In such a diverse safety-critical workplace, it is inevitable that the challenge of differences in opinion, behavior, perceptions, and training methodology to name a few, will all contribute to the decision making process in a Multi-Crew environment. These decisions may be mutual and agreed upon, controversially, they may cause disagreement between crews or other staff concerned, and if this typical situation is not addressed in the correct manor, using a structured, industry recognized approach, the result has all the potential to create disastrous consequences. My idea of this blog is to give a bit of background information, and outline various aspects of CRM and Multi-Crew before sharing my experience of my course at SIMTECH AVIATION in a later blog.
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| DA42 Twinstar, Flight Training, CTC Wings Take-Off |
Approximately, 75% of aircraft accidents involve Human Factor elements or CRM breakdown. To just stop and think of how significantly the flying machines of today have advanced, involving the complexity of electrical, hydraulic, fuel, pneumatic and automation systems, that are all highly sophisticated in their own right, and the main cause of accidents in the present day is not down to 'Technical Issues' but the Human Beings flying them, who have themselves gone through highly sophisticated and demanding flight training courses to enable them with a 'Professional Pilot's Licence' is shocking. I state 'automation' in bold as I think it is important to highlight that such a fundamental system in present day operations, the 'Central Nervous System' in control of the aircraft, is not the main cause of accidents, it is related to the crews controlling the automation. Aircraft Automation is much worthy of a totally separate blog, so I don't want to digress away from how it is concerned with CRM. The automation (otherwise known as the 'virtual crew member'), is of vital importance, especially when dealing with an abnormal demanding situation where you need to use Multi-Crew skills and Crew Resource Management to their maximum efficiency. Although it is naturally perceived that the Auto-Pilot reduces pilot workload, surprisingly, it can actually lead to increased workload, as in effect, you have another crew member to monitor, one which can be subject to producing latent errors which if go unnoticed can quite easily short change the crews original idea of 'reducing workload'!
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| During the cruise, B757 Flight Deck |
'Auto-Pilot is a cue to wake-up, not the other way around'!
A common misunderstanding is that when you join the small minority of the population who hold a Frozen Airline Transport Pilot Licence, (less than 1500 hours total time plus a few other things), you have been trained to act as Single Pilot In Command, the sole manipulator of an aircraft's controls. Therefore, to fly for one of the majority of airline operators and their associated anti-gravity machines of the present day that demands more than one flight crew, there is a requirement to complete a Multi-Crew Co-operation and in association, Crew Resource Management Course. The Multi-Crew concept basically implies that there is more than one of you working towards a common goal, another colleague whose presence and input on how to achieve the task in hand must be acknowledged and considered during both normal and abnormal eventualities. This essential transition from Single Pilot to Multi-Crew combined with Crew Resource Management knowledge has all the potential to significantly reduce accidents and incidents occurring within the Aviation Industry.
I read some time ago one of many interesting articles by Lembit Opik on the subject of Multi-Crew Co-operation....for Beginners. To give an overview of Lembit's experience, the day started with what is usually a routine familiar journey for most General Aviation Pilot's, to your home airfield however, in Lembit's case, his 'non standard' journey to Sleap Airfield where his trustworthy Mooney awaited for him, involved a ride in a brand new Aston Martin Vantage S, driven by one of the world's most accomplished drummers of the progressive rock band, 'Emersonm Lake and Palmer' with the intention of being Lembit's passenger for the short leisurely flight that day. Mr Palmer's response to being asked if he had ever flown 'upfront' before appeared to take Lembit by suprise (and no doubt most readers of Flight Training News). His answer to such a rhetorical question didn't just stop at 'yes', as Mr Palmer went on to reveal he flies Airbus A340's for Virgin Atlantic! Pre flight, the usual rituals of flight planning were assessed and analysed but this time, Mr Palmer introduced even at this early stage, 'desired Crew Resource Management behavior' by becoming familiar with, and discussing vital speeds and various other details, including an in-depth assessment of the Mooney's systems and airworthiness. Before even leaving the planning room, the threats had been assessed, and the error management had been considered, limiting and mitigating any possible error that could be avoided.
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| Virgin Atlantic 747 taxiing out of Manchester to 05L |
After the power checks had been completed at the hold for runway 23, just prior to take-off, a 'low voltage' light appeared accompanied by the battery showing a negative charge of 8 amps. After clearing the runway returning to the hold, Mr Palmer (assisting passenger), 'did something obvious', that Lembit said he wouldn't have done at all, and referred to the aircraft manual for the procedure to be carried out, an action taken by commercial pilot's on without doubt, a daily basis for various abnormalities that may arise.
'The manual exists for a reason - Use It'
Second time round, they both successfully became airborne without eventuality until 200ft that is....where the low voltage light returned after retracting the undercarriage. ''I'll do diagnostics and radio, you fly the aircraft" said Mr Palmer. Delegation of tasks for maximum efficiency, with clear, concise and timely instructions turned this 'slight' eventuality into a manageable one and after they managed to extend the undercarriage electrically, they made it safely back to terra firma, where the atmosphere remained calm with no panic or crisis. This is a classic piece on this subject that can be found in Flight Training News, Issue 294, July 2013 by Lembit Opik.
Even with more than 99% less passengers than an A340, Mr Palmer's approach of bringing the 6 letters, CRM and MCC to the table, rewarded them with a landing they both could walk away from. The CRM dealt with the utilization of all available resources in the most efficient effective way to find a solution. The MCC dealt with the sharing and delegation of tasks, using effective communication to share a common understanding of the task in hand. The pre-flight preparation dealt with well, being prepared and 'familiar' with aircraft speeds and operating procedures to free up mental capacity that can be used to deal with anything that decides to be 'unforgiving' on the day of flight. As Lembit said, there was no worry of thunderstorms closing in, or air displays in the vicinity, because simply, they had checked.
If I was to be asked to define 'Crew Resource Management', in support of everything I have so far talked about, I would expand upon the 6 core practical ingredients that we inherited and continuously demonstrated on our MCC & JOC course at SIMTECH AVIATION. These are:
Communications
Decision-Making
Leadership/Teamwork/Crew Co-ordination
Situational Awareness
Workload Management
Threat And Error Management
Threat And Error Management
Threats are countered by applying desired CRM behaviors which help to avoid and mitigate any potential errors.
Why would any Private Pilot on the journey to becoming a Professional Pilot not want to become familiar and demonstrate these desired behaviors even in their early stages of training or hour building? Simply 'because it is not an obligation' is not a wise thought process. By putting this invaluable theory into practice during every flight you make, will give you plenty of ammunition not just towards airline interview questions that encompass the subject, but more importantly, one day, may prevent all the 7 layers of Swiss Cheese from aligning and causing a fatal accident within the General Aviation Industry.
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| PA28 Cherokee - Checkout at Liverpool |
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| Multi-Crew in Practice, en-route to East Grand Canyon, USA |
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| 10,600ft displayed on our 3-point barometric altimeter |
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| En-route to California, San Bernardino Mountains |
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| Approaching Big Bear, California, 9,500ft in challenging terrain |
Another experience I want to share of 'my contribution' to CRM involves this time, going back to when I was flying as Cabin Crew, an event that occurred during the final approach stage into Glasgow on a 323 seat Airbus A330-200, with myself being 'Cabin Secured and Crew Seated' at door L3 (Approximately 45metres/147ft away from the cockpit)! It was then, I noticed a shallow fine mist emerging from the overhead lockers throughout the rear of the A330's cabin, that was persistent and becoming noticeable to passengers. Signalling to my colleague at the opposite door (R3) for their opinion matched mine....CONCERN! My first and only thought at this point was a fire in it's early stage. The mist was increasingly filling up the cabin, and although didn't resemble the usual dense breathtaking smoke from a fire, I was not to assume anything. Now my options at this time, alongside re-assuring passengers it would be safer to remain seated coming into land, than run up and down the cabin in a state of panic, were to inform the Senior, inform the flight crew, get up and investigate (not wise) or stay seated and mentally rehearse in my mind the appropriate action and drills to be taken if this were to develop into an evacuation on the ground! I decided upon the latter but in addition, I knew there was also 1 extra crew member in the flight deck that was able to answer the inter phone at such a critical stage of flight. Matching my tone and rate of speech to give a true representation of the situation which at this point was not an emergency, I informed the additional flight crew member so they could be situationally aware and prepared should an emergency develop, but also, a scenario that undoubtedly would have had an effect on a go-around decision and where to vacate the runway as quick as possible. Upon vacating the runway, the additional crew member came to take a look, which by this time, the smoke had seemed to disperse but still a sense of erryness among the cabin remained. The outcome....well one I was assured not to be embarrassed about in the slightest, that it was actually a common thing on this particular aircraft, that when the outflow valves begin to open and the cabin starts to de-pressurize below a certain altitude, the air conditioning and pressurization packs emit this familiar mist! (Well familiar to all those who have most likely done the same as me) however, I must emphasize, that in this specific case and many others, being 'familiar' can also be deceitful....
We call it environmental capture; carrying out a certain task very frequently or becoming 'too' familiar of a normality (like in my example) which can easily result in selecting the incorrect course of action or incorrectly diagnosing something. This could then lead on to confirmation bias; looking for information to 'confirm' your understanding whilst ignoring evidence to to the contrary. These both play a major part concerning the Human Factors involved with CRM.
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| Wing View from a B757 during Cabin Crew days |
For example, 'environmental capture' and 'confirmation bias' contributed to the fatal night of the Kegworth disaster. The combination of heavy engine vibration, noise, shuddering and associated smell of fire lead the captain to believe the right engine was malfunctioning due to the smell of smoke in the cockpit because in previous 737 variants, the 'bleed air' (air taken from the engine for the air conditioning), was taken from the right engine and also because the right engine fire warning light was flashing however, the aircraft the crew were flying on this particular night was a different variant of the 737, a 737-400, and Boeing had re-designed the system to use bleed air from both the engines, proving the captains assumption to be fatal as the fire was actually in the left engine. As the right engine was throttled back (assimilating the indications on the engine instrument display), coincidentally, the left engine surges and vibrations reduced, convincing them into confirmation bias, that they had selected the correct engine to shut down. As we know, this was not the correct case and even though several cabin staff and passengers had noticed unburnt fuel igniting in the left engine, they failed to inform the pilots as they all assumed that the pilots were aware of a problem with the left engine. Shutting down the wrong engine resulted in 47 fatalities that could have been avoided through CRM in practice. Having knowledge of this disaster alone was enough to take the action I did whilst I was cabin crew and alert the Flight Crew of what was occurring 45 meters behind them, no matter how minor or irrelevant you deem the situation to be!
'60% of all human communication is non-verbal, (body language), 30% is your tone, which means 90% of what your saying ain't coming out your mouth' (Will Smith)
This bold statement just demonstrates how important our communication within CRM really is, especially in such an environment that deprives us of at least 60% of what we are trying to say!
The aviation industry will never stop learning with ways to enhance the safety, by creating systems that are better able to tolerate the occurrence of any errors associated with such a complex form of travel. The industry has proven to take previous accidents involving among other contributors, the break down (or non-existence) of CRM and Human Factors into deep contemplation and in result, emphasizing and mandating for all the airline crews of the present and future, the vital importance of Crew Resource Management in a Multi-Crew Environment. We never stop learning in our industry, in addition, we should never ever reach the point of thinking we have learnt everything about aviation....
'Once you think you have learnt everything about aviation, stop as its that that will kill you'
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| Approach at Sunset, Bournemouth, during CTC Flight Training |
A sad truth is that the most useful knowledge we inherit in order to develop safety even further, arises from previous devastating accidents. The most significant that come to my mind include:
Eastern Airlines, 1972
A L-1011 Tristar crashed into the Everglades, Miami, as the crew became distracted from a faulty nose gear warning light. Failure to delegate duties lead to the flight path being un-monitored and in result, 101 fatalities.
Tenerife Disaster, 1977
A collision of a KLM 747 and a Pan Am 747 on the runway due to the KLM commencing take-off role in dense fog without clearance due to a misunderstanding and mix up of communications, leading to 335 fatalities.
Air France 447, 2009
Flight Crews utterly failing to engage in CRM, with no co-operation, unclear who is responsible for what or even who is doing what, lead to a fatal deep stall from an approximate 35000ft, causing fatalities to all 228 on board.
United Airlines, 1978
A Douglas DC-8 was making an approach into Portland, when a landing gear abnormality arose. The captain decided to enter a holding pattern to try fix the problem. Focusing on the landing gear problem for over an hour, whilst ignoring repeated hints from his First Officer and Flight Engineer about there fuel state. When the engines started to flame out, it was too late, resulting in the aircraft crashing in a wooded suburb, with the deaths of 2 flight crew and 8 passengers.
'We must have respect for the ones who have gone before us, especially when they have given us the privilege of learning from their mistakes'
By PianoPilot
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