequently fly raw data approaches. Significant differences exist between different route profiles:
while 79.4% of the participating long-haul pilots indicated to frequently hand fly beyond 3,000 ft after
take-off, only 15.8% stated to frequently conduct raw data approaches.

Concerning autopilot use during approach in adverse weather conditions (e.g. turbulence or gusty wind),
80.2% of the participants answered to switch the autopilot off rather early (by 1,500 ft), while 19.8%
indicated to switch the autopilot off around approach minimum. Asked about the reasons, the first group
mostly indicated better, direct control of the aircraft (49.3%), slow reaction of autopilot and/or
autothrottle (37.8%), and “To get a feeling for the handling of the aircraft in the respective weather
conditions” (92.2%). Those who indicated to switch the autopilot off rather late mostly mentioned
smooth autopilot and autothrottle performance (47.8%), workload management (82.1%), and tiredness
or fatigue (39.5%). Long-haul pilots gave different replies here as well, as 63% cited tiredness or fatigue
as reason for a late autopilot disconnection in adverse weather.

While 58.8% confirmed that they have manually flown their current aircraft type in high altitude
(>25,000 ft), 41.2% replied negatively. Rather inexperienced pilots (<1,000 flight hours) and Airbus
A380 pilots were those with the lowest manual flying experience in high altitude (34.8% and 28.3%,
respectively).

33
5.2.3 Manual Flying and Simulator Training

88.9% (n=1,327) of the participating pilots stated that their company uses simulator recurrent sessions
to train manual flying skills. Paradoxically, only 75.0% of pilots flying in a strictly limited procedural
environment gave that answer – in contrast to 92.5% of those most supported in manual flying.

79.1% (n=1,181) agreed or strongly agreed that simulator training is helpful to train manual flying skills,
while only 7.6% disagreed (n=113) and 0.6% strongly disagreed (n=9). However, asked if simulator
training is sufficient as primary or even only means to improve and maintain their manual flying skills,
only 1.4% strongly agreed (n=21) and 9.2% agreed (n=138), while 79.8% disagreed or strongly
disagreed (n=1,191).

5.2.4 Manual Flying Opportunities

One of the key questions of the survey (“In general, would you prefer to have more opportunities to
improve or maintain your manual flying skills?”) revealed significant differences among different
comparison groups; therefore, those results are displayed in-depth in tables 1 and 2. In general, 43.9%
indicated to prefer more manual flying opportunities during normal line operations (n=656), while
16.3% would prefer those opportunities during simulator recurrent training (n=243). 39.3% stated to
have enough opportunities (n=587), and only 0.5% were not interested in more such opportunities (n=7).

Regarding different functions, management pilots and captains were rather satisfied with their manual
flying opportunities compared to first officers or cruise relief pilots. A comparison of tenure and
experience confirmed this impression: those flying less than two years and those with less than 1,000
flight hours would prefer more manual flying opportunities compared to rather experienced pilots.
Comparing different operator types, most cargo pilots would prefer more manual flying opportunities,
while pilots in leisure airlines mostly indicated to have sufficient opportunities. Concerning route
profiles, only 35.5% of long-haul pilots agreed or strongly agreed to have sufficient manual flying
opportunities, while 79.9% of medium- and short-haul pilots gave these replies. Accordingly, a clear
correlation could be observed: the lower the number of weekly sectors flown, the higher the preference
for more manual flying opportunities. A comparison of different aircraft types underlined the difficulty
of long-haul pilots to gain sufficient manual flying proficiency: those indicating to have least manual
flying opportunities were pilots flying long-haul aircraft such as the Boeing 777, Airbus A380, Boeing
747, or Airbus A330/A340. In contrast, most pilots flying the Boeing 737 or the Dash 8-Q400 indicated
to have sufficient manual flying opportunities.

34
Table 1: Pilot Preferences concerning Manual Flying Opportunities (different Comparison Groups)

35
Table 2: Pilot Preferences concerning Manual Flying Opportunities (different Comparison Groups)
(continued)

36
Comparing different aircraft automation categories (see Appendix E for details), 52.3% of pilots flying
the least automated aircraft (category 3A, EFIS cockpit) indicated to have sufficient manual flying
opportunities, while 45.1% of pilots flying glass cockpit aircraft (category 3B) gave that reply. In
contrast, concerning Fly-by-Wire aircraft, only 19.2% of pilots flying category 4A aircraft and 35.6%
of pilots flying category 4B aircraft confirmed to have sufficient manual flying opportunities.

5.2.5 The Influence of the Procedural Environment

Significant differences could be observed between different procedural environments. A clear

correlation revealed in the replies to basically every question: the more restrictive the procedural
environment, the more extensive the use of automation, and the less the manual flying. For example,
while 10.5% of pilots in a strictly limited procedural environment stated to switch the autopilot off at or
above 3,000 ft for landing, 61.1% of those being unrestricted in their manual flying indicated to do so.
For a better overview, the answers of the different procedural comparison groups to several questions
are displayed in tables 3 and 4.

Coherently, 77.5% of pilots obliged to use the flight director would prefer more manual flying
opportunities during line operations, while only 30.8% of pilots who are completely unrestricted in
manual flying gave that answer. In turn, while 54.6% of the latter group indicated to have sufficient
manual flying opportunities, only 10.0% of those who must use the flight director (and no pilot in a
strictly limited procedural environment) confirmed that (see table 2).

Asked for the reasons why pilots feel restricted concerning manual flying, rather balanced replies
between automation policy (13.1%), SOPs (15.3%), and company culture (13.6%) were given.
However, asked why pilots feel supported concerning manual flying, a majority mentioned their
company culture (64.5%) ahead of automation policy (25.5%) and SOPs (19.4%). While only 13.1% of
pilots in restricted procedural environments indicated to feel supported by their company culture, 69.4%
in supportive procedural environments gave that reply.

37
Table 3: Differences between Pilots’ Procedural Environments – Answers to Key Questions

38
Table 4: Differences between Pilots’ Procedural Environments – Answers to Key Questions (continued)

39
5.3 Limitations of the Survey

In general, an online survey highly depends on the honesty of its participants, and the replies are of a
subjective nature. As nearly 1,500 pilots completed the survey, however, a solid statistical level has been
reached. Nevertheless, as most survey participants indicated to fly in rather supportive procedural
environments, additional research addressing pilots in restricted procedural environments could be
desirable.

It might have been of interest for further analysis to ask all participants in which geographical region
they are based. However, a full-scale cultural evaluation would have been beyond the scope of this
paper.

Moreover, it became evident during the research phase of this paper that new pilot training programs
like the Multi-Crew Pilot Licence (MPL) represent a paradigm change. To discover possible differences
in automation use and manual flying, it might have been helpful to ask participants for their licence
background in the survey.

Finally, it might have been useful to ask the survey participants if they have flown any aircraft with
conventional flight decks since flight training (and before possibly transitioning to more sophisticated
aircraft) to evaluate if there are differences between pilots with or without conventional flight deck
background.

40
6 Discussion & Recommendations

The role of pilots has changed considerably over the past decades. Initially rather a craftsmanship, the
profession has evolved towards the role of a system manager in a high-tech environment. Automation
has largely contributed to commercial aviation safety, and system accuracy, workload reduction,
increased airspace utilisation, or increased fuel efficiency are examples for improvements of the aviation
system through automation.

The necessary pilot skillset has shifted accordingly; while psychomotor or “hand-eye” skills are rarely
used today, the cockpit has become an environment where mainly cognitive skills are required.
However, this transition has downsides: the constant monitoring of highly reliable systems can lead to
over-reliance and complacency, and system complexity has often contributed to deficient human-
automation interaction. A recent audit report (Department of Transport 2016, p. 15) stated:

Maintaining [flight safety] depends on ensuring pilots have the skills to fly their aircraft
under all conditions. Relying too heavily on automation systems may hinder a pilot’s ability
to manually fly the aircraft during unexpected events.

These skills must be acquired and maintained; however, recent research presented clear evidence that
pilots are susceptible to “skill fade” or “skill rusting”, with the bigger effect resulting from lack of recent
manual flying compared to elapsed time since flight training (Ebbatson et al 2010; Casner et al 2014). In
most long-haul or enlarged crew operations, pilots just make a few take-offs and landings over periods
of weeks (or even months), often influenced by tiredness or fatigue (cf. chapter 5); pilots flying in such
environments (or otherwise reduced flying duty, e.g. management pilots, or pilots in parental leave) are
groups where proficiency issues have proven to be more severe compared to pilots operating multiple
sectors each duty week (Haslbeck & Hoermann 2016). Ebbatson et al (2010, p. 268) raised the concern
that “the infrequent opportunity to exercise manual flying skills in modern flight operations may
diminish a crews’ basic manual flying ability over time.” Simulator training alone might not provide
sufficient opportunities to stay proficient, even if four annual sessions per crew member are conducted
(Haslbeck & Hoermann 2016). With further advances concerning airspace structure and required flight
path precision on the doorstep, “(…) opportunities air carrier pilots have during live operations to
maintain proficiency in manual flight are limited and are likely to diminish”, the Department of
Transport (2016, p. 6) warned.

The short timeframes after take-off and before landing when pilots manually control their aircraft can
be further reduced by company restrictions, e.g. automation policies or related SOPs mandating a
maximum use of automation, or company cultures not tolerating manual flying beyond a minimum.
Several airlines prescribe the use of the flight director today, thus reducing pilots’ opportunities to
maintain basic “pitch & power” flying skills.

41
In that regard, Landry (2014, p. 24) warned:

However, when you manually fly the aircraft using flight director commands you are not
performing all the complex mental calculations of pitch, power, and airspeed control
required for flight path management of both vertical and lateral navigation. Relying on flight
directors is still using “automation” and is therefore insufficient for the purposes of fully
exercising manual flying skills.

The Manual Flying Skills Online Survey revealed significant differences between pilots working in
different procedural environments (see chapter 5). Pilots in restricted procedural environments have far
less opportunities to hand fly their aircraft and to maintain their “pitch & power” proficiency. Asked if
they have sufficient opportunities during daily line flying to improve or maintain their manual flying
skills, 68% of pilots flying in supportive procedural environments agreed, compared to only 26% of
pilots flying in restricted procedural environments. While 41% of pilots in supportive procedural
environments prefer more opportunities to maintain and improve their manual flying skills during
normal line operations (a high value for itself), an alarming 75% of those flying in restricted procedural
environments gave that reply.

The adverse effect of deficient manual flying skills on flight safety is considerable. Loss of Control In-
flight (LOC-I) represents the biggest threat to commercial aviation safety (IATA 2015a), and deficient
aircraft handling is the biggest contributory factor in this accident category (CAA 2013a). As Upset
Prevention and Recovery Training (UPRT) is usually limited to simulators that cannot completely
reproduce an aircraft’s behaviour in edge-of-the-envelope situations (IATA 2016), pilots’ basic “pitch
& power” flying skills play a crucial role in such dynamic scenarios. Pilots’ opportunities to acquire and
retain resilient manual flying skills highly depend on the procedural environment and the respective
freedom of manoeuvre they can use. In turn, it becomes evident that an adequate formulation of
automation policies and related SOPs is of paramount importance. The Flight Deck Automation
Working Group (2013, p. 33) warned that “(…) pilots who have not yet developed extensive manual
flying skills may not get opportunities to practice and develop those skills, due to an increased emphasis
on the use of automated systems.”

Based on the broad research body and the statistical evidence presented in this paper, it seems to be
highly advisable to provide pilots all tools required to keep their proficiency. These tools should be part
of an integrated approach consisting of thorough and comprehensive training as well as balanced
automation policies and SOPs that allow pilots to maintain and improve their manual flying skills during
line flying. Especially if pilots fly only few sectors a month, they should have sufficient opportunities
to get acquainted with the aircraft in different configurations and with different levels of automation.
Last, but not least, supportive and non-punitive company cultures are desirable where pilots have the
freedom of manoeuvre to hand fly as long as safe and precise flight conduction, rules and regulations,

42
effective Crew Resource Management (CRM), and workload management are not compromised.
Appendix F presents an example for a balanced automation policy that reflects these aspects.

James Reason (1997, p. 46) once stated: “In their efforts to compensate for the unreliability of human
performance, the designers of automated control systems have unwittingly created opportunities for new
error types that can be even more serious than those they were seeking to avoid.” As fail-safe automation
is not available so far, these words of Captain Chesley B. Sullenberger (2015) will keep their validity:
“Throughout the 112-year history of powered flight, one thing has been true. The most important safety
device in any airliner is a well-trained, experienced pilot. That is even more true today, especially as we
transition from my generation of pilots to the next.” Thus, although the cost/benefit case for additional
safety measures or regulatory changes might be “very challenging” (Flight Deck Automation Working
Group 2013, p. 2) due to the low accident rate in commercial aviation, it seems to be highly advisable
to invest in pilots’ ability to acquire and maintain resilient manual flying skills. Commercial flight safety
might not be kept at the present, high level if pilots are unduly restricted in their ability to deliberately
control their aircraft across all levels of automation.

43
7 Further Research

The issues discussed in chapter 6 fall in another transition phase of commercial aviation. Over time,
generations of pilots became acquainted to sophisticated automation, however on the broad foundation
of solid manual flying skills built during flight training, initial career, and daily flight operations. Most
research studies mentioned in this paper (Ebbatson et al 2010; Casner et al 2014; Haslbeck & Hoermann
2016) investigated the manual flying skills of comparably experienced pilots who had most probably
acquired their skills in a rather supportive procedural (and cultural) environment concerning manual
flying; the same applies to most participants of the Manual Flying Skills Online Survey (see chapter 5).

In a situation characterised by a pilot shortage in several markets (Boeing 2016b), many airlines employ
pilots holding a Multi-Crew Pilot Licence (MPL) (IATA 2015b). This qualification scheme is largely
based on synthetic flight training and requires far less actual flight time than a “classic” Airline Transport
Pilot Licence (ATPL) (ICAO 2011b). In the United States, pilots mostly require 1,500 flight hours to
fly in air carrier operations (FAA 2013d). In other regions of the world, MPL-qualified pilots often start
their careers on “4th generation” aircraft featuring highly sophisticated and complex automation. Long-
haul flying, a domain of highly experienced pilots in the past, becomes a career option for comparably
low-hour pilots nowadays; for example, airlines in the Middle and Far East employ pilots for their long-
haul fleets requiring only 1,500-2,000 flight hours as minimum qualification (Cathay Pacific 2017;
Emirates 2017). Especially if those pilots continue then in the role of a cruise relief pilot (EASA 2014a),
they will only perform take-offs and landings during simulator training.

Moreover, many of the airlines with the largest growth rates are based in regions where manual flying
is, often for cultural reasons, not appreciated to an extent comparable to “classic” aviation regions, e.g.
Europe and North America (Sherman et al 1997). As many of these airlines have a highly
inhomogeneous workforce, rigorous automation policies are often used as a tool to reconcile the
multitude of aeronautical and cultural backgrounds resembled in their pilot corps, often accompanied
by rather restrictive or even punitive company cultures (Reader et al 2016).

Issues around automation over-reliance and manual flying deficiencies (see chapter 3.5) might sharply
increase if at one stage, both pilots of an airliner have never been able to intensely acquire and maintain
robust manual flying skills due to reduced flight training and rigid automation policies, SOPs, or
company cultures. Casner et al (2014, p. 1515) clearly stated that their recommendations assumed “(…)
that pilots attain an initial level of mastery with these skills (…). Any change in the way that pilots are
trained in the future, particularly a reduced emphasis on stick-and-rudder or instrument scanning skills,
may invalidate the findings we have presented here.” Haslbeck & Hoermann (2016, p. 544) added that
interventions concerning manual flying skills “(…) have to be applied in the earlier stages of a pilot’s
career before degradation can take place. Otherwise, avoidance behaviors and a feeling of discomfort

44
according to manual flying could lead into a negative spiral of permanently less manual flight
conduction.” According to the Manual Flying Skills Online Survey, nearly half of those pilots feeling
restricted in their manual flying opportunities did not spend a prolonged phase of their career in an
environment where manual flying was more common (see chapter 5).

For the reasons outlined, further research is highly advisable. This research should investigate the ability
to acquire and maintain manual flying skills regarding a new generation of commercial pilots that can
be defined by one or more of the following characteristics:

- Pilots that have completed a flight training scheme comprising a reduced actual flying time (e.g.
MPL) compared to traditional training schemes (ATPL);

- Pilots without previous experience in conventional flight decks, or in an environment where

manual flying is either necessary, appreciated, or common in daily operations;

- Pilots flying in an environment where manual flying is either officially restricted (by means of
strict automation policies or SOPs), or obstructed on a cultural level (e.g. pilots refraining
voluntarily from manual flying due to a punitive company culture);

- Pilots flying for fast-growing airlines offering a comparably quick advancement to long-haul
flying (especially cruise relief pilots) and/or from first officer to captain.

The following aspects should also be addressed by further research:

- Which amount of experience and practice in line operations is required to acquire and retain
resilient manual flying skills enabling each pilot to react adequately in normal as well as non-
normal situations?

- How important are opportunities to perform “raw data” flying and/or visual approaches during
line operations for pilots’ manual flying proficiency?

45
8 Conclusion

This paper investigated the correlation between pilots’ procedural environment and their manual flying
proficiency in times of sophisticated flight deck automation. Based on current literature, a
comprehensive background around these topics was presented, and an analysis of related safety statistics
was performed. Deficient manual flying skills have a significant adverse effect on flight safety,
especially concerning Loss of Control In-flight (LOC-I) accidents. The Manual Flying Skills Online
Survey was performed among more than 1,500 pilots world-wide to capture the perspective of pilots on
the issues of Standard Operating Procedures (SOP) and manual flying skills.

The results of the survey clearly supported industry initiatives and related research voicing concerns
over diminishing manual flying opportunities of pilots, especially concerning comparably restricted
procedural environments, rigid company cultures, and long-haul or enlarged crew operations. To keep
commercial flight safety on the present, high level, a balanced and integrated procedural approach can
be recommended – an approach that leaves a certain “freedom of manoeuvre” to hand fly during line
operations, thus enabling pilots to acquire and maintain resilient manual flying skills.

46
References
Abbott, K.H. (2001): “Human Factors Engineering and Flight Deck Design”, in: The Avionics
Handbook, Spitzer, C.R. (ed.), CRC, Boca Raton, FL; London
Abbott, K.H (2015): Some Lessons Learned About Flight Deck Automated Systems, Presentation held
at the 2015 Safety Forum, Brussels, Belgium, 2 Jun. 2015
Abbott, K.H., Slotte, S., Stimson, D., Amalberti, R. R., Bollin, G., Fabre, F., Hecht, S., Imrich, T.,
Lalley, R., Lydanne, G., Newman, T., & Thiel, G. (1996): The Interfaces Between Flightcrews and
Modern Flight Deck Systems, Report of the FAA Human Factors Team, Federal Aviation
Administration, Washington, DC
Airbus (2015): Commercial Aviation Accidents 1958-2014 – A Statistical Analysis, Airbus S.A.S.,
Blagnac Cedex, France
Airbus (2017a): Fly-By-Wire, Airbus S.A.S., source: http://www.airbus.com/innovation/proven-
concepts/in-design/fly-by-wire/ (30.01.2017)
Airbus (2017b): Commonality in Flight Training, Airbus S.A.S., source:
http://www.airbus.com/support/training/flight/commonality-in-flight-training/ (30.01.2017)
ALPA (2010): ALPA Administrative Manual, Section 80 – Engineering and Air Safety Part 5 –
Human Factors and Training Group, P. Automation Dependency / Maintenance of Manual Flying
Skills, Air Line Pilots Association, pp. 68-69
ATSB (2008): In-flight upset – 154 km wet of Learmonth, WA – 7 October 2008 – VH-QPA – Airbus
A330-303, Aviation Occurrence Investigation AO-2008-070 Final, Australian Transport Safety Bureau
ATSB (2013): In-flight uncontained engine failure – Airbus A380-842, VH-OQA, Aviation
Occurrence Investigation AO-2010-089 Final, Australian Transport Safety Bureau
Bainbridge, L. (1983): “Ironies of automation”, Automatica, 19, 6, pp. 775-779
Baxter, G., Besnard, D. & Riley, D. (2007): “Cognitive mismatches in the cockpit: Will they ever be a
thing of the past?”, Applied Ergonomics, 38, 4, pp. 417-423
BEA (2012): Final Report On the accident on 1st June 2009 to the Airbus A330-203 registered F-
GZCP operated by Air France flight AF 447 Rio de Janeiro – Paris, Bureau d’Enquetes et d’Analyses
pour la securité de l’aviation civile, Ministère de l’Écologie, du Développement durable, des
Transports et du Logement
BEA (2013): Study on Aeroplane State Awareness during Go-Around, Bureau d’Enquetes et
d’Analyses pour la securité de l’aviation civile, Ministère de l’Écologie, du Développement durable,
des Transports et du Logement
Belcastro, C.M. & Foster, J.V. (2010): Aircraft Loss-of-Control Accident Analysis, Paper presented at
the AIAA Guidance, Navigation and Control Conference, Toronto, Canada, 2-5 Aug. 2010
BFU (2015): Interim Report BFU 6X014-14, BFU – Bundesstelle für Flugunfalluntersuchung /
German Federal Bureau of Aircraft Accident Investigation
Billings, C.E. (1991): “Toward a Human-Centered Aircraft Automation Philosophy”, The
International Journal of Aviation Psychology, 1, 4, pp. 261-270

47
Billings, C.E. (1996): Human-Centered Aviation Automation: Principles and Guidelines, NASA
Technical Memorandum 110381, National Aeronautics and Space Administration, Ames Research
Center, Moffett Field, CA
Boeing (2016a): Statistical Summary of Commercial Jet Airplane Accidents – Worldwide Operations
1959-2015, Boeing Commercial Airplanes, Seattle, WA
Boeing (2016b): Long-Term Market – Current Market Outlook 2016-2035 – Demand for locally
sourced and qualified pilots, Boeing, source: http://www.boeing.com/commercial/market/long-term-
market/pilot-and-technician-outlook/#/demand-for-locally-sourced-and-qualified-pilots (30.01.2017)
Bundesanstalt für Verkehr (2006): GZ.85.007/0001-FUS/2006 Untersuchungsbericht – Flugunfall mit
dem Motorflugzeug Type Airbus A310 am 12. Juli 2000 am Flughafen Wien-Schwechat,
Niederösterreich, Republik Österreich, Bundesanstalt für Verkehr – Unfalluntersuchungsstelle, Wien
Burian, B.K., Barshi, I. & Dismukes, K. (2005): The Challenge of Aviation Emergency and Abnormal
Situations, NASA Technical Memorandum 2005-213462, National Aeronautics and Space
Administration, Ames Research Center, Moffett Field, CA
CAA (2004): CAA Paper 2004/10 Flight Crew Reliance on Automation, Civil Aviation Authority,
Safety Regulation Group, Aviation House, Gatwick Airport South, West Sussex, Great Britain
CAA (2013a): CAP 1036 Global Fatal Accident Review 2002 to 2011, Civil Aviation Authority,
Safety Regulation Group, Aviation House, Gatwick Airport South, West Sussex, Great Britain
CAA (2013b): CAA Paper 2013/02 Monitoring Matters – Guidance to the Development of Pilot
Monitoring Skills, Civil Aviation Authority, Loss of Control Group, Aviation House, Gatwick Airport
South, West Sussex, Great Britain
Campbell, R.D. & Bagshaw, M. (2002): Human Performance and Limitations in Aviation, 3rd edn.,
Blackwell Science, Malden, MA; Ames, IA; Oxford
Casner, S.M., Geven, R.W., Recker, M.P. & Schooler, J.W. (2014): “The Retention of Manual Flying
Skills in the Automated Cockpit”, Human Factors: The Journal of the Human Factors and
Ergonomics Society, 56, 8, pp. 1506-1516
Casner, S.M. & Schooler, J.W. (2014): “Thoughts in Flight: Automation Use and Pilots’ Task-Related
and Task-Unrelated Thought”, Human Factors: The Journal of Human Factors and Ergonomics
Society, 56, 3, pp. 433-442
CAST (2008): Safety Enhancement 30, Revision 5 – Mode Awareness and Energy State Management
– Aspects of Flight Deck Automation, Final Report, Commercial Aviation Safety Team
Cathay Pacific (2017): Jobs in the air – Pilots, Cathay Pacific, source:
https://www.cathaypacific.com/cx/en_HK/about-us/careers/jobs-in-the-air/pilots.html (30.01.2017)
Childs, J.M. & Spears, W.D. (1986): “Flight-Skill Decay and Recurrent Training”, Perceptual and
Motor Skills, 62, 1, pp. 235-242
Christiansen, G. (2015): A350 XWB Flight Crew Training Concept, Airbus S.A.S., source:
https://www.halldale.com/files/halldale/attachments/Gary%20Christiansen.pdf (30.01.2017)
Curtis, M.T., Jentsch, F. & Wise, J.A. (2010): “Aviation Displays”, in: Human Factors in Aviation, 2nd
ed., Salas, E. & Maurino, D.E. (eds.), Academic Press/Elsevier, Amsterdam; Boston, MA, pp. 439-478

48
Degani, A. & Wiener, E.L. (1994): On the Design of Flight-Deck Procedures, NASA Contractor
Report 177642, National Aeronautics and Space Administration, Ames Research Center, Moffett
Field, CA
Degani, A. & Wiener, E.L. (1997): “Procedures in complex systems: the airline cockpit”, IEEE
Transactions on Systems, Man, and Cybernetics - Part A: Systems and Humans, 27, 3, pp. 302-312
Dekker, S.W.A. (2015): “The danger of losing situation awareness”, Cognition, Technology & Work,
17, 2, pp. 159-161
Dekker, S.W.A., Cilliers, P. & Hofmeyr, J. (2011): “The complexity of failure: Implications of
complexity theory for safety investigations”, Safety Science, 49, 6, pp. 939-945
Department of Transport (2016): Audit Report - Enhanced FAA Oversight could reduce Hazards
associated with increased Use of Flight Deck Automation, Report Number AV-2016-013, Department
of Transport, Office of Inspector General, Washington, DC
Dunlap, J.W. (1948): The Human Factor in the Design of Stick and Rudder Controls for Aircraft,
NACA Technical Report, The Psychological Corporation, Division of Bio-Mechanics, New York, NY
Dutch Safety Board (2010): Crashed during approach, Boeing 737-800, near Amsterdam Schiphol
Airport, 25 February 2009, The Dutch Safety Board, The Hague, Netherlands
Dzindolet, M.T., Peterson, S.A., Pomranky, R.A., Pierce, L.G. & Beck, H.P. (2003): “The role of trust
in automation reliance”, International Journal of Human - Computer Studies, 58, 6, pp. 697-718
EASA (2013a): EASA Safety Information Bulletin SIB No. 2013-05: Manual Flight Training and
Operations, European Aviation Safety Agency
EASA (2013b): European Aviation Safety Plan 2013-2016 – Final, European Aviation Safety Agency
EASA (2013c): EASA Safety Information Bulletin SIB No. 2013-02: Stall and Stick Pusher Training,
European Aviation Safety Agency
EASA (2014a): Notice of Proposed Amendment 2014-25 – Requirements for relief pilots, European
Aviation Safety Agency
EASA (2014b): EASA Emergency Airworthiness Directive AD No.: 2014-0266-E, European Aviation
Safety Agency
EASA (2015): EASA Safety Information Bulletin SIB No. 2010-33R1: Automation Policy – Mode
Awareness and Energy State Management, European Aviation Safety Agency
EASA (2016a): Annual Safety Review 2016, European Aviation Safety Agency
EASA (2016b): European Plan for Aviation Safety 2016-2020 – Final, European Aviation Safety
Agency
Ebbatson, M. (2009): The Loss of Manual Flying Skills in Pilots of Highly Automated Airliners,
ProQuest Dissertations Publishing
Ebbatson, M., Harris, D., Huddlestone, J. & Sears, R. (2010): “The relationship between manual
handling performance and recent flying experience in air transport pilots”, Ergonomics, 53, 2, pp. 268-
277

49
Emirates (2017): Emirates Group Careers – Pilots – Minimum Requirements, Emirates, source:
http://www.emiratesgroupcareers.com/english/Careers_Overview/Pilot_Jobs/Minimum_Requirements
.aspx (30.01.2017)
European Commission (2013): Ethics for researchers, European Commission, Directorate-General for
Research and Innovation, Directorate B – European Research Area, Unit B.6 – Ethics and gender,
Brussels
European Commission (2017): Welcome to the SESAR Project, European Commission, source:
http://ec.europa.eu/transport/modes/air/sesar/index_en.htm (30.01.2017)
FAA (2003): Advisory Circular 120-71A – Standard Operating Procedures for Flight Deck
Crewmembers, Federal Aviation Administration, Flights Standards Service, Washington, DC
FAA (2011): Federal Aviation Administration Task Force On Air Carrier Safety and Pilot Training –
Report from the Air Carrier Safety and Pilot Training Aviation Rulemaking Committee, Federal
Aviation Administration, Air Carrier Safety and Pilot Training Aviation Rulemaking Committee,
Washington, DC
FAA (2013a): Safety Alert for Operators 13002 – Manual Flight Operations, Federal Aviation
Administration, Flights Standards Service, Washington, DC
FAA (2013b): Aviation Safety Action Program, Federal Aviation Administration, source:
http://www.faa.gov/about/initiatives/asap/ (30.01.2017)
FAA (2013c): Qualification, Service and Use of Crewmembers and Aircraft Dispatchers, Regulatory
Evaluation, Final Rulemaking (14 CFR Part 121), Federal Aviation Administration, Office of
Aviation Policy and Plans, Regulatory Analysis Division, Washington, DC
FAA (2013d): Pilot Certification and Qualification Requirements for Air Carrier Operations, 14 CFR
Part(s) 61, 121, 135, 141, and 142 (Docket No.: FAA-2010-0100; Amdt. Nos. 61-130; 121-365; 135-
127; 141-1; 142-9) RIN 2120–AJ67, Federal Aviation Administration, Washington, DC
FAA (2015): Advisory Circular 120-111 – Upset Prevention and Recovery Training, Federal Aviation
Administration, Flights Standards Service, Washington, DC
FAA (2017): NextGen, Federal Aviation Administration, source: https://www.faa.gov/nextgen/
(30.01.2017)
Ferris, T., Sarter, N. & Wickens, C.D. (2010): “Cockpit Automation: Still Struggling to Catch Up…”,
in: Human Factors in Aviation, 2nd ed., Salas, E. & Maurino, D.E. (eds.), Academic Press/Elsevier,
Amsterdam; Boston, MA, pp. 479-503
Flight Deck Automation Working Group (2013): Operational Use of Flight Path Management
Systems – Final Report of the Performance-based operations Aviation Rulemaking Committee /
Commercial Aviation Safety Team Flight Deck Automation Working Group, Federal Aviation
Administration, Washington, DC
Flight Safety Foundation (2008): “Autoflight Audit”, AeroSafetyWorld, June 2008, pp. 30-35
FlightGlobal (2016): World Airliner Census 2016, FlightGlobal
García-Gavilanes, R., Tsvetkova, M. & Yasseri, T. (2016): “Dynamics and biases of online attention:
the case of aircraft crashes”, Royal Society Open Science, 3: 160460, source:
http://dx.doi.org/10.1098/rsos.160460 (30.01.2017)

50
GCAA (2016): Runway Impact During Attempted Go-Around, Accident – Preliminary Report – AAIS
Case No: AIFN/0008/2016, General Civil Aviation Authority, Air Accident Investigation Sector,
Dubai, UAE
Gillen, M.W. (2008): Degradation of Piloting Skills (unpublished master’s thesis), University of North
Dakota, Grand Forks, ND
Gillen, M.W. (2010): “Diminishing Skills?”, AeroSafetyWorld, July 2010, pp. 30-34
Hart, C.A. (2014): Emerging Aviation Safety Issues, National Transportation Safety Board, source:
https://app.ntsb.gov/doclib/speeches/hart/Hart_141105.pdf (30.01.2017)
Haslbeck, A. & Hoermann, H.-J. (2016): “Flying the Needles: Flight Deck Automation Erodes Fine-
Motor Flying Skills Among Airline Pilots”, Human Factors: The Journal of the Human Factors and
Ergonomics Society, 58, 4, pp. 533-545
Helmreich, R.L. (2010): “Why CRM? Empirical ad Theoretical Bases of Human Factors Training”, in:
Crew Resource Management, 2nd edition, Kanki, B.G., Helmreich, R.L. & Anca, J.M. (eds.),
Academic Press/Elsevier, Amsterdam; Boston, MA, pp. 3-57
Hoeft, R.M., Kochan, J.A. & Jentsch, F. (2006): “Automated Systems in the Cockpit: Is the Autopilot,
“George,” a Team Member?”, in: Creating High-Tech Teams: Practical Guidance on Work
Performance and Technology, American Psychological Association, Washington, DC, pp. 243-259
IATA (2015a): Loss of Control In-Flight Accident Analysis Report 2010-2014, 1st edition,
International Air Transport Association, Montréal – Geneva
IATA (2015b): Guidance Material and Best Practices for MPL Implementation – Effective July 2015,
2nd Edition, International Air Transport Association, Montréal – Geneva
IATA (2015c): New ‘Loss of Control’ Training for Pilots, International Air Transport Association,
source: http://airlines.iata.org/agenda/new-loss-of-control-training-for-pilots (30.01.2017)
IATA (2016): IATA Safety Report 2015 – Issued April 2016, 52nd edition, International Air Transport
Association, Montréal – Geneva
IATA (2017): 2016 Accident Update, Performance at 13 Jan 2017, Jan-Dec, International Air
Transport Association, Montréal – Geneva
ICAO (2002): Doc 9803 AN/761 – Line Operations Safety Audit (LOSA) – First Edition – 2002,
International Civil Aviation Organization, Montréal, Quebec, Canada
ICAO (2010): Annex 6 to the Convention on International Civil Aviation – Operation of Aircraft, Part
I – International Commercial Air Transport - Aeroplanes, Ninth Edition – July 2010, International
Civil Aviation Organization, Montréal, Quebec, Canada
ICAO (2011a): ADS-B Implementation and Operations Guidance Document, Edition 4.0 – September
2011, International Civil Aviation Organization, Montréal, Quebec, Canada
ICAO (2011b): Annex 1 to the Convention on International Civil Aviation – Personnel Licensing –
Seventh Edition – July 2010, International Civil Aviation Organization, Montréal, Quebec, Canada
ICAO (2013): Doc 9859 AN/474 – Safety Management Manual (SMM) – Third Edition – 2013,
International Civil Aviation Organization, Montréal, Quebec, Canada
ICAO (2016a): ICAO Safety – ICAO Performance Based Navigation Programme, International Civil
Aviation Organization, source: http://www.icao.int/Safety/pbn/Pages/default.aspx (30.01.2017)

51
ICAO (2016b): Safety Report – 2015 Edition, International Civil Aviation Organization, Montréal,
Quebec, Canada
ICATEE (2017): There’s No Silver Bullet in Effective Loss of Control In-Flight Mitigation,
International Committee for Aviation Training in Extended Envelopes, source:
http://icatee.org/defining-the-loss-of-control-in-flight-threat/theres-no-silver-bullet-in-effective-loss-
of-control-in-flight-mitigation/ (30.01.2017)
Interstate Aviation Committee (2015): Final Report, Airplane Boeing 737-500 (53A) VQ-BBN,
Interstate Aviation Committee, Air Accident Investigation Commission
Interstate Aviation Committee (2016): Interim Report, Boeing 737-800 A6-FDN, Interstate Aviation
Committee, Air Accident Investigation Commission
Jacobsen, A.R, Graeber, D.A. & Wiedemann, J. (2010): “Crew Station Design and Integration (for
Human Factors in Aviation Chapter 18)”, in: Human Factors in Aviation, 2nd ed., Salas, E. & Maurino,
D.E. (eds.), Academic Press/Elsevier, Amsterdam; Boston, MA, pp. 175-215
Kochan, J.A., Breiter, E.G., Hilscher, M.B. & Priest, J.E. (2005): “Pilots Perceptions and Retention of
In-Flight Upset Recovery Training: Evidence for Review and Practice”, Human Factors and
Ergonomics Society Annual Meeting Proceedings, 49, 3, pp. 371-375
Komite Nasional Keselamatan Transportasi (2015): Aircraft Accident Investigation Report – PT.
Indonesia Air Asia, Airbus A320-216; PK-AXC, Karimata Strait, Coordinate 3°37’19”S –
109°42’41”E, Republic of Indonesia, 28 December 2014, Komite Nasional Keselamatan Transportasi,
Republic of Indonesia
Ladkin, P. (1996a): Report on the Accident to Airbus A320-211 Aircraft in Warsaw, Universität
Bielefeld, Germany, source: http://www.rvs.uni-
bielefeld.de/publications/Incidents/DOCS/ComAndRep/Warsaw/warsaw-report.html (30.01.2017)
Ladkin, P. (1996b): AA965 Cali Accident Report, Universität Bielefeld, Germany, source:
http://sunnyday.mit.edu/accidents/calirep.html (30.01.2017)
Landry, D.J. (2006): Automation Addiction, Conference Paper presented at the 59th annual
International Air Safety Summit (IASS), Paris, France, Oct. 2006
Landry, D.J. (2014): “Keeping Manual Flying Skills Sharp”, Air Line Pilot, June 2014, pp. 24-25
Landry, D.J. (2017): Loss of Control In-Flight LOC-I – Prevention Strategies – Manual Flight during
Line Operations, Presentation prepared for the Loss of Control In-Flight Safety Symposium,
Shanghai, China, Mar. 2017
Langewiesche, W. (1944): Stick and rudder: an explanation of the art of flying, McGraw-Hill, New
York, NY; London
Luchtvaartfeiten.nl (2016): Cockpit Automation Factsheet, www.luchtvaartveiten.nl
Mallis, M.M., Banks, S. & Dinges, D.F. (2010): “Aircrew Fatigue, Sleep Need and Circadian
Rhythmicity”, in: Human Factors in Aviation, 2nd ed., Salas, E. & Maurino, D.E. (eds.), Academic
Press/Elsevier, Amsterdam; Boston, MA, pp. 401-436
Martin, W., Murray, P., Bates, P. & Lee, P. (2015): “Fear-Potentiated Startle: A Review from an
Aviation Perspective”, International Journal of Aviation Psychology, 25, 2, pp. 97-107

52
Mosier, K.L. (2010): “The Human in Flight: From Kinestethic Sense to Cognitive Sensibility”, in:
Human Factors in Aviation, 2nd ed., Salas, E. & Maurino, D.E. (eds.), Academic Press/Elsevier,
Amsterdam; Boston, MA, pp. 147-173
Mosier, K.L., Sethi, N., McCauley, S., Khoo, L. & Orasanu, J.M. (2007): “What You Don’t Know
Can Hurt You: Factors Impacting Diagnosis in the Automated Cockpit”, Human Factors: The Journal
of the Human Factors and Ergonomics Society, 49, 2, pp. 300-310
Mosier, K.L. & Skitka, L.J. (1999): “Automation Use and Automation Bias”, Human Factors and
Ergonomics Society Annual Meeting Proceedings, 43, 3, pp. 344-348
Mosier, K.L., Skitka, L.J., Heers, S. & Burdick, M. (1998): “Automation Bias: Decision Making and
Performance in High-Tech Cockpits”, The International Journal of Aviation Psychology, 8, 1, pp. 47-
63
Mouloua, M, Hancock, P., Jones, L., Vincenzi, D. (2010): “Automation in Aviation Systems: Issues
and Considerations”, in: Handbook of Aviation Human Factors, 2nd edn., Wise, J.A., Hopkin, V.D., &
Garland, D.J. (eds.), CRC, Boca Raton, FL; London, pp. 8-1 - 8-11
NASA (2017): Aviation Safety Reporting System, National Aeronautics and Space Administration,
source: http://asrs.arc.nasa.gov/ (30.01.2017)
National Transportation Safety Committee (2012): Aircraft Accident Investigation Report
KNKT.12.05.09.04 FINAL, National Transportation Safety Committee, Ministry of Transportation,
Republic of Indonesia
Noort, M. C., Reader, T. W., Shorrock, S. & Kirwan, B. (2016): “The relationship between national
culture and safety culture: Implications for international safety culture assessments”, Journal of
Occupational and Organizational Psychology, 89, 3, pp. 515–538
NTSB (2010a): Aircraft Accident Report AAR-10/01 – Loss of Control on Approach, Colgan Air, Inc.,
Operating as Continental Connection Flight 3407, Bombardier DHC-8-400, N200WQ, Clarence
Center, New York, February 12, 2009, National Transportation Safety Board, Washington, DC
NTSB (2010b): Aircraft Accident Report AAR-10/03 – Loss of Thrust in Both Engines After
Encountering a Flock of Birds and Subsequent Ditching on the Hudson River, US Airways Flight
1549, Airbus A320‐214, N106US, Weehawken, New Jersey, January 15, 2009, National Transportation
Safety Board, Washington, DC
NTSB (2014): Aircraft Accident Report AAR-14/01 – Descent Below Visual Glidepath and Impact
With Seawall, Asiana Airlines Flight 214, Boeing 777-200ER, HL7742, San Francisco, California,
July 6, 2013, National Transportation Safety Board, Washington, DC
Parasuraman, R. & Manzey, D.H. (2010): “Complacency and Bias in Human Use of Automation: An
Attentional Integration”, Human Factors: The Journal of the Human Factors and Ergonomics Society,
52, 3, pp. 381-410
Parasuraman, R. & Riley, V. (1997): “Humans and Automation: Use, Misuse, Disuse, Abuse”, Human
Factors: The Journal of the Human Factors and Ergonomics Society, 39, 2, pp. 230-230
Parasuraman, R., Sheridan, T.B. & Wickens, C.D. (2000): “A model for types and levels of human
interaction with automation”, IEEE Transactions on Systems, Man, and Cybernetics - Part A: Systems
and Humans, 30, 3, pp. 286-297
Patankar, M., Brown, J. & Sabin, E. (2012): Safety Culture: Building and Sustaining a Cultural
Change in Aviation and Healthcare, Ashgate Publishing Ltd, Farnham

53
Reader, T.W., Parand, A. & Kirwan, B. (2016): European pilots’ perceptions of safety culture in
European Aviation, Future Sky Safety
Reason, J. (1997): Managing the Risks of Organizational Accidents, Ashgate Publishing Ltd,
Aldershot
Reinig, N. (2014): Children of Magenta, Youtube, source:
https://www.youtube.com/watch?v=pN41LvuSz10 (30.01.2017)
Sarter, N.B., Mumaw, R.J. & Wickens, C.D. (2007): “Pilots’ Monitoring Strategies and Performance
on Automated Flight Decks: An Empirical Study Combining Behavioral and Eye-Tracking Data”,
Human Factors: The Journal of the Human Factors and Ergonomics Society, 49, 3, pp. 347-357
Sarter, N.B. & Woods, D.D. (1995a): “How in the World Did We Ever Get into That Mode? Mode
Error and Awareness in Supervisory Control”, Human Factors: The Journal of the Human Factors
and Ergonomics Society, 37, 1, pp. 5-19
Sarter, N.B. & Woods, D.D. (1995b): “From Tool to Agent: The Evolution of (Cockpit) Automation
and Its Impact on Human-Machine Coordination”, Human Factors and Ergonomics Society Annual
Meeting Proceedings, 39, 1, pp. 79-83
Sarter, N.B. & Woods, D.D. (1997): “Team Play with a Powerful and Independent Agent: Operational
Experiences and Automation Surprises on the Airbus A-320”, Human Factors: The Journal of the
Human Factors and Ergonomics Society, 39, 4, pp. 553-569
Sherman, P.J., Helmreich, R.L. & Merritt, A.C. (1997): “National Culture and Flight Deck
Automation: Results of a Multination Survey”, The International Journal of Aviation Psychology, 7, 4,
pp. 311-329
Sherry, L. & Mauro, R. (2014): “Controlled Flight into Stall (CFIS): Functional complexity failures
and automation surprises”, 2014 Integrated Communications, Navigation and Surveillance Conference
(ICNS) Proceedings, IEEE, pp. D1-1 - D1-11
Sklar, A.E. & Sarter, N.B. (1999): “Good Vibrations: Tactile Feedback in Support of Attention
Allocation and Human-Automation Coordination in Event-Driven Domains”, Human Factors: The
Journal of the Human Factors and Ergonomics Society, 41, 4, pp. 543-552
Sullenberger, C.B. (2015): My Testimony Today Before the Senate Subcommittee on Aviation
Operations, Safety, and Security, Chesley B. Sullenberger, source:
http://www.sullysullenberger.com/my-testimony-today-before-the-senate-subcommittee-on-aviation-
operations-safety-and-security/ (30.01.2017)
Sumwalt, R.L., Thomas, R.J. & K. Dismukes (2002): Enhancing Flight-crew Monitoring Skills Can
Increase Flight Safety, Paper presented at the 55th International Air Safety Seminar, Dublin, Ireland, 4-
7 Nov. 2002
SUST (2016): Schlussbericht Nr. 2293 der Schweizerischen Sicherheitsuntersuchungsstelle SUST über
den schweren Vorfall des Verkehrsflugzeuges Airbus A321-111, HB-IOC, vom 9. März 2014 auf dem
Flughafen Genf (LSGG), Schweizerische Sicherheitsuntersuchungsstelle SUST, Bereich Aviatik,
Schweizerische Eidgenossenschaft
TNO (2017): EU Project: Simulation of UPset Recovery in Aviation, TNO, source:
https://www.tno.nl/en/focus-area/defence-safety-security/human-effectiveness/supra/ (30.01.2017)
Transport Canada (2015): Advisory Circular AC 600-006 – Flight Deck Automation Policy and
Manual Flying in Operations and Training, Transport Canada, Commercial Flight Standards

54
Traverse, P., Lacaze, I. & Souyris, J. (2006): Airbus Fly-by-Wire – A Process toward Total
Dependability, Paper presented at ICAS 2006 – 25th International Congress of the Aeronautical
Sciences, Hamburg, Germany
Tullo, F.J. (2010): “Teamwork and Organizational Factors”, in: Crew Resource Management, 2nd
edition, Kanki, B.G., Helmreich, R.L., Anca, J.M. (eds.), Academic Press/Elsevier, Amsterdam;
Boston, MA, pp. 59-78
Veillette, P.R. (1995) “Differences in Aircrew Manual Skills in Automated and Conventional Flight
Decks”, Transportation Research Record, 1480, pp. 43-50
Warm, J.S., Parasuraman, R. & Matthews, G. (2008): “Vigilance Requires Hard Mental Work and Is
Stressful”, Human Factors: The Journal of the Human Factors and Ergonomics Society, 50, 3, pp.
433-441
Wiener, E.L., Chidester, T.R., Kanki, B.G., Palmer, E.A., Curry, R.E. & Gregorich, S.E. (1991): The
Impact of Cockpit Automation on Crew Coordination and Communication. Volume 1: Overview,
LOFT Evaluations, Error Severity, and Questionnaire Data, NASA Contractor Report 177587,
National Aeronautics and Space Administration, Ames Research Center, Moffett Field, CA
Wiener, E.L. & Curry, R.E. (1980): “Flight-deck automation: Promises and problems,” Ergonomics,
23, pp. 995–1011
Wilborn, J.E. & Foster, J.V. (2004): Defining Commercial Transport Loss-of-Control: A Quantitative
Approach, Paper presented at the AIAA Atmospheric Flight Mechanics Conference and Exhibit,
Providence, RI, 16-19 Aug. 2004
Williamson, A., Lombardi, D.A., Folkard, S., Stutts, J., Courtney, T.K. & Connor, J.L. (2011): “The
link between fatigue and safety”, Accident Analysis and Prevention, 43, 2, pp. 498-515
Young, J.P., Fanjoy, R.O. & Suckow, M.W. (2006): “Impact of Glass Cockpit Experience on Manual
Flight Skills”, Journal of Aviation/Aerospace Education & Research, 15, 2, pp. 27-32

55
Appendix A: Terminology

In aviation, as in many other industries, a wide variety of different terminologies exist. This appendix
displays the terms and definitions used for this paper.

Concerning a flight crew member, the author preferably uses the term pilot; however, in a more generic
context (e.g. automation issues, ergonomics, etc.), the term (system) operator is also used. Therefore,
to avoid misunderstandings, the author refers to aircraft operators or airlines in the sense of companies
commercially operating aircraft. No preference, however, is given to either the terms cockpit or flight
deck.

Manual flying skills describe the skills “(…) necessary to control the aircraft’s flight path without the
autopilot engaged under instrument reference” (ALPA 2010, p. 68). Some documents also refer to
manual flight skills or basic flying skills; while the meaning is similar, the author uses the term manual
flying skills in this paper. Furthermore, raw data flying describes manual flying without flight director
assistance, using reference to conventional navigation sources and displays only (Landry 2006).
Automation policies or SOPs considerably restricting pilots’ manual flying opportunities, including the
obligation to use the flight director during normal operations, are referred to as restrictive procedural
environment throughout this paper (including the analysis of the Manual Flying Skills Online Survey,
see chapter 5). In contrast, procedural environments encouraging pilots to hand fly are referred to as
supportive procedural environment.

Science, research, and regulators use both the terms situation awareness and situational awareness in
different documents. For streamlining purposes, the author only uses the latter term in this paper.
Concerning the term automation, a manifold variety of meanings and definitions are possible, mostly
depending on a specific context. Billings (1991, p. 261) referred to automation as an “automatic
operation or control of a process, equipment, or a system”. While this definition can be related to many
aircraft systems comprising a large variety of different automated features, the author uses an adequately
narrowed scope. In this paper, automation refers to automated aircraft systems assisting in aircraft
control, such as “autopilot, flight director, autothrottle/autothrust, flight management
computers/systems (…) and associated flightcrew interfaces” (Flight Deck Automation Working Group
2013, p. 13), often called autoflight system or Automatic Flight Control System (AFCS) in their entirety.
Fly-by-Wire (FBW) flight control technology is included in this definition as it directly affects pilot
control. For standardisation purposes, the term Flight Management System (FMS) is generally used
instead of Flight Management and Guidance System (FMGS) or its system components Flight
Management Computer (FMC) and Control Display Unit (CDU).

1
Appendix B: Practical Examples of Automation Issues

Detail 1: Fly-By-Wire and Envelope Protection Issues

By preventing pilots from entering potentially dangerous areas outside the operational envelope – e.g.
low speed buffet, high speed buffet or, in general, aerodynamically unstable aircraft attitudes – envelope
protection is a worthwhile contribution to flight safety. However, if sensors or Flight Control Computers
(FCC) transmit or process faulty data, pilots can be surprised by an automated system that does not
behave as expected, as in the crash of an Air France Airbus A330 (BEA 2012), the crash of an Indonesia
AirAsia Airbus A320 (Komite Nasional Keselamatan Transportasi 2015) or in severe in-flight upsets
involving a Qantas Airbus A330 (ATSB 2008) or a Lufthansa Airbus A321 (BFU 2015).

Sometimes, “hard” envelope protection algorithms even restrict pilots in controlling their aircraft
according to the safest course of action if this would require a breach of preset design limits. The
accident of a Lufthansa Airbus A320 in Warsaw in 1993 (Ladkin 1996a) marked an example in this
regard: after a soft touched down on a wet runway, the aircraft’s sensors did not allow the aircraft to
transit to “ground mode” thus blocking spoiler and thrust reverser deployment. Therefore, the Airbus’
pilots were not able to stop before runway end, and the aircraft collided with an embankment. The logics
of the automated systems had a safety-related and principally useful background: to prevent pilots from
using spoilers and thrust reversers before touchdown. In this case, however, it prevented the pilots from
stopping the aircraft in time. According to Sherry & Mauro (2014, p. D1-8), such a case represents a
“functional complexity failure”: “(…) there is no physical component malfunction, the automation
behaves as it was designed, but the functional complexity results in a failure condition.” Thus, the human
error that was intended to be reduced or eliminated by the automated systems had in fact been shifted
from the pilots to the automation designer, a classic “Irony of Automation” (Bainbridge 1983). Similar
aspects even played a minor role in the “Miracle on the Hudson”, the successful ditching of an Airbus
A320 on the Hudson River following a dual engine failure due to bird ingestion (NTSB 2010b). The
Airbus’ software automatically restricted a nose-up movement of the aircraft when Captain Chesley B.
Sullenberger gave inputs to reduce the sink rate prior impact; therefore, the aircraft hit the water with a
higher vertical speed than intended, and the fuselage was damaged as a result (Hart 2014).

Moreover, it is comparably difficult to reset or disable the FCCs on modern Airbus aircraft, as pilots
cannot easily access the respective switches or might even be forced to leave their seats to reach for
related circuit breakers, a circumstance that played at least a certain role in recent incidents and accidents
(BFU 2015; Komite Nasional Keselamatan Transportasi 2015) and initiated an EASA Emergency
Airworthiness Directive (EASA 2014b). In contrast, the Fly-by-Wire envelope protection of the
Embraer 170/190 series can be switched off using three guarded pushbuttons located within easy reach
of both pilots between the control stand and the central display screen (see figure 14).

1
Figure 14: Central Part of an Embraer 195 Flight Deck (Wikimedia Commons)

Detail 2: The Normal Go-Around – A Complex, High-Workload Situation

In its 2015 Safety Report, IATA (2016, p. 122) referred to the normal (all engine) go-around, a high
workload situation which seems to be highly susceptible to deficient flight crew interaction with
automated systems: “There are (…) cases when the crew engage the autopilot to reduce the workload,
but instead put the aircraft in an undesired situation due to a lack of situational awareness with the
automation” (cf. BEA 2013). Transport Canada (2015, p. 6) assisted: “A go-around with all engines
operating can present a significant challenge. This is because of the high performance capability of
modern two-engine aeroplanes and the automation mode changes associated with a go-around”,
especially if the aircraft has a rather low weight in combination with a low target level off altitude (Flight
Deck Automation Working Group 2013). Recent accidents during all engine go arounds where deficient
manual aircraft handling and/or inefficient interaction with automation influenced the sequence of
events involve the crash of a Tatarstan Airlines Boeing 737-500 in Kazan (Interstate Aviation
Committee 2015) and the crash of a flyDubai Boeing 737-800 in Rostov (Interstate Aviation Committee
2016). Most probably, the recent failed go around of an Emirates Boeing 777 in Dubai (GCAA 2016)
represents an example for automation over-reliance (cf. chapter 3.5.5): after the pilot flying initiated the
go-around by pushing the Take-Off/Go-Around (TOGA) button, he followed the rising flight director
commands, yet without verifying that the autothrottle system increased thrust for the go-around.
According to system logic, however, the thrust had to be set manually as the aircraft had touched down
meanwhile. Reaching 85 feet, the airspeed had declined critically, and the aircraft sank back to the
runway.

2
Detail 3: Qantas 32 – Complexity of Alerts and Warnings

Qantas flight 32, an Airbus A380 that just had taken off from Singapore (ATSB 2013), represents an
exemplary case regarding the complexity of alerts and warnings. Following an uncontained failure of
one engine that damaged several aircraft systems, the pilots had to work through dozens of Electronic
Centralized Aircraft Monitoring (ECAM) messages which were not displayed according to their severity
from a pilot’s perspective, but according to the algorithms of the aircraft’s systems. Flying one of the
most advanced aircraft of their time, one of the biggest challenges for the four pilots occupying the flight
deck was to prioritise the presented warnings and cautions and to find the safest course of action in a
complex and partly contradictory situation to land their aircraft safely.

Detail 4: Hapag-Lloyd 3378 – Over-Reliance on FMS Calculations

The forced landing of a Hapag-Lloyd Airbus A310 in Vienna in 2000 (Bundesanstalt für Verkehr 2006,
in German) following fuel starvation on both engines was an example for flight crew reliance on a faulty
FMS calculation: the aircraft’s commander trusted the FMS’ calculation of remaining fuel at the planned
diversion airport without cross-checking the actual fuel consumption – and without knowing that the
FMS calculated the lower speed and altitude of the aircraft, but not the additional drag of the landing
gear that was kept lowered during flight due to a technical defect.

Detail 5: Automation Complexity, Mode Confusion, and Task Saturation

Complex automation or inscrutable automation behaviour can contribute to pilots’ mode confusion,
mode errors, or even a loss of situational awareness as pilots become task saturated: “(…) during times
of high workload (…), the myriad of tasks required of the pilots result in no one monitoring the flight
path of the airplane, or breakdown in communication between the pilots, or breakdown of cross-
verification procedures or inputs” (Flight Deck Automation Working Group 2013, p. 58). If both pilots
allow themselves to go “head down” in a high workload situation in low altitude or proximity to terrain,
there is a considerable risk that nobody is actively flying the aircraft (with or without autopilot engaged),
and fatal accidents have occurred in such situations (e.g. the crash of an American Airlines Boeing 757
near Cali, Colombia, cf. Ladkin 1996b).

Detail 6: Asiana 214 – Automation Over-Reliance and a Silent Mode Transition

Autoflight modes are designed in a way that modes can transit automatically, e.g. when approaching a
selected altitude, this altitude can be automatically captured. Normally, pilots expect this behaviour and

3
are usually trained to monitor the Flight Mode Annunciator (FMA) on their respective Primary Flight
Display (PFD). Abbott et al (1996) however criticised the insufficient salience of mode annunciations
as well as silent mode transitions, and Mosier (2010, p. 162) revealed that “(…) the selection of (…)
VNAV in the descent and approach phases of flight results in the engagement of one of six possible
trajectories – and that these trajectories will change autonomously as the situation evolves.” An
exemplary case where automation over-reliance and a silent mode transition played a key role in the
sequence of events is the crash landing of Asiana 214 in San Francisco, involving a Boeing 777 in 2013
(NTSB 2014). As the pilots approached the ideal approach profile from above in manual flight, they did
not realise that the engaged autothrottle system had silently transited to another mode that neither
provided speed control nor minimum speed protection. When the pilot flying reduced the sink rate, the
engines remained in idle. The speed finally dropped below stall speed, and the aircraft struck a seawall
short of the landing runway.

4
Appendix C: Survey Background

From the very beginning of this study, it was the author’s intention to combine the latest academic and
scientific research on the topics of manual flying skills and automation with a comprehensive and
quantitative review of these issues from pilots’ perspective in order to develop and present a deeper
understanding of the impact different procedures regarding automation and manual flying have on
pilots’ manual flying abilities.

During the planning phase of the project, the author discussed the original draft of the questionnaire
with fellow pilots and MSc students to develop a short, however concise and expedient sequence of
questions. After acceptance of the project proposal, the questionnaire was further refined with the
author’s project supervisor; for example, management pilots as function were integrated, and a question
on manual flying in high altitude was added.

In line with the objectives of this paper, the questionnaire was intended to enable the author to evaluate
the issues of manual flying skills and automation under the following aspects:

- To differentiate between pilots flying in an environment where manual flying is rather common
or even appreciated, and pilots flying in an environment where manual flying is clearly
restricted;
- To compare between functions (captain / first officer / cruise relief pilot / management pilot)
- To differentiate according to the participants’ experience (years in commercial aviation as well
as flight hours);
- To differentiate between aircraft types or aircraft generations (i.e. aircraft with EFIS-equipped
flight decks vs. aircraft featuring Fly-by-Wire technology; see Appendix E for further details);
- To differentiate between different operators (i.e. network, low-cost, or cargo airlines);
- To differentiate between the participants’ route profile (i.e. short- or long-haul flying) and the
number of sectors flown per duty week to evaluate the extent of manual flying opportunities;
- To analyse if previous experience in an environment where manual flying was more common
plays a role even if a pilot works in a rather restricted environment now;
- To investigate if there are differences between pilots who receive manual flying training during
simulator recurrent sessions – and pilots who do not.

Although certain cultural differences concerning Standard Operating Procedures (SOP) and automation
exist (see chapter 3.6.3), a differentiation between different geographical regions was considered to be
beyond the scope of this paper; it was the author’s primary intention to analyse operator’s procedural
environments irrespective of the respective regional or cultural background.

A final questionnaire was completed by mid-August (see Appendix D). It was composed of multiple
choice-type questions only, however offering the opportunity to give general comments at the end of

1
the survey and to specify some questions using text fields. In order to fulfil the objectives mentioned
above, the survey comprised of 10 initial questions on the aeronautical background of each participant,
including questions on the participants’ operator’s policy concerning manual flying and the use of
simulators to train manual flying skills. This first part was followed by 16 questions on the use of
automation and manual flying in the participants’ daily operation, including questions when each
participant usually switches the autopilot “on” after take-off and “off” prior landing and questions
concerning the frequency of “raw data” flying. The use of automation in adverse weather during
approach was enquired in a group of questions investigating the participants’ preference of manual or
automated flight – and the rationale behind. Concerning simulator training, the survey asked if the
participants deem it adequate to support or even replace the training of manual flying during line
operations. Direct questions were asked if the participants feel restricted or supported in their daily line
operation, if they have sufficient opportunities to hand fly, or if they would prefer to have more
opportunities, either during line operations or during simulator training. Following a question asking for
a subjective assessment if increased experience can compensate for manual flying opportunities, the
participants were finally asked if they think that their manual flying skills help them to be better pilots.

Following final adjustments with the author’s project supervisor and ethics approval by City University,
the Manual Flying Skills Online Survey was released on August 21st, 2016. Initial distribution channels
included City University’s Moodle online platform, where a message to all fellow MSc students was
sent using the Aviation Student and Lecturer Forum, and the author’s company, where approximately
600 pilots could be contacted by mailing list following approval by the Director of Flight Operations.
Moreover, the US safety and risk management company Curt Lewis & Associates displayed an
invitation to take part in the survey in its daily flight safety newsletter for two weeks, thus reaching a
large number of pilots among subscribers world-wide. Thus, the survey received immediate attention,
and after four days, nearly 300 pilots had participated.

During the following weeks, personal contacts to colleagues flying in different regions of the world (and
different procedural environments) assured a further distribution of the survey, and a broad public could
be reached using social media. Two colleagues involved in the board and the Accident Analysis &
Prevention (AAP) committee of Germany’s airline pilot association Vereinigung Cockpit (VC) arranged
a distribution of the survey invitation to all VC members (approximately 9,600 pilots) via e-mail and,
using contacts to the International Federation of Air Line Pilots’ Associations (IFALPA), a further
spreading to each AAP and Human Performance (HUPER) committee of all IFALPA member
associations. Among other positive replies, the AAP committee of the Brazilian National Flight Crew
Union confirmed a distribution among its 3,000+ members.

Based on these distribution channels, the survey received contributions from more than 1,500
participants world-wide. After 15 weeks online, the survey was terminated on December 7th, 2016.

2
Appendix D: Manual Flying Skills Online Survey Questionnaire
On the following pages, the complete questionnaire used in the Manual Flying Skills Online Survey (see chapter 5) is displayed.
Following 10 questions in Part I (“Your Background”), 16 questions could be answered in Part II (“Manual Flying in Your Daily Operation”). A field to leave
general comments or feedback completed the survey.
Mandatory questions are marked with an asterisk.

1
2
3
4
5
Appendix E: Aircraft Categories used for Survey Analysis

From the author’s perspective, a refined and more specific categorisation according to the technological
level of aircraft, their human-machine interface (HAI) and automation sophistication is required. In
Airbus’ categorisation (Airbus 2015), no difference has been made between “3rd generation” aircraft
offering just two EFIS screens for each pilot (while e.g. engine information continues to be displayed
on a multitude of separate analogue “steam gauges”, e.g. Boeing 737-500, see figure 15) or aircraft
featuring a complete “glass cockpit” where large cathode ray tube (CRT) screens have replaced (nearly)
all analogue instruments in the flight deck, including e.g. “moving map” Navigation Displays (ND) and
Engine Indicating and Crew Alerting System (EICAS) displays (e.g. Boeing 737-800, see figure 16). In
the same context, the described “4th generation” comprises aircraft featuring Fly-by-Wire (FBW)
technology, however remaining equipped with a “classic” control column (providing an interconnection
between both pilots’ controls as well as artificial tactile feedback, e.g. Boeing 777/787), as well as FBW-
equipped aircraft featuring sidesticks, thus lacking any tactile feedback (e.g. Airbus A380, see figure 6).
For more details on related FBW and envelope protection issues, see Appendix B, Detail 1.

Over the past few years, nearly all aircraft belonging to the 1st or 2nd generation have been retired
(FlightGlobal 2016). Thus, it might prove helpful to analyse the prevailing 3rd and 4th generation aircraft
in greater detail to discover more precise information about advantages or disadvantages regarding their
respective human-machine interface. Therefore, the following categories will be used for analysis of the
Manual Flying Skills Online Survey:

- Categories 1/2: Conventional flight deck; analogue, round-dial instruments; no FMS

(examples: Boeing 707/727, Douglas DC-8/DC-9); number of survey participants: negligible
- Category 3A: “Early glass cockpit” or “EFIS cockpit”; first screens, however merely
replacing similar-looking round-dial instruments; FMS initially without advanced functions
(aircraft types: Airbus A300-600/A310, Avro RJ / BAe 146, Boeing 737 Classic, Boeing
757/767, Dash 8-100/-200/300, MD-80 series, Saab 340); number of survey participants: 140
- Category 3B: Fully integrated “glass cockpit” incl. advanced FMS functions such as VNAV;
however, without Fly-by-Wire technology (aircraft types: Boeing 717, Boeing 737NG, Boeing
747 (-400/-8), CRJ-200/-700/-900/-1000, Dash 8-Q400, Dornier 328, Embraer 135/145,
Fokker 70/100, MD-11); number of survey participants: 514
- Category 4A: Glass cockpit, Fly-by-Wire technology, conventional flight control column,
“soft” envelope protection (aircraft types: Boeing 777, Boeing 787, Embraer 170/190);
number of survey participants: 96
- Category 4B: Glass cockpit, Fly-by-Wire technology, side stick, “hard” envelope protection
(aircraft types: Airbus A320, Airbus A330/340, Airbus A350, Airbus A380); number of
survey participants: 721

1
This refined categorisation will help providing a much more in-depth view into human-machine
interaction issues and possible effects on manual flying skills.

However, the author is aware that the equipment of each airframe is highly individual, and many systems
(such as Flight Management Systems) or features (such as VNAV) can be retrofitted or updated at a
later stage on operator’s demand.

Figure 15: Boeing 737-500 Flight Deck (Wikimedia Commons)

Figure 16: Boeing 737-800 Flight Deck (Wikimedia Commons)

2
 Appendix F: Proposed Automation Policy

In line with the discussion and recommendations of this paper, this appendix presents an example of a
balanced automation policy. As a contribution to efficient safety management, this policy can be adopted
by aircraft operators to enable their pilots to maintain a robust manual flying proficiency during line
operations – without compromising flight safety, workload management, flight path precision, efficient
aircraft operations, or passenger comfort.

The aviation system requires pilots to deliberately use all levels of automation to
facilitate safe flight operations. Manual flying proficiency is crucial for aircraft control in
normal as well as non-normal situations.

As long as conditions permit – and given that rules, regulations and procedures are
adhered to – manual flight (with or without flight director) is encouraged to maintain
pilot proficiency.

Special consideration should be given to aspects such as situational awareness, workload

management, flight path precision, meteorological conditions, traffic density, efficient
aircraft operations, Crew Resource Management (CRM), and passenger comfort.

At all times, flight safety is of paramount importance.

View publication stats