Safety on the NAT: B+ with room for improvement

The eighth Annual Safety Report for the North Atlantic Region is out, and it looks good. A solid B+ for pilots and ATC alike.

But there is still room for performance improvement, so here are the highlights from the report to focus on.

Did anyone fly in 2020?

The number of flight hours in the NAT HLA through 2020 was 892,137 which was unsurprisingly a decrease on the 2019 hours (2,063,908 in case you’re wondering).

The peak week was July 15-21 when it saw 5,621 flights crossing, compared to 13,733 for the peak week of 2019.

If you want to check and compare all the stats to 2019 then here is our post on that.

What have they been monitoring?

Safety Performance in the NAT HLA is monitored and measured in 12 areas. The targets for 6 of these were achieved in 2019, while 2020 achieved an impressive 8.

The biggest improvements seem to be:

  • Less Large Height Deviations where Datalink was not in use
  • A reduction in the amount of time aircraft with datalink spent at the wrong flight level
  • A reduction in the number of GNE events involving aircraft with datalink

How likely are you to fly into someone else?

Much of the safety focus in the NAT really boils down to this – it is an area of reduced separation and high density traffic. So, they also worked out the risk of collision and in 2020 it reduced by 74%, which is probably down to less aircraft but also to less mess-ups. 

SLOP is one of the main factors in reducing this number. And it doesn’t just reduce the risk of collision, it reduces your risk of running into wake turbulence as well. So keep up that slopping, up to 2nm right (and 0.1nm increments).

Who’s to blame for the times it did go wrong?

Ok, ok, the purpose of the report is not to point fingers, but to understand where improvements can be made.

The Top 10 factors in errors haven’t really changed – ATC coordination errors are top, closely followed by “crew other” (which pretty much means crew not doing what they’re told, messing up etc) and then interestingly application of contingency (other than weather).

So here is a quick recap on those Contingency Procedures to follow

Follow it!

Some facts and figures

Since 2019, 70% of core NAT traffic has been using ADS-B.

There have been no accidents in the NAT since at least 2017. 2020 also saw no losses of lateral separation for the first time since 2017.

They did see 47 LHDs, 57 Lateral Deviations (15 were GNEs, the other 13 were caught and corrected by ATC), 26 coordination events, 1 longitudinal loss of separation and 30 events they prevented where someone was basically just flying the wrong flight profile.

18% of events were down to ATC coordination between different ATC sectors.

18% also came down to fight plan versus clearance issues.

11% were weather related. 

Issues with dispatch contributed another 8% and everything else was down to, well, lots of other things.

How can we improve?

Follow the Golden Rules of operating in the NAT HLA:

  • Have the Right Equipment: If you ain’t sure then check out our Circle of Entry.
  • Have a Clearance: If you can’t get it on CPDLC then have those HF or VHF frequencies ready for a voice clearance, and make sure you read it back and confirm it correctly.
  • Check your Route: This means flying what you’ve actually been told to fly which means checking what is in the airplane box matches what is in the clearance. It probably should say ‘flight profile’ because it means route, altitude and speed.
  • Know your Contingencies: We added the picture above to help. Read more about this here.

And don’t forget to SLOP.

Keep up to date on NAT info

Photo @Algkalv from Wikimedia Commons


2019: Safety Net on the NAT

2019 seems so long a go. A golden age for aviation with airplanes swooshing happily through the skies, and none so happy as those crossing the NAT.

Or were they?

Well, now we can check because the NAT Systems Planning Group 2019 Annual Safety Report has just been released. 2019 might seem a fair old while ago, but the report speaks of a time before Covid when aviation was at normal levels and so offers good guidance on what’s up in the NAT world normally.

What is monitored?

If you were thinking the only things you’re monitored on are your competencies and KSAs in sim assessments, then think again. You are being watched all the time, and especially so in the NAT where 12 Safety Key Performance Indicators are watched like a hawk watches a juicy mouse in long grass.

Targets for reducing the number of errors in these areas are set using three year rolling data.

So, how did we all do?

Well, in 2019, six of the targets were met and there were notable improvements in these three areas:

  • Percentage of long duration height deviations
  • Rate of long duration height deviations where datalink was not in use
  • Number of minutes spent at wrong fight level for aircraft not using datalink

So, pilots have got better at reading their altimeters and not flying at the wrong altitude.

The risk of vertical collision estimate saw an impressive 30% improvement, and they reckon with the use of SLOP this can be reduced another 77% making it… 30/100*77{equation stuff}#100[somethingbysomethingoversomethingelse]… a lot less likely we will fly into each other. Good job all.

What is going less well?

Lateral collision risk estimates reduced, but there were still 80 reported lateral deviations. So we’re flying at the right altitude, but sometimes in the wrong place.

Flight plan versus what ATC actually cleared pilots to do are the top of the list, making up 30% of  the total. 49 of those were prevented by ATC. Not adhering to ATC clearances increased from 10% in 2018, to 13% in 2019, and weather was another biggie making up 17% of all lateral deviations.

ATC coordination errors were also in the top 5 (11%) so don’t congratulate them too much. ATC were also provided with conformance monitoring tools which highlighted cleared versus selected level differences, and route assignment monitoring tools to help them intervene and prevent deviations. With these in place, the performance in the second half of 2019 did improve a lot.

Ok, congratulate them a lot, they’ve made it much safer for us up there.

Overall, what’s the verdict?

No gold star because there were still 266 events reviewed in 2019 by the SPG. These included:

  • 83 large height deviations
  • 118 (actual) lateral deviations including
    • 42 GNEs
    • 44 ATC interventions where ATC prevented pilots making GNEs
  • 73 prevented events where ATCOs stopped aircraft flying an uncoordinated flight profiles or entering the wrong airspace sort of things.

It isn’t always pilots going wrong though. Some of these were down to equipment issues, some down to ATC not responding quick enough. Here is the full breakdown – 

What else is going on up there?

Well, in 2019, when a normal number of aircraft were still flying, they were able to properly monitor the communication and surveillance side of things too, and a whopping 70% of core NAT traffic were using ADS-B. 83% of aircraft were making use of CPDLC over HF radio as well, and the use of these is a big factor in improving the safety and efficiency up there.

The report says this leads to a ‘greater focus on strategic rather than tactical techniques’ which sounds like ‘we are now planning aircraft not to fly near each other’ rather then ‘when aircraft get too close we move them out of each other’s way’.

As a reminder, you have until February 25 to get yourself Datalinkable – the NAT Datalink mandate comes in then.

What next?

2020 data might be a little skewed given a lot less traffic flew, (and many of those who did probably did so after a big gap of not flying), but the overall trend is big improvements. ADS-B is an excellent thing, ATC have a bunch of tools to help them make us safer, and pilot errors are reducing.

There is also a NAT2030 vision plan which is aiming for:

  • more flexibility through ‘dynamic airborne rerouting”
  • improved contingency procedures
  • better comms and surveillance and new technologies
  • a focus on improving the environmental impact
  • and maybe even some new visitors to the region in the shape of unmanned aircraft supersonic aircraft and even balloons

Until then, get out your own balloons and have a little celebration because safety is improving on the NAT. Now put them away. There is still work to be done.

The full report can be checked out here


No Room for Error – GNE’s and the North Atlantic

Advances in technology mean that aircraft in the North Atlantic High Level Airspace (NAT HLA) are flying laterally, longitudinally, and vertically closer than ever before. But North Atlantic gross navigational errors (GNE’s), which are lateral off-track deviations of 10nm or more, still occur regularly, and jeopardise the safety of you and the traffic around you. So don’t leave it up to Air Traffic Control (ATC) to discover your GNE! In this article, let’s look at some common human slip up’s that lead to GNE’s, and what we can do to prevent them.

[heading]Pre-Flight[/heading]Operating to the highest standards of navigational performance demands the tedious and careful monitoring of aircraft systems. Unfortunately, humans are by nature not the best monitors. During the long quiet of an oceanic crossing, we can fall victim to cognitive traps such as change blindness, expectation bias, and complacency.

But the potential for error on Atlantic crossings begins well before the first coast-out waypoint. In fact, it begins before take off. The following four areas are where strategies in mitigating a GNE begin.

1) Data Entry

Via ACARS:

Many pilots now use ACARS to automatically downlink the entire flight plan and winds aloft directly to the FMS. But an over-reliance on automation can lead to complacency, and so the more reliable the system, the more complacent we become as monitors. In one incident, a Boeing 747 suffered a GNE of 120nm. The flight plan downlink from ACARS unfortunately contained one bad coordinate that went unnoticed. Once lured into complacency by such reliable technologies, there can be a temptation to omit cross-checking.

What can we learn from this? Always verify the full coordinates in an ACARS downlinked flight plan. Similarly, if several different flight plans were run, ensure that you request your downlink using the most current and filed flight plan number.

Manually:

A manual entry means a pilot inserts the flight plan’s waypoints directly into the aircraft’s flight management system (FMS). But no matter how meticulously one may be, manual data entry can still produce errors. Then how do we guard ourselves against these errors?

Firstly, avoid using ARINC 424 shorthand for programming oceanic points. This has been a factor in many GNE’s, given how easy it is to misplace the letter as a prefix or suffix. For instance, consider how simply misplacing the “N” could cause a drastic lateral deviation:

  • 50N60 = 50N 160W
  • 5060N = 50N 060W

If you have the capability on your aircraft, use the full coordinates, including minutes.

For the last few years, use of half degrees of separation has been on the rise in an attempt to enhance airspace efficiency. But on flight displays units that only show 7 digits, these half degree coordinates are misleadingly displayed as full coordinates. For instance, the half coordinate N55°30’ W020° will display as N55°W020° (see image below, which shows identical waypoint labels for points separated by half a degree!). In this case, it is imperative to view the expanded version of coordinates (degrees and minutes).

Another frequent error leading to GNE’s is transposing numbers during data entry. This commonly occurs when you complete almost the entire crossing along one degree of latitude, then fly the last waypoint at a different latitude. For example, with a cleared route of 57°N 050°W, 57°N 040°W, 57°N 030°W, 56°N 020°W, one can accidentally enter 57°N 020°W. This will put you 60nm off course.

But there is good news! These errors are easy to recognize and avoid by having a specific method of waypoint verification.

2) Waypoint Verification

Whether entered via ACARS or manually, both crew members must come together to perform a thorough cross-check. The following method recommended by ICAO in Doc007 seems to work the best:

  • One pilot reads the waypoint/coordinates, bearing and track from the FMS.
  • On the master document, the other pilot will circle the waypoint to signify the insertion of the correct FULL coordinates in the navigation computers
  • The circled waypoint number is ticked, to signify the relevant track and distance information matches
  • (In flight) The circled waypoint number is crossed out, to signify that the aircraft has overflown the waypoint.

[fancy_box box_style=”default” icon_family=”none” color=”Accent-Color” border_radius=”default” image_loading=”default”]

Cognitive Traps:

Expectation Bias is when your perception is influenced by your preconceptions. It is vital that the second crew member crosschecks from the FMS/CDU to the master document – and not vice versa – thereby increasing the chance of spotting an error.

 

Pop-up trip hustle – It’s one thing reading about waypoint verification, but it’s another thing actually sitting down and taking the time to do it. Do not be tempted to crosscheck your own work because you’re in a time crunch – it requires at least two separate sets of eyes.[/fancy_box]

3) Initialisation of navigation systems

The navigational integrity of your entire flight is predicated on an accurate starting position. Even a small error with on the ground can translate into a gross error later down the line in flight.

The FMS GPS position and your current parking coordinates (found on the 10-9 pages) must match. Avoid using “last position” function in the FMS – if you were towed overnight, the “last position” will be your previous location, not your current one! Sounds obvious, but mistakes happen.

Inertial systems, once aligned, must also complement the GPS coordinates. Initialisation of inertial navigation systems can take between 6-15 minutes, and errs on the longer side at more northerly latitudes – so be patient! Moving the aircraft during alignment will cause an alignment error. Bottom line: avoid repositioning/towing the aircraft during alignment, even it is to a nearby spot on the same ramp area. Position errors like this cannot be corrected once in flight.

4) Your Master Clock – (iPhones not authorised!)

Since our ETAs for oceanic waypoints must be accurate within +/- 2 minutes, it is vitally important that, prior to entry into the NAT HLA, your master clock is accurately synchronised to UTC. ICAO Doc007 has a list of approved sources from which you can set your aircraft master clock (and your iPhone isn’t one of them!). You are approved to use the GPS time which can be found in the FMS.[fancy_box box_style=”default” icon_family=”none” color=”Accent-Color” border_radius=”default” image_loading=”default”]

Cognitive Trap:

Close to the E/W Greenwich line or close to the equator, you’ll just be on the fringes of the opposing segment. So, take a close look at the E/W or N/S letter coordinates, especially if you are usually accustomed to flying from one particular geographic area.[/fancy_box][heading]Clearances & Communication[/heading]With a move away from spoken communications and towards datalink procedures, requesting, copying and verifying a clearance becomes a much simpler task! But it is still important to know your own limitations in the rare instance that you need to copy a clearance via voice.

Casual radiotelephony should be avoided

Casual radiotelephony can be the source of misunderstanding coordinates or clearances, and so all waypoint coordinates must be read back in detail, adhering strictly to standard ICAO phraseology. An example of standard ICAO phraseology requires enunciation of every individual digit. 52 North, 030 West would be read back as “Fife two north, zero tree zero west” as opposed to “fifty-two north thirty west”. Have no doubt about it, Shanwick can be the most strict in this regard.

 

Distractions and workload

If your departure airport is close to the oceanic boundary, e.g. Shannon or Miami, the benefit is that you will copy your oceanic clearance on the ground. Unencumbered by distractions typically associated with being in flight, you can focus almost fully on the task at hand. However, most flights pick up an airborne clearance, and it is important to prioritise this for a period of low workload.

Take the example of a Bombardier Global Express crew that narrowly avoided a GNE after copying a clearance. While they were in the midst of crosschecking the clearance with the FMS and climbing to their initial altitude, the flight attendant approached them with an issue. Instead of waiting, one of the pilots attended to the problem. A new waypoint wasn’t entered, and it was later caught by ATC in a position report. Try to avoid non-vital tasks until ALL the steps regarding copying, verifying and inputting a clearance are complete.

Following these simple standard operating procedures (SOPs) step-by-step will guard against clearance errors. If the steps are interrupted for any reason, start again from the beginning.

  • Two pilots monitor and record the clearance. The Pilot Monitoring (PM) will contact clearance delivery, while Pilot Flying (PF) monitors both the primary ATC frequency and the clearance delivery frequency.
  • The PM then records the clearance on the master document. The PF also copies down the clearance separately.
  • Clearance is read back to ATC. Any disparities between both pilots’ interpretations of the clearance must be clarified with ATC.
  • A deliberate cross check of the clearance to the filed flight plan and the FMS is made.

Re-Clearance

According to ICAO Doc007, “In the event that a re-clearance is received when only one flight crew member is on the flight deck…changes should not be executed…until the second flight crew member has returned to the Flight Deck and a proper cross-checking and verification process can be undertaken.” Sorry, they just don’t trust you to do this by yourself, and neither should you!

Errors associated with re-clearances, re-routings and/or new waypoints continue to be the most frequent cause of GNE’s. Therefore, a re-clearance or amended clearance should be treated virtually as the start of a new flight and the procedures employed should all be identical to those procedures employed at the beginning of a flight.

  • Both crews note the re-clearance
  • Reply to ATC via ACARS or voice
  • Amend the Master Document
  • Load the new waypoints into the FMS from the updated Master Document
  • One pilot verifies the input of the new waypoints reading from the FMS
  • Verify the new tracks and distances, if possible
  • Prepare a new plotting chart/re-plot in Jeppesen EFB

With datalink, you might have the capability to load the new route directly from the ATC message into your FMS flight plan. This will eliminate a transcription error on your part, but you cannot always count on the FMS to load this seamlessly. Oftentimes, if a revised coast-in waypoint doesn’t connect with your originally planned domestic airspace airway, it might cause a discontinuity. Worse, some crew have experienced their entire domestic flight plan drop out, left with only the oceanic portion.

Conditional Clearances – There’s always a catch!

A conditional clearance is an ATC clearance given to an aircraft with certain conditions or restrictions, such as changing a flight level based on a time or place. Conditional clearances add to the operational efficiency of the airspace, but are commonly misinterpreted by flight crews.

Shannon has been known upon first VHF contact to provide lateral conditional clearances on coast-in. For example: “N135AC, after DINIM, direct ELSOX”. Often, crew have been known to read back the correct transmission, but then execute the wrong procedure by proceeding directly to ELSOX.

Why is this happening? In studies of linguistics, verbs (such as ‘direct’) have been noted as having a perceptual priming effect, that more easily grabs our attention at the expense of weaker prepositions (such as ‘from’ or ‘after’). Listen carefully for prepositions. Similarly, in aviation vernacular, the word ‘direct’ means to proceed now to the specified waypoint. As pilots, we can distinguish this meaning with very little effort, and most of the time can expect to proceed present position direct. Thus, we are primed to go direct.

While this isn’t a complex sentence, research indicates that transmissions involving serial recalls (such as “proceed here then here…”) are susceptible to distortion, with the last word or item more commonly interfering with recall of the previous item.

A really simple way to prevent this is to write down clearances as they are being read to you, then read-back the transmission. You can also call attention to a conditional clearance by prefixing their read-back with the word “Verify” or “Confirm” over the radio. Via datalink, sufficient care always must be taken when factoring in all the contents of a clearance before acknowledging the message. The initial phrase “MAINTAIN FLIGHT LEVEL 300” is included to stress that the clearance is conditional. If the message is about to time out, and you need more time to process its contents, reply using “Standby”. Respond at your own pace![fancy_box box_style=”default” icon_family=”none” color=”Accent-Color” border_radius=”default” image_loading=”default”]

Cognitive Trap:

On the longer route segments between New York and Santa Maria, “when able higher” (WAH) reports might be solicited. ATC acknowledgement of a WAH report must not be misconstrued as a conditional clearance to climb. Any climb clearances will be issued separately from a WAH acknowledgement.[/fancy_box][heading]Miscellaneous[/heading]

10-minute Check – put the (Bad) Elf on the shelf for this

One of the best ways to capture a potential GNE and refresh your situational awareness is with the sublimely simple 10-minute check. Ten minutes after waypoint passage, you’ll use your current coordinates to plot your position on your plotting chart. If the coordinates don’t land on the plotted track line, an investigation into the source of the error must begin immediately. It doesn’t hurt to even make additional plots between waypoints too, but ICAO only requires the one 10-minute check.

Today, more pilots are carrying independent GPS units in their flight bags, providing crew with own-ship on their oceanic route map. Tempting though it may be to use this for present position information, it is currently not an approved source of navigation, and should NOT be used in lieu of a 10-minute check.[fancy_box box_style=”default” icon_family=”none” color=”Accent-Color” border_radius=”default” image_loading=”default”]

Cognitive Trap

It is easy to forget about the 10-minute check. Setting a timer once your waypoint passage tasks have been completed will help remind you to do so.[/fancy_box]

Autopilot mode – “Wait, are we supposed to be in heading?”

Incorrect autopilot mode selection has been known to be a factor in GNE’s. On an oceanic crossing, you can bank on being in NAV or LNAV most of the way across the Atlantic. But perhaps you used heading mode to deviate for weather or to intercept a SLOP. It is not uncommon among pilots to spare your passengers two steep banking turns (thanks LNAV!) by manually flying a SLOP intercept in heading mode. But if you forget to re-engage LNAV, you will continue drifting on your merry way, further and further off course.

Distraction, fatigue or complacency are common reasons for losing mode awareness, so the following simple tricks will help mitigate autopilot induced GNE’s.

  • It helps to verbally announce when you are transitioning temporarily into heading mode, to bring both pilots in the loop.
  • Employing sterile cockpit until you’re back in LNAV will help mitigate distractions.
  • In an abundance of caution, you can keep a finger on the heading button or heading dial until you are back in LNAV will serve as a reminder.

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Cognitive Trap:

The flight mode annunciators (FMA’s)  are the most reliable indicators of automation selection – more so than the flight guidance panel! Yet, a study found that pilots pay superficial attention to the FMA’s during critical mode changes. Don’t waste a valuable resource, and do consciously bring the FMA’s into your scan.[/fancy_box]Deliberate cross-checking and monitoring are a critical last line of defense for which we, as pilots, don’t get explicit training, but are nevertheless expected to perform effortlessly. But over the North Atlantic, there is little room for error. So, let’s recap what can be done!

  1. Allow sufficient time on the ground to set up
  2. Closely scrutinise data entry – whether the source is human or ACARS!
  3. Work together on waypoint verification
  4. Don’t work single pilot – always keep all crew in the loop
  5. Deal with clearances and re-clearances methodically

Understanding our vulnerabilities is key to the process of mitigating errors. Armed with an understanding of our own limitations, and an appreciation for the practices and habits mentioned above, a ‘would-be’ GNE can be averted.

Links

ICAO Doc 007 

Global Operational Datalink Document (GOLD)


Oceanic Errors

Unfortunately, we don’t fly with three in the cockpit anymore – or even four. The navigators job falls squarely onto the front two seats. Over one weekend in April there was one Gross Navigation Error, and two close calls reported on the North Atlantic.

April 22nd (Friday)
Democratic Republic of the Congo Boeing 727 100 (9QCDC/DRC001) from Santa Maria Island, Azores (LPAZ) to St. John’s NL (CYYT)
At 1235Z, Observed on radar to be over position 4720N 4745W, which was approximately 60 miles north of the cleared route 45N 45W – 47N 50W. The crew reported correctly while in oceanic airspace. The flight was cleared direct to YYT and landed without incident at CYYT. There was no traffic, and no other impact to operations.

April 24th (Sunday)
Neos Airline Boeing 767-300 (INDDL/NOS730) from Ferno, Italy (LIMC) to Havana, Cuba (MUHA)
Cleared via 49N030W 48N040W 45N050W. At 30W, the flight reported 48N040W 44N050W. The aircraft recleared to 45N050W prior to proceeding off course.

Apr 25th (Monday)
Transportes Aereos Portugueses Airbus A330-202 (CSTOO/TAP203) from Lisbon, Portugal (LPPT) to Newark, NJ (KEWR)
Cleared 46N030W 46N040W 45N050W. The aircraft reported proceeding via 46N030W 46N040W 44N050W, as per the original flight plan. The aircraft was recleared via 45N050W prior to proceeding off course.

Did you notice how hard it was to find the error in the above two examples?

 

Gross Navigation Errors are a really interesting topic, and relevant not just on the North Atlantic but in any Oceanic or Remote airspace where ATC cannot monitor the aircraft tracking.

What defines a GNE? Normally, 25nm: That is, when on “own navigation” the aircraft departs the cleared route by more than 25nm. The NAT Central Monitoring Agency (CMA) now defines a Gross Navigation Error as 10nm instead of 25nm.

Annually, the biggest offenders in order of “market share” are: 1. Corporate/Private, 2. Military/State 3. Civil airlines.

How to Avoid a GNE?
(aka How to avoid a Nastygram from the Authorities):

In general, when operating outside of ATC Radar coverage in any airspace:

  • Crews: Don’t have more than one paper copy of the Flight Plan in the cockpit. Mark the active one “Master Document”. Hide any other copies where you won’t find them.
  • Ops: If you send a new Flight Plan to the crew, tell them what the changes are – especially if you’ve filed a different route in Oceanic or Remote Airspace.
  • Fly the Clearance, not the Filed Plan. This is the biggest gotcha. As soon as you reach the Oceanic Entry Point, or leave radar airspace – refer only to the most recent Clearance from ATC. The filed plan is a request only – sounds obvious, but most GNE’s occur because the crew fly the filed plan although there was a reroute.
  • Be aware of the ‘ARINC424 problem’: In the aircraft FMS, and map display, the current common waypoint format is 5230N for position 52N030W (as prescribed by ARINC 424). To show position 5230N030W – ARINC 424 offers a format N5230. The potential for confusion is clear. ICAO, in NAT Ops Bulletin 3/15, have recommended that operators use the format H5230, if a five-letter FMS format waypoint is required. In addition pilots are recommended to cross check any waypoints that don’t have a ‘name’.
  • Use a plotting chart – it’s mandatory. You don’t have to use ours, but use one.
  • Use an Oceanic/Remote Area Checklist (sample link below).

And specifically on the Atlantic:

  • Read the advice on the Daily Track Message – waypoint cross check, Fly the Clearance (and be sure it is the clearance!)
  • Know the weather deviation procedures: Even with the new “Half Tracks”, there are no changes to the in flight contingency procedures and weather deviation procedures as detailed in PANS ATM Doc444 Para15.2 & 15.2.3.

Here’s some links and resources that we think are really useful:

 

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