How do Flight Crews Detect and Prevent Errors? Findings from a Flight Simulation Study

In order for a team to maintain safety in a high-risk engineered environment, its members must monitor each other's behavior, as well as the situation. The advantage of a team structure is that members can support each other, catching errors and preventing problems from developing into serious situations. In its analysis of aviation accidents in which crew behavior played a role, the National Transportation Safety Board (1994) observed that most of those accidents involved “monitoring and challenging” errors. After an error occurred, the crew either failed to detect it or to communicate effectively in order to ameliorate the outcome. This paper describes a simulator study that examined two factors thought to affect monitoring and challenging: (a) level of physical risk in a developing situation and (b) degree of face threat involved in a challenge. Events were scripted to present errors committed by a confederate pilot (high face threat) or problems developing outside the flight deck (low face threat). Videotapes of performance showed that captains were more assertive and responded earlier than first officers, often preventing the problems from developing. This difference, however, was only evident in high-risk situations. First officers were more sensitive to face threat than captains, indicating a need for techniques to overcome limits to error mitigation in high-face threat situations.