Cross-checking Process
Cross-checking Process
Description
The human mind is fallible and error can occur for many reasons, for example, from a misheard message, from a memory slip, or the incorrect appreciation of the situation.
Error is particularly likely in certain circumstances, especially when there is pressure to complete a task quickly (e.g. to expedite departure or during an emergency or abnormal situation), but may also occur in normal situations.
Error in aviation can have severe consequences and the Cross-checking Process is used wherever possible to eliminate errors.
Cross-checking and the Pilot
The Cross-checking Process is a vital element of a pilot’s duties, particularly in a multi-crew situation where the roles of the two pilots are defined as Pilot Flying and Pilot Not Flying. The Pilot Not Flying (PNF) – alternatively referred to as the Pilot Monitoring – has the responsibility for monitoring the actions and awareness of aircraft control of the Pilot Flying (PF).
Whilst the monitoring role of a PNF must not be limited to specific parts of flight crew duties, Company SOPs should include a minimum list of defined actions that are to be cross-checked, for example:
- One pilot calculates aircraft performance and makes mass and balance calculations; the other pilot closely monitors, cross-checks, or duplicates the calculations.
- A Load and Trim Sheet prepared (exceptionally) by a member of a flight crew must be subject to meaningful cross-checking before acceptance.
- ATC clearances will normally be monitored by both pilots and consequent action including readback taken by one pilot will be confirmed/monitored by the other.
- Equipment settings such as altimeter pressure settings, cleared altitude, frequency change, and navigation routings, are set by one pilot and cross-checked by the other.
- Adherence to defined Stabilised Approach gates and calculated Reference Speeds and AFM Limitations
Cross-checking and the Controller
Cross-checking is equally important for the ATCO, and comprises two elements:
Cross-checking the actions of pilots
Where possible, the controller should monitor the actions of the pilot, either by reference to the radar screen or by visual observation, to ensure that instructions are followed correctly.
The extent to which a controller can cross-check the actions of pilots depends on his/her workload; however, every effort should be made to do so in situations where an error is likely to occur.
For example, when the pilots are dealing with an aircraft’s unserviceability, or when the pilot appears to be inexperienced, confused, or has limited language ability.
A particular example of a situation where monitoring by radar or directly may be conducive to safety is the execution of issued VFR clearances in airspace such as Class ‘D’; in this situation, loss of separation against IFR traffic can occur due to poor situational awareness of the IFR aircraft flight crew, who might wrongly assume that they benefit from ATC-controlled separation from VFR traffic as well as from other IFR traffic.
Controllers should pay particular attention to aircraft maneuvering on the ground near runway hotspots and to potential conflicts which can arise in the air when intersecting runways are in use simultaneously and this involves intersecting approach, missed approach, or take-off flight paths.
System support can be used to help controllers with performing this task. Examples of this are various monitoring tools, e.g. for a potential or actual level bust, horizontal deviation, the downlink of Mode S selected level, etc. Nevertheless, controllers should be aware that such tools are not supposed to replace the existing ATC procedures.
Cross-checking the actions of colleagues
Cross-checking is a normal part of the duties of an ATC Assistant if these exist; otherwise, controllers rarely have the free capacity to monitor the duties of other controllers and such action could not be expected to form part of their duties. Nevertheless, the following areas are important:
- When there are two controllers assigned to a sector, communication with aircraft is normally done by the executive controller. The planner controller however also monitors the radio exchanges (to the extent possible) so that they can detect lapses, incorrect readbacks, etc.
- Also not official and subject to personal workload, a tower and an approach controller (or a tower and a ground controller) may monitor the other controller’s frequency e.g. to make sure agreed coordination is appropriately communicated to the aircraft.
- Controllers taking over responsibility for a sector have much information to absorb and the potential for error or oversight is high. The controller going off duty should monitor the actions of their replacement for a few minutes after hand-over to ensure that neither has overlooked any significant aspect of the prevailing traffic situation and to be available to deal with any questions that might arise;
- Inexperienced controllers or controllers who are new to their positions may not become fully proficient for some time. Appropriate mentoring procedures should be in place until their unaided performance is assessed as satisfactory.
- When a controller is dealing with an abnormal situation, e.g. an aircraft emergency or very high-density traffic, the enlistment of any off-duty controllers to assist can be an important safety net.
Accidents & Incidents
Events in the SKYbrary database which include Ineffective Monitoring as a contributory factor:
On 3 November 2019, a Boeing 787-8 descending towards Barcelona experienced an unanticipated airspeed increase and the unduly abrupt manual pitch response which resulted in a large and rapid oscillation in vertical acceleration during an otherwise smooth descent resulted in two serious injuries, one to a passenger and the other to one of the cabin crew.
It appeared that the cause of the airspeed increase was an unexplained vertical mode reversion from VNAV SPD to VNAV PTH about 20 seconds before the upset caused by the response to it.
On 22 August 2019, a Boeing 737-800 positioning visually from downwind after accepting clearance to approach and landing on runway 03L at Hyakuri instead lined up on temporarily closed runway 03R and did not commence a go-around until around 100 feet agl after seeing a vehicle on the runway and the painted runway threshold identification.
The Investigation concluded that the event was solely attributable to the individually poor performance of both the Captain and the First Officer, the latter in respect of a failure to monitor and correct the runway identification error made by the Captain.
On 3 March 2021, a Boeing 737-800 departing Lisbon only just became airborne before the end of runway 21 and was likely to have overrun the runway in the event of a high-speed rejected takeoff.
After a significant reporting delay, the Investigation established that both pilots had calculated takeoff performance using the full runway length and then performed takeoff from an intersection after failing to identify their error before FMS entry or increase thrust to TOGA as the runway end was close.
This was the aircraft operator’s third almost identical event at Lisbon in less than five months.
On 2 March 2018, a Cessna 441 conducting a single-pilot scheduled passenger flight to Broome suffered successive failures of both engines due to fuel exhaustion, and a MAYDAY was declared.
Unable to reach the destination or any other aerodrome by the time this occurred, an uneventful landing was made on the area’s main highway.
The Investigation found that the fuel quantity was over-reading due to water in the fuel tanks, that cross-checking of fuel used versus indicated fuel in tanks was not done, and that when the possibility of fuel exhaustion was first indicated, an available diversion was not made.
On 16 July 2020, an Antonov AN26 on which a new Captain’s final line check was being performed made two consecutive non-precision approaches to Runway 33 at Birmingham both of which resulted in ATC instructing the aircraft to go around because of failure to follow the prescribed vertical profile.
A third approach using the ILS procedure for runway 15 was successful. On the limited evidence available, the Investigation was unable to explain the inability to safely perform the attempted two non-precision approaches to runway 33 or the continuation of them until instructed to go around by ATC.
Further Reading
- Checklists and Monitoring in the Cockpit: Why Crucial Defenses Sometimes Fail, July 2010
- A Practical Guide for Improving Flight Path Monitoring, November 2011
UK CAA
- Monitoring Matters: Guidance on the development of Pilot Monitoring Skills, CAA Paper 2013/02.
Flight Safety Foundation ALAR Briefing Notes:
- No. 1.3 – Golden Rules
- No. 1.4 – Standard Calls
- No. 1.5 – Normal Checklists
- No. 1.6 – Approach Briefing
- No. 2.1 – Human Factors
- No. 2.2 – Crew Resource Management
- No. 2.3 – Pilot-Controller Communications
Read more:
Automatic Dependent Surveillance-Broadcast (ADS-B)