Aviation Safety Connection
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Cockpit Concepts: January 2015
Once Again, CRM.
The TV golf season has begun and it is interesting to observe the interaction of these skilled players with their caddies. They discuss the risks/rewards associated with each upcoming shot by assessing wind and weather conditions, past experiences and any number of other factors. The player is clearly in charge but the caddy has a great deal of influence as mutual trust is developed. A positive relationship depends on pre-round preparation and briefing as well as developing alternative strategies. These teams often stay together throughout the season.
Contrast today’s familiar scene with the way the irascible Julius Boros dealt with his caddies. As a highly skilled and successful golfer from an earlier era—Boros won three majors including two U.S. Opens—he had an entirely different on-course relationship. His instructions were simple and direct: “Hand me the club I ask for and keep your mouth shut!”
Two different types of “CRM” on the golf course. I suspect that Mr. Boros prepared himself well for every tournament and was extremely confident in his ability, but the golfer today more than likely gets an extra edge from being able to call on a reliable resource for confirmation and support.
So much for golf. Let’s look again at cockpit CRM, a topic on this forum on many occasions. Two recent tragic, fatal accidents point to the need to weave CRM into daily flight operations. The need for advancing cockpit leadership attributes in both positions and predefining the role of each crewmember and their related task assignments is fundamental. In both cases there were numerous opportunities for either pilot to take initiatives to improve the safety of the flight.
Flight 81, a Hawker Beechcraft 100A, was a nonscheduled passenger flight from NJ to MN in 2008.1 It crashed after attempting a go-around after touchdown and all aboard perished, six passengers and crew of two. This accident was the subject of last month’s SMS Perspectives because of the organizational issues involved but, nonetheless, there were flight crew failures of omission and decision making. While it can be argued that these stemmed from inadequate operational procedures and training, in situations where appropriate organization standards are lacking pilots must be prepared to step up and provide the personal leadership their situation demands and be loyal to their own personal codes of conduct. This SMS Perspectives can be read in the Flight Line section of our website and also by following this link: http://aviation.org/linkedin/sms1412.asp.
Consider also a private Part 91 fight in a Beechcraft 390 Premier (Premier IA). The cockpit crew of two pilots was not bound by any CRM regulations but, as events demonstrate, good cockpit management practices are always desirable. In February 2013 this aircraft was transporting a medical team from Nashville, TN to their home base in Thomson, GA. “During the flight, the copilot reminded the pilot about a speed restriction and also . . . to adjust his altimeter.”2 In response to this second reminder the pilot stated, “Say, I’m kinda out of the loop or something. I don’t know what happened to me there but I appreciate you lookin’ after me there.”3 The flight was otherwise uneventful until the landing approach when, after the landing gear was extended, the ANTI SKID FAIL message appeared and “the copilot commented on the illumination.” The pilot continued the approach; he did not respond to the copilot and did not refer to . . . the Abbreviated Pilot Checklist to address the antiskid system failure message.”
It is important to note that (1) with a faulty antiskid braking system the proper flap setting for landing is either 0 or 10 degrees and (2) the runway was of insufficient length with either of these settings with the antiskid system inoperative. However, the pilot continued the approach with Flaps30 selected. About 7 seconds after touchdown and realizing deceleration was insufficient, the pilot initiated a go-around or balked landing. The airplane lifted off near the departure end of the runway with the lift dump still extended and flaps retracting. However, this airplane is not controllable in flight with the lift dump extended. It struck a utility pole and crashed. All five passengers perished; both pilots sustained serious injuries but survived.
As reported in post-accident interviews, a different copilot who flew with this airline transport-rated pilot stated he was experienced, professional and possessed good flying skills.” Significantly, both copilots, including the accident copilot, stated they “did not have a specific role when flying with him” in this aircraft.
These two accidents are more than a failure of CRM, they illustrate that a unifying concept of cockpit management is lacking. It’s fine to tout “principles” such as coordination, communications, and monitoring, but “Where’s the Beef” (as in the sandwich commercial). What is coordinated? What is communicated and when? Roles and team responsibilities need to be understood and specific tasks assigned. Plus the labeling of the copilot as PM (Pilot Monitoring) diminishes his or her role in the conduct of safe flight. The second in command must do much more, including assuming a leadership position when one is required.
--Bob Jenney (firstname.lastname@example.org)
1NTSB/AAR-11/01 accident report.
2Quotes are from NTSB ERA13MA139 accident report.
3The possibility of pilot fatigue is mentioned in the report.