The Birth of CRM?

I’ve just finished reading “The Wright Brothers”, a definitive study of the aviation pioneers by David McCullough. Very appropriate too, with man’s first self sustained flight on 17th December 1903 being remembered soon.

Its a great read with vast reference material, illuminating the brothers’ relationships with their siblings and parents, taking you from their childhood through to Orville’s death in 1948.

One aspect, which fascinated me, was their intense attention to detail. Nothing was left to chance and every aspect of their work was carefully studied, crafted, tested and rebuilt. At an early stage they realised that the figures and formulas they’ve used from the Smithsonian and revered aeronautical fundis of the time like Otto Lilienthal and Octave Chanute were pure speculation and simply wrong, so they worked out their own. In fact they built their own wind tunnel to test and verify their wing designs.

This research took years – trekking between their home in Dayton, Ohio to the windswept Outer Banks of North Carolina, first with gliders and finally with the engine built to their specs by Charlie Taylor.

wright-bros5

Crumpled glider, wrecked by the wind, 10th October 1900.

The brothers had a number of close shaves – one could hardly expect every new attempt at achieving what many believed was the delusional dream of a few madmen to go off without any problems.

But throughout their persistent experimenting, they remained patient and constantly erred on the conservative side.

In fact – it struck me that, although unbeknownst to them, they were adhering to the basic tenets of CRM:
1. Plan and Operate (Prevent and Avoid).
2. Detect and Correct (Monitor and Challenge).
3. React and Recover (Mitigate the Consequences).

While Wilbur was in France to demonstrate the “Flyer” (with great success), he received a letter from his father, the Bishop Milton Wright, urging him to “avoid all unnecessary personal risk”. At the same time Wilbur wrote to Orville, who was then about to demonstrate the “Flyer” to the US military at Fort Myer, Virginia:

“I tell them plainly that I intend for the present to experiment only under the most favorable conditions…I advise you most earnestly to stick to calms, till after you are sure of yourself. Don’t go out even for all the officers of the government unless you would go equally if they were absent. Do not let yourself be forced into doing anything before you are ready. Be very cautious and proceed slowly in attempting flights in the middle of the day when wind gusts are frequent…Do not let people talk to you all day and all night. It will wear you out, before you are ready for real business. Courtesy has limits. If necessary appoint some hour in the daytime and refuse absolutely to receive visitors even for a minute at other times. Do not receive anyone after 8 o’clock at night”.

He then discussed some technical details about the rudder, concluding with:

“I can only say be extraordinarily cautious”.

Here was an aviator who understood the danger of weather conditions, the threat of external pressure and distraction, as well as the disabling power of fatigue.

Apparently Orville heeded his brother’s advice and the first two weeks of the demonstration flights went off well. But on the 17th September 1908 a blade of the right hand prop cracked and broke off, vibrating enough to break a stay wire which had supported the rear rudder system. This rendered the aircraft uncontrollable and Orville crashed. He was severely injured and his passenger, Lt. Thomas Selfridge became the first fatality of powered flight.

wright-bros4

The wreck of Orville’s crashed aircraft at Fort Myer.

Wilbur was at his shed at Camp d’Auvoirs, Le Mans on the 18th September when he received the news of Orville’s crash. This led to another profound CRM statement:

“Now you understand why I always felt that I should be in America with Orville. Two heads are better than one to examine the machine”.

Erring on the side of caution was one of the Wright Brothers’ enduring qualities. They understood that risk was inevitable once one decided to become airborne – but they believed in well calculated risks.

With 2016 about to become history, perhaps it is time to once again reflect on how far we’ve come since the dawn of powered flight at Kill Devil Hill, Kitty Hawk. I certainly do when I cruise in air conditioned comfort at high altitudes and Mach numbers.

Perhaps it is also time to realise that we disregard many of the lessons learnt by those pioneers of flight at our own peril. Rather let us take a leaf out of the Wright’s book and “be extraordinarily cautious”.

Here’s wishing everyone bon voyage and safe flights in 2017!

 

 

 

 

 

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The Law is an Ass

If the law supposes that,” said Mr. Bumble, squeezing his hat emphatically in both hands, “the law is a ass — a idiot.”
 – Charles Dickens: Oliver Twist –

It would appear that a number of pilots would agree with Mr Bumble (perhaps not in as much as they are unhappy spouses of domineering wives – as Mr Bumble was), but feeling that some laws are applied contrary to common sense.

I find it interesting that the application of law should actually require lawyers, people schooled in law, who could stand in court and argue totally divergent points of view on how the same law should be applied. Often the stated law is interpreted on the intent of the law – clearly an indication that the law is poorly drafted.

Undergrad law students learn that the four principal purposes and functions of the law are establishing standards, maintaining order, resolving disputes, and protecting liberties and rights. The law should be a guidepost for minimally acceptable behaviour in society.

So it should be simple to apply the law, but experience has shown that serial criminals could be absolved and innocent people could become victims of those laws, which should actually protect them. Sometimes the application of the law defies any common sense – perhaps one has to agree with Mr Bumble…

As pilots, we also have to deal with a plethora of laws. While subject to the laws of the land, we are also subject to the various laws as set out in the subdivisions of the Aviation Act. (I’m referring to the South African situation).

The Civil Aviation Technical Standards (CATS) and the Civil Aviation Regulations (CARS) with their many Parts apply in various stages to everything we do in, with and around our aircraft.

In effect, these aviation laws are an extension of the laws of the land and international law setting the guidelines for minimally acceptable behaviour in our society  – and aviation in particular. (We’re back to Law 101 now).

The aviation laws are clear – the interpretation of some laws are perhaps debatable – but the very basic aim is to ensure safety.

However, the laws of nature leave very little space for argument: Newton’s apple will eventually have to succumb to gravity.

Yet we hear daily of pilots defying the laws of nature: overloading aircraft, disregarding density altitudes, flying into adverse weather conditions – the list goes on and on…

Add to this the tendency to feel that “the law is an ass – it doesn’t apply to me, in fact it only applies to others…”.

Here it is instructive to note that in a study overseen by the FAA in an attempt to discover what would make a pilot “accident prone”, they found five common traits in pilots who were prone to having accidents:

  1.  Disdain toward rules.
  2.  High correlation between accidents in their flying records and safety violations in their driving records.
  3. Frequently falling into the personality category of “thrill and adventure seeking”.
  4. Impulsive rather than methodical and disciplined in information gathering and in the speed and selection of actions taken.
  5. Disregard for or under-utilization of outside sources of information, including copilots, flight attendants, flight service personnel, flight instructors and air traffic controllers.

The first trait is probably the most illuminating.

This week I encountered the argument that the skies should be free and that recreational pilots should be left to self-regulate.

I’m afraid that this argument only strengthens the FAA’s first trait of accident prone pilots (above).

The skies would only be “free” if you were the only aircraft around (disregarding your legal obligations to those on the ground and to society), but as soon as two aircraft share the same airspace, some rules need to be applied: Who has right of way, direction of circuits, see-and-avoid, etc.

Whether you regard the law as an ass – or not, please pay heed to what well known flight instructor Rod Machado has to say about aviation law:

“Rules, regulations and SOP’s are symbolic of aviation’s accumulated wisdom. Each one is a historical whisper of errors made, planes lost and limits challenged. Herein lie the posthumous tokens of aviation’s best lessons. They linguistically map out aviation’s hazardous territory. To operate beyond these areas is to thumb our noses at the gods of probability”.

Sully the Movie – A Pilot’s Perspective

“So what did you think of the movie?”

I was immediately faced with that question as I walked out of the screening of Sully, Clint Eastwood’s film about the 2009 landing in the Hudson River, starring Tom Hanks as Captain Chesley “Sully” Sullenberger.

Well, here’s what I think:

Firstly, I thoroughly enjoyed the film for the technical accuracy of the flight and subsequent river landing with very realistic use of CGI. It had to be accurate as so much of the material has already been published. The transcripts of the CVR (Cockpit Voice Recorder)  were already published in Sullenberger’s 2009 book Highest Duty – My Search for What Really Matters, which also told his life story and related the events of the day in great detail.

These CVR recordings lead me to the one aspect I did not appreciate as much – the movie has the CVR played for the first time during the public hearing, while in fact, according to Sullenberger there were only six people present in the audio lab where they first listened to it. But this would not have suited Eastwood’s whole premise for the movie. He built the dramatic edge around the NTSB ruthlessly pursuing Sullenberger and Jeff Skiles, the First Officer (very ably played by Aaron Eckhart). In Eastwood’s mind the NTSB were the bad guys, out to get the good guys – the pilots – who were assumed guilty until proven not guilty.

It bears stating here that any accident investigation by nature is uncompromising. Nothing can simply be assumed and every detail has to be interrogated to arrive at a definitive answer. The objective is not to apportion blame, but to learn and make recommendations to avoid similar events in future.

Sullenberger himself was very clear about the conflict in his own mind – could they possibly have made it back to La Guardia or even Teterboro? Here his whole career of over forty years would be judged on 208 seconds and one decision. I could clearly identify with this self-doubt, something we as professional pilots know well. There is always the nagging worry that something could have been handled better, it is the perfectionist nature of our occupation.

Hanks captures the gravitas of Sullenberger in this situation perfectly. He has proved before that he can deliver empathetic portrayals of men in difficult situations (Apollo 13, Captain Phillips), balancing human frailty with steely resolve.

Sully is a great movie, which caters for a general movie audience who would simply enjoy a rollicking drama of good people conquering adversity. Yet it still satisfies those aviators, who have more than just a passing interest in the dramatic events of January 15th, 2009.

Hopefully the movie will also allow a glimpse into how seriously professional pilots take their occupation – Hanks’s Sullenberger provides the ideal example. His one decision on that day led to 155 souls surviving a dual engine failure and a subsequent forced water landing – pilots daily make hundreds of decisions with less dramatic impact, but which directly affects the lives of passengers worldwide.

Go and see the movie!

 

 

Royal Aeronautical Society | Insight Blog | Lives before luggage

I have posted a number of blogs regarding passengers’ apparent disregard for their own safety. As valuable additional reading, here is an insightful blog about evacuations from the RAeS:

During the recent emergency evacuation of the Emirates 777 which caught fire in Dubai, a number of passengers endangered their safety and those of others by stopping to collect their luggage. BILL READ FRAeS looks at some of the ideas being proposed to prevent such actions reoccurring and how it may be time for a rethink of the regulations governing aircraft emergency evacuations.

Source: Royal Aeronautical Society | Insight Blog | Lives before luggage

Leave Everything Behind! (Exit before Tweeting…)

Yesterday we witnessed the crash of an Emirates B773 at Dubai. I use the word “witnessed” as we may just as well have been eyewitnesses, what with visuals instantly available on the major TV channels, uploaded from social media. Had it happened a few years ago, we would simply not have had access to these dramatic visuals captured by actual eyewitnesses.

(See my previous blogs on the emergency and social media aspects of this phenomenon: Evacuate! Evacuate! Are you ready? and Beware the Jabberwock, my son! ).

What I find disturbing though, are the visuals recorded by passengers during the actual evacuation of EK521, with a life-threatening emergency in full swing:
Pax Evacuation EK521

During many previous aircraft emergencies we’ve witnessed this behaviour before: Cell’phones on, visuals recorded and instantly shared on social media. Allow me to be blunt: This type of behaviour deserves a Darwin Award for Deadly Stupidity!

It would appear that in aviation we’re not alone in this:

1013_in-case-of-fire-exit-building-before-tweeting-about-it_543-720

Pic: socialsmiling.com

 

So what allows us to exhibit this kind of stupidity? What level of intelligence would allow a normally stable individual to jeopardize not only his/her own life, but the lives of others as well?

I can only assume that it is the same level of intelligence which would allow passengers to blatantly disregard the safety regulations, ignore safety briefings and refuse to obey lawful instructions regarding electronic devices.

The bottom line is that anything which could distract one during an emergency should be avoided at all costs – hence the announcement by cabin crew regarding no cell’phones or headphones before departure or arrival. When the fire is at your heels and the smoke is choking you, that is not the time to worry about your branded hand luggage or your personal effects – that is when saving lives should be your one and only concern.

I know that passenger safety is our single-minded concern. As professional air crew we’ll do everything possible to ensure that, but passengers also have a role to play in their own safety!

However, it would appear that any commonsense, reason and responsibility is zipped up and stowed in the luggage when passengers check in….

 

 

Legal, Safe or Wise?

Whenever an aircraft goes down, pilots immediately want to know “what went wrong?”

If the aircraft involved is similar to the type you happen to fly, the interest in possible causes takes on an even more personal imperative. The recent crash of the FlyDubai B738 at Rostov-on Don, Russia lead to much speculation – and as I fly the B738, I obviously took a personal interest in the crash.

The recent interim report by the Russian Authorities provides some insights into the situation leading up to the crash. This preliminary report clearly states that, in accordance with ICAO standards and practices its sole objective is to prevent aviation accidents and no blame or liability is apportioned. The Flight Data Recorder and Cockpit Voice Recorder are still being interpreted and that information will undoubtedly provide further insights into the factors involved.

What is insightful is the final paragraph, which reads:
“For the purpose of preventive measures the investigative team recommends to:”
And then adds 5 recommendations, all relating to the same issue – here summarised in their para.2: “Have additional training on elements of go-arounds in various conditions, in manual control mode with two engines operative from various heights and with insignificant flight weights”.

They also refer to the 2013 B735 crash at Kazan and the 2006 A320 crash near Sochi, stating that the safety recommendations issued by the investigation teams should be “repeatedly studied and analyzed”.

It would thus appear that, at this early stage no malfunctions are reported and that the second go-around ended in a loss of control situation. This led the investigative team to feel that they needed to publish immediate recommendations regarding training.

Just looking at the facts presented: There were 7 crew members and 55 passengers on board, which makes for a very light aircraft. Take-off weight is given as 68 tons. Just doing the simple maths, I would reckon that they had a zero-fuel weight of anywhere between 50 – 55 tons, depending on whether any freight was carried. That would mean that they could have carried anywhere between 13 to 18 tons of fuel. The report does not indicate how much they had, but they flew for just over four hours, made an approach and went around, then held for just over 1 hour and 40 minutes before requesting a second approach. Just using raw numbers, calculating conservatively they had probably used around 12 tons of fuel by then.

So on the second go-around the aircraft would have been very light and at TOGA thrust it would have climbed very rapidly – as indeed indicated in the report.

Both approaches were manually flown using the HUD system. FlyDubai’s B738 airframes are apparently not certified for dual channel approaches and auto-lands, so this would have been according to their SOP’s. (A number of operators prefer this option, probably because of the lower costs associated – pure speculation on my part).

Importantly though, the report states that both approaches were flown “without significant heading or altitude deviations” – in other words, these were well flown approaches.

So it appears to be the go-around that went wrong – and from a Human Factors perspective I would await the final report and CVR analysis with great interest.

I have no idea how long the crew had been on duty, but they had clearly flown for more than 5.5 hours at that stage and were conducting the second approach well after midnight. The report uses Z time, but the local time was just before 04h00. Needless to say, as we know from dire experience – humans are diurnal beings and we do not perform well nocturnally.

Neither do we perform well when tired or fatigued. I have just recently presented a CRM workshop at ICEM 2016 and the emergency medical fraternity were extremely aware of the dangers when humans are tasked to perform in demanding situations while fatigued.

While the preliminary report suggests that training for go-around manoeuvres is required, I sincerely hope that the CRM aspects will be thoroughly investigated when the final report is published.

My own experience in airline operations is that what may be completely legal may not necessarily be safe – nor wise.

 

 

 

 

 

Beware the Jabberwock, my son!

“It seems very pretty,” she said when she had finished it, “but it’s rather hard to understand!” (You see she didn’t like to confess, even to herself, that she couldn’t make it out at all.)
– From Through the Looking Glass and what Alice found There, by Lewis Carroll.

Earlier today I had a discussion with a journalist regarding a TV programme about decompression events in aircraft, for which he had done the research. This leads me to my blog’s musings for today: What influence does the crew have on passengers’ experience and their recollections after an incident? We’re not discussing serious accidents here, only the run-of-the-mill events such as go-arounds, diversions, technical problems and, yes – pressurisation problems.

“This is your captain speaking…”

You would hear these words on almost every commercial flight. It is probably the most quoted sentence when passengers discuss their experiences in the air. Yet very few people would be able to tell you what the captain, or the cabin crew for that matter, had actually said. Not always because the announcements sounded like some comedian’s rip off – simply because people do not pay attention.

I’ve discussed passengers’ behaviour during emergencies before (see my previous post Evacuate, Evacuate! Are you ready?) as well as the power of the media in Good News vs Bad News.

What concerns me here is the widely disparate perceptions passengers report after an incident. “Report” is the correct verb here – anyone with a cellphone becomes an instant reporter and social media allow immediate “reports” on events as they unfold.

Unfortunately, most passengers are not experts in matters aviation and, much like Alice we don’t want to confess that we simply have not the faintest idea of what is happening, has just happened or had happened. However, cellphones allow us to become instant and expert commentators.

Phrases such as “near death experience”, “hysterical cabin crew” or “terrified passengers” abound. Snippets of accurate, factual information are few and far between. “Facts” often prove to be completely wrong perceptions – in one recent event a passenger commented that “the person who tweeted this could not have been on the same aircraft!”.

The dangerous reality is that a perfectly safe airline can have its reputation in tatters and face bankruptcy as a result of 140 instant characters.

Most airlines, like most businesses have an online presence and a department dedicated to following social media. They hope to catch the complaints and negative comments, attempting to counter them – essentially damage control. Unfortunately modern humans have an incredibly short attention span and by the time your positive reply hits social media, we are already onto the next 140 characters of interest.

During the QF32 emergency social media declared that the A380 had crashed, even while Captain De Crespigny and his crew were working the problem and getting their passengers back safely. Fortunately the hysteria calmed down once the facts became clear.

Have a look at this YouTube Video clip from News24:

Despite the headline, I think the passengers do not look too concerned – very few are wearing their oxygen masks, most have the time and presence of mind to turn their cellphones on to film the goings-on.  (Just joking – they were on anyway…) There is the sound of a baby crying, understandable as infants cannot equalise quickly and their ears would hurt with any pressure differential.

So where did the reports of “terrified” passengers originate?

Other social media reports indicated trauma and high drama – clearly not everyone was as composed as the people visible in this clip. I saw reports of “oxygen not flowing” – probably from those who forgot the briefing to give a tug to start it flowing.

Which brings me to the role of the crew – all professionals, all trained to deal with these situations. However, although most airlines would provide standard announcements for various events – some pilots and cabin crew are simply better able to communicate and calm frayed nerves.

When United 232 lost all hydraulics and all controls when the no. 2 engine failed catastrophically over Iowa, passengers spoke afterwards about Captain Al Haynes being “firm, but soothing” while informing them via the PA system.

Similar complimentary comments were made about the way the crew of QF32 handled the PA announcements.

QF32 Fire engines

QF 32  (Pic: criticaluncertainties.com)

As pilots we make decisions in difficult situations based on the old A-N-C acronym – Aviate, Navigate, Communicate. Our primary task is to fly the aircraft, whatever the situation. Once the flight path is under control, we need to fly it somewhere – the navigate bit – whether it be to a diversion airfield or to a ditching. Then we tell people what we are doing – ATC, our crew, and when time allows, our passengers.

It would appear that we should improve that last little bit – keeping passengers informed and comforted could avoid most of the negative and destructive social media rants.

In fact, after Captain De Crespigny had debriefed the passengers of QF32, TV crews were eager to record the dramatic stories of survival which these passengers surely had to tell – to their dismay, most of the passengers had no complaints and only praise for the crew.

Pilots train exhaustively for any possible mishap. Dealing with incidents and problems is the easy part  – how you address the passengers when they feel like Alice is a major challenge. However, allowing them to make sense of our “inverted world”, reading in reverse in the mirror could allow them to slay their Jabberwocks and turn the negative experiences and comments into compliments.