Culture & air crashes3

AIR INDIA and CRM

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March 2011

Human Factors Teamwork Communication Workload Management & automation Decision Making & Leadership Situational Awareness Fatigue

Threat & Error Management CRM LOFT

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Direct Causes: Mangalore AIX crashThe Court of Inquiry determines that the cause of this accident was Captain’s failure to discontinue the ‘unstabilised approach’ and his persistence in continuing with the landing, despite three calls from the First Officer to ‘go around’ and a number of warnings from EGPWS.

Contributing Factors to the Accident-In spite of availability of adequate rest period prior to theflight, the Captain was in prolonged sleep during flight, which could have led to sleep inertia. As a result of relatively short period of time between his awakening and the approach, it possibly led to impaired judgment. This aspect might have got accentuated while flying in the Window of Circadian Low (WOCL). In the absence of Mangalore Area Control Radar (MSSR), due to unserviceability, the aircraft was given descent at a shorter distance on DME as compared to the normal. However, the flight crew did not plan the descent profile properly, resulting in remaining high on approach.- Probably in view of ambiguity in various instructions empowering the ‘copilot’ to initiate a ‘go around’, the First Officer gave repeated calls to this effect, but did not take over the controls to actually discontinue the ill-fated approach.

Contributing Factors to the Accident-In spite of availability of adequate rest period prior to theflight, the Captain was in prolonged sleep during flight, which could have led to sleep inertia. As a result of relatively short period of time between his awakening and the approach, it possibly led to impaired judgment. This aspect might have got accentuated while flying in the Window of Circadian Low (WOCL). In the absence of Mangalore Area Control Radar (MSSR), due to unserviceability, the aircraft was given descent at a shorter distance on DME as compared to the normal. However, the flight crew did not plan the descent profile properly, resulting in remaining high on approach.- Probably in view of ambiguity in various instructions empowering the ‘copilot’ to initiate a ‘go around’, the First Officer gave repeated calls to this effect, but did not take over the controls to actually discontinue the ill-fated approach.

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The captain (55, Serbian, ATPL, 10,215 hours as pilot in command, 2,844 hours on type) was described by

collegues as a friendly person and ready to help the first officers with professional information. He was

"assertive" and tended to indicate he was always right.

The first officer (40, Indian, ATPL, 3,620 hours total flying experience, 3,319 on type) was known as a man

of few words and meticulous in his adherence to standard operating procedures. He had filed a complaint

about another of the foreign captains, the company had therefore instructed rostering personnel to not pair

the two before counseling had taken place (which did not occur before the crash).

Air India Express had mandated that due to the table top runway takeoffs and landings in Mangalore had to

be flown by the captain.

The crew had performed the outbound flight IX-811 to Dubai and was to conduct flight IX-812 back to

Mangalore. Ground personnel in Dubai reported that both crew appeared normal and healthy. They had left

the aircraft and gone to the terminal building and the duty free shop during their 82 minutes turn over in

Dubai. The crew did perform all pre-departure checks according to observations by ground personnel. The

flight was to depart at 01:15 local Dubai time (21:15Z), which is 02:45 local Mangalore time and was

estimated to arrive at 06:30 local Mangalore time (01:00Z).

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Data off the flight data recorder and ATC recordings show the departure, climb and cruise of the aircraft

were uneventful.

The cockpit voice recorder featured a capacity of 125 minutes. During the first 100 minutes of the

recording there was no communication between the pilots however, all radio communication was done

by the first officer. The captain's microphone occasionally recorded sounds consistent with deep

breathing and mild snoring, at the later stages sounds of clearing the throat and coughing.

The first officer reported to Mangalore Area Control Center while overflying waypoint IGAMA at FL370

and requested radar identification at which time he was told that Mangalore's radar was out of service

(starting May 20th 2010). About 5 minutes later, about 130nm before Mangalore, the first officer

requested the type of approach to expect, was told to expect the ILS DME Arc approach to runway 24, and

requested descent. ATC denied the descent however due to procedural control available only and

instructed IX-812 to report at 80 DME on radial 287 of Mangalore's VOR MML.

About 9 minutes after reporting over IGAMA - and about 25 minutes before the overrun of the runway -

the first verbal communication ("What?") by the captain was captured by the captain's microphone.

About 13 minutes after overflying IGAMA the first officer reported 80 DME on radial 287 and was cleared

to 7000 feet, the descent commenced at 77nm from Mangalore VOR.

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While the aircraft descended through FL295 an incomplete approach briefing was carried out, no

standard approach briefing was conducted. At some stage during the descent, the actual time not

mentioned in the report, the speed brake handle was placed in the flight detent and speed brakes

deployed accordingly.

About 25nm before Mangalore the airplane was descending through FL184, still substantially above the

descent profile, when the air traffic controller cleared the aircraft to 2900 feet.

The aircraft was subsequently handed to Mangalore Tower, who requested the crew to report once

established on the 10 DME Arc. At about that time yawning was recorded by the first officer's

microphone.

After the crew reported established on the Arc ATC requested to report when established on the ILS. At

that time it is obvious the captain realised the airplane was too high on the approach. He had the gear

lowered while descending through 8500 feet, speed brakes were still extended.

The aircraft continued to be high, intercepted the localizer beam and captured the false glideslope beam

at double the correct approach angle (6 instead of 3 degrees descent). There was no cross check

between actual altitudes/heights with the descent profile provided in the approach chart conducted by

the crew.

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Flaps were extended to 40 degrees, speed brakes were still extended.

On final approach, about 2.5nm from touch down, the radar altimeter went through 2500 feet, the

first officer reacted to the aural message with "It is too high" and "runway straight down", the

captain responded "Oh my God". The captain disconnected the autopilot and increased the rate of

descent reaching about 4000 feet per minute sink rate. The first officer asked "Go Around?", to

which the captain responded "wrong loc ... localizer ... glide path". The CoI analysed that this was

indicative of the captain recognizing the error and not being incapacitated due to his subsequent

actions to correct the error. The speed brakes were stowed and armed.

The first officer called a second "Go Around! Unstabilized!", however , the first officer did not take

any further action to initiate a go-around, although company procedures required the first officer to

take control after a second call to go around not complied with by the captain.

The captain further increased the rate of descent, the speed brakes were extended again until 20

seconds before touch down.

Numerous EGPWS aural warnings ("Sink Rate!" "Pull Up!") were issued in this phase of the

approach.

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The airplane crossed the runway threshold at 200 feet AGL at a speed of 160 KIAS instead of the target 50 feet AGL at 144 KIAS and touched down about 4500 feet down the runway, bounced and touched down a second time 5200 feet down the runway with just 2800 feet of paved surface remaining. Soon after touchdown the captain selected reverse thrust, autobrakes set to level 2 operated. About 6 seconds after the brakes began operating and after the reversers were selected the captain announced "Go Around" - against Boeing standard operating procedures not permitting go-arounds after selecting reverse thrust -, the brakes pressure decreased, the thrust reversers returned to their stowed position, both thrust levers were moved fully forward, the speed brakes retracted and remained retracted, the engines accelerated to 77.5/87.5% N1. The airplane departed the paved surface, the right wing impacted the localizer antenna, the aircraft went through the airport perimeter fence, fell down a gorge, broke up in three major parts and burst into flames. No distress call was received at any time. All but 8 passengers aboard perished.The survivors, while getting up from their seats, heard and saw a number of other passengers unbuckle their seat belts, but they could not move due to the rapid spread of fire. All survivors escaped through cracks of the fuselage. 7 survivors received serious injuries, one escaped with minor injuries.Boeing later determined that if the crew had applied maximum manual braking after second touch down, the airplane would have stopped 7600 feet past the runwaythreshold meaning the aircraft would have stopped within the paved surface of the runway (8033 feet long).

Unstablised Approach

No briefing

No standardCall-outs or

deviation calls

Omit check list

High & fast

Decide to land

Runway Over run

Forget flaps

Late descent

A HIGH RISK APPROACH

High workload

Poor planning

AVIATION HAS MANY SAFETY MECHANISMS

WHICH MAY CONTAIN CERTAIN GAPS

THESE GAPS ARE CALLED THREATS, AND

ARE TRAPPED BY HAVING MULTIPLE LEVELS OF SAFETY MECHANISMS

ACCIDENTS OCCUR WHEN ALL THE GAPS IN THE DEFENCE MECHANISMS LINE UP:

THE CREWIS THE LAST LINE OF DEFENCE

We repeat the same AVOIDABLE mistakes OVER and OVER.

WHY ?

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Multiple Crew Based Operations

• Unfamiliar Crews from different backgrounds and cultures

Unusual Operating Environment:

Large network with diverse destinations- Terrain, Weather & ATC variations.• Scheduling pressures and irregular rosters• Different time zones and jet lag• Fatigue

Contributing Factors to the Accident-I- Probably in view of ambiguity in various instructions empowering the ‘copilot’ to initiate a ‘go around’, the First Officer gave repeated calls to this effect, but did not take over the controls to actually discontinue the ill-fated approach.

Modern technology has ensured reliable fail-safe hardware.

Operating Environment is now More Demanding, which

Requires Better Decision Making By Pilots

The Human Factor is now The Weakest Link

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Yourself Other pilot (s) Despatcher AME Traffic Assistant Cabin Crew Members ATC Checklists, on board documents etc

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A professional pilot uses all resources available to manage situations

CAPT – What do you say ?F/O – Yup !F/E – Is he not clear that Pan AmCAPT – Oh yes!F/O - Oh yes!

[Pan Am] B-747 Pan AmericanCAPT – Let’s get the hell out of here !F/O – Yeh, he’s anxious isn’t he.F/E – Yeh, after he held us up for an hour & a half.. Now he’s in a rushCAPT – There he is ..look at him Goddamn .. That son-of-a-bitch is coming ! Get off Get off ! Get off !

Ground collision between two 747’s after KLM crew took off without clearance. 583 Die as Jumbos hit

Captain was possessed of that double-edge sword, male egotism.

He was KLM’s chief flying instructor, a man of great prestige in the

company.

A man to be respected and trusted .

Flying with management captain is never relaxing.

The Co-pilot did not question the Captain and assumed that the

captain was always right.

That concept can, combined with factors like time pressure,

conformity and the desire to please, produce a lethal situation.

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Who is right- the co-pilot did not question the commander

( accident could have been avoided if

co-pilot had undergone- Assertive Training)

What is right: requires good

communication: the F/E was right, but over-ridden by the pilots.

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F/E – Is he not clear that Pan AmCAPT – Oh yes!F/O - Oh yes!

HUMAN FACTORS Personality and Attitudes Team Building Communication (Information Transfer) and Behaviour Workload management and use of automation Decision Making Maintaining Situational Awareness

THREAT AND ERROR MANAGEMENT

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Extract of the Court of Inquiry Report: The captain (2,844 hours on

type) was described by colleagues as a friendly person and ready to

help the first officers with professional information. He was

"assertive" and tended to indicate he was always right.

The first officer (40, Indian, ATPL, 3,620 hours total flying experience,

3,319 on type) was known as a man of few words and meticulous in

his adherence to standard operating procedures.

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CRM AT AN INDIVIDUAL LEVEL

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Personality trait Positive trait Negative Trait(Teamworkbreaks down)

Child Happy and free(leads to good teamwork)

Reacts emotionally to situations

Parent: Nurtures people(leads to good teamwork)

Can become too critical:

Adult

Unemotional focus on meeting the challenges of the situation(gets work done)

Can appear too aloof


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Desirable: Happy Free child/nurturing parent when interacting with crew : Rational Unemotional Adult when dealing with work situations

WHAT IS YOUR PERSONALITY LIKE?

Un-desirable: Angry/unhappy child/critical parent when interacting with crew or dealing with work situations


The MACHO Pilot “big talker, show off”!

The Impulsive Pilot “Do something’, quick!”

The Invulnerable Pilot “ I’m the best!”

The “Antiauthority” Pilot

The Resigned Pilot

WHAT IS YOUR HAZARDOUS ATTITUDE?

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1. Antiauthority: Don’t Tell Me! (Deviates from SOPs)

2. Impulsivity: Do something quickly (makes inadvertent errors)

3. Macho: Takes risks

4. Resignation: What’s the Use?

5. Invulnerability: It won’t happen to me!(low situational awareness)

1. Follow the Rules, They are usually Right

2. Not so fast, Think First

3. Taking Chances is foolish

4. I’m not helpless, I can make a difference. I will fight to the end.

5. It could happen to me...

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HAZARDOUS ATTITUDE- INVULNERABILITY


SUMMARY On 9th January, 1993 a TU-154 wet leased by Indian Airlines from Uzbekistan Airways was operating flight IC-840 from Hyderabad to Delhi. The aircraft was being flown by Uzbeki operating crew and there were 165 persons on board including the crew.

The aircraft touched down slightly outside the right edge of the runway, collided with some fixed installations on the ground, got airborne once again and finally touched down on kutcha ground on the right side of the runway. At this stage the right wing and the tail of the aircraft broke away and it came to rest in an inverted position. The aircraft caught fire and was destroyed. Most occupants of the aircraft escaped unhurt. The probable cause of accident has been attributed to :

"(a) The failure of the Pilot-in-Command to divert to Ahmedabad when he was informed that the RVR on runway 28 was below the minima applicable to his flight.

(b) The switching on of landing lights, at a height of only about ten metres, resulting in the loss of all visual references due to the blinding effect of light reflections from fog.

(c) The failure of Pilot-in-Command carry out a missed approa-ch when visual reference to the runway was lost.“

Discipline is controlling the feeling that you have the ability and

experience to do the job without following SOPs

SUMMARY On 9th January, 1993 a TU-154 wet leased by Indian Airlines from Uzbekistan Airways was operating flight IC-840 from Hyderabad to Delhi. The aircraft was being flown by Uzbeki operating crew and there were 165 persons on board including the crew.

The aircraft touched down slightly outside the right edge of the runway, collided with some fixed installations on the ground, got airborne once again and finally touched down on kutcha ground on the right side of the runway. At this stage the right wing and the tail of the aircraft broke away and it came to rest in an inverted position. The aircraft caught fire and was destroyed. Most occupants of the aircraft escaped unhurt. The probable cause of accident has been attributed to :

"(a) The failure of the Pilot-in-Command to divert to Ahmedabad when he was informed that the RVR on runway 28 was below the minima applicable to his flight.

(b) The switching on of landing lights, at a height of only about ten metres, resulting in the loss of all visual references due to the blinding effect of light reflections from fog.

(c) The failure of Pilot-in-Command carry out a missed approa-ch when visual reference to the runway was lost.“

Discipline is controlling the feeling that you have the ability and

experience to do the job without following SOPs

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Pilots can avoid accidents by

controlling their hazardous attitudes


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Extract of the Court of Inquiry Report: : Ground personnel in Dubai reported that

both crew appeared normal and healthy. They had left the aircraft and gone to the

terminal building and the duty free shop during their 82 minutes turn over in

Dubai. The crew did perform all pre-departure checks according to observations

by ground personnel.

• synergy

• authority vs leadership

• assertiveness

• barriers

• cultural influence

• roles- leader/follower

• credibility

• team responsibility

CRM AT A TEAM LEVEL

1+1 is more than 21+1 is more than 2

Synergy means increased effectiveness of two individuals when they work as a team

CRM AT A TEAM LEVEL

Some conditions for synergy

cogs turning & interconnecting

smoothly: requiresGood communication& decision making

a leader

a shared objective

a correct task allocation

ObjectiveTask LeaderAtmosphere


CRM AT A TEAM LEVEL

Was there synergy in the IX 812 cockpit?“ During the first 100 minutes of the recording there was no communication between the pilots however, all radio communication was done by the first officer….”

Was there synergy in the IX 812 cockpit?“ During the first 100 minutes of the recording there was no communication between the pilots however, all radio communication was done by the first officer….”

• what will I - he/she/ the machine do next ?• what can happen to us ?• what should I - he/she monitor ?

A shared plan for actionObjectiveTask LeaderAtmosphere


CRM AT A TEAM LEVEL

Was there a shared plan of action in the IX812 cockpit?:

“While the aircraft descended through FL295 an incomplete approach briefing was carried out, no standard approach briefing was conducted…”

Was there a shared plan of action in the IX812 cockpit?:

“While the aircraft descended through FL295 an incomplete approach briefing was carried out, no standard approach briefing was conducted…”

A cooperative atmosphere

• First contact is crucial• The Leader must set the tone• The team members must

show their willingness to cooperate


Is everybody happy?!!

CRM AT A TEAM LEVEL

Was a co-operative atmosphere present in the IX 812 cockpit?

“..both crew appeared normal and healthy. They had left the aircraft and gone to the terminal building and the duty free shop during their 82 minutes turn over in Dubai. The crew did perform all pre-departure checks…”

Was a co-operative atmosphere present in the IX 812 cockpit?

“..both crew appeared normal and healthy. They had left the aircraft and gone to the terminal building and the duty free shop during their 82 minutes turn over in Dubai. The crew did perform all pre-departure checks…”

AuthorityObjectiveTask LeaderAtmosphere

Every team needs a boss

To be the boss, you need to have some authority

Authority comes from rank within the airline: appointment to post.

Authority is not same as leadershipCaptain Zebra

CRM AT A TEAM LEVEL

Authority and Leadership


Authority also comes from personal leadership qualities:

• Personality, attitudes• Experience• Maturity• Professionalism

Authority also comes from personal leadership qualities:

• Personality, attitudes• Experience• Maturity• Professionalism

CRM AT A TEAM LEVEL

Was there professionalism in the IX 812 cockpit?“ The captain's microphone occasionally recorded sounds consistent with deep breathing and mild snoring, at the later stages sounds of clearing the throat and coughing..About 6 seconds after the brakes began operating and after the reversers were selected the captain announced "Go Around" - against Boeing standard operating procedures not permitting go-arounds after selecting reverse thrust

Was there professionalism in the IX 812 cockpit?“ The captain's microphone occasionally recorded sounds consistent with deep breathing and mild snoring, at the later stages sounds of clearing the throat and coughing..About 6 seconds after the brakes began operating and after the reversers were selected the captain announced "Go Around" - against Boeing standard operating procedures not permitting go-arounds after selecting reverse thrust

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No matter what position you occupy in the crew you must learn to become a leader in that position

Leadership Requires Honesty, Foresight, Professionalism, Intelligence and Inspirational qualities- with ideas and actions to influence the thought and behavior of others

Leadership is accomplished through the use of examples, persuasion, & understanding the goals and desires of the team

CRM AT A TEAM LEVEL

Motivating crew members Directing and coordinating crew activities Structured Decision making involving all crew Ensuring information flow Using non-confrontational “key phrases”

“I’m uncomfortable” and gradually escalated action if required

ARE YOU JUST A COMMANDER/FIRST OFFICER IN THE AIRLINE HIERARCHY OR A TRUE LEADER?

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CRM AT A TEAM LEVEL

Requires setting and achievement of high standards of timely, error free performance. Aviation is a 12 sigma industry- 1.5 errors per million cycles.

Accurate and logical reasoning and good decisions Is achieved only after extensive training, comprehension

and application, (not rote memorisation techniques) and preparation based on study and research.

Requires ability to think out of the box when required. Requires high ethical standards

HOW PROFESSIONAL ARE YOU?

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CRM AT A TEAM LEVEL

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In the end…it is the attention to detail

that makes the difference

It is the thing that separates

the winners from the losers,

the men from the boys, and very often

the living from the dead.

Aggressive High task oriented & low relationship oriented First consideration to the task or goal Can become autocratic, intimidating and abusive

Relationship Oriented First consideration to the feeling of others Caring or nurturing style of behavior Can become ineffective with inadequate focus on task

achievement.

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CRM AT A TEAM LEVEL

Intended to be the middle ground

Best of aggressiveness (without the putting down the team member) Best of non-assertiveness (without loss-of-self) Expressing one’s position firmly without

dominating the other

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CRM AT A TEAM LEVEL

In the IX 812 cockpit, was the wrong person being assertive?..“ The captain (2,844 hours on type) was "assertive" and tended to indicate he was always right…..” In the IX 812 cockpit, was the wrong person being assertive?..“ The captain (2,844 hours on type) was "assertive" and tended to indicate he was always right…..”

ServiceIndustry

PolicyChanges

LineOperations

RuleEnforcement

Safety

TakeControl

Insist

Discuss

GiveRationale

Point Out

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CRM AT A TEAM LEVEL

In the IX 812 cockpit, was the first officer assertive enough?..“Probably in view of ambiguity in various instructions empowering the ‘copilot’ to initiate a ‘go around’, the First Officer gave repeated calls to this effect, but did not take over the controls to actually discontinue the ill-fated approach.

In the IX 812 cockpit, was the first officer assertive enough?..“Probably in view of ambiguity in various instructions empowering the ‘copilot’ to initiate a ‘go around’, the First Officer gave repeated calls to this effect, but did not take over the controls to actually discontinue the ill-fated approach.

As a crew member, you have the right to assure that your life will not be compromised by any action / inaction, miscommunication, or misunderstanding.

Assertive behavior in the cockpit does not challenge authority; it clarifies position, understanding or intent, and as a result enhances the safe operation of the flight.

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CRM AT A TEAM LEVEL

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Contributing Factors to the Accident

-I- Probably in view of ambiguity in various instructions

empowering the ‘copilot’ to initiate a ‘go around’, the

First Officer gave repeated calls to this effect, but did not

take over the controls to actually discontinue the ill-

fated approach.

CRM AT A TEAM LEVEL

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CRM AT A TEAM LEVEL

Power distance refers to the degree of democracy in human relationships.

In a high power-distance culture (e.g., India, Malaysia, & Philippines),leaders are more likely to be expected to be decisive, and subordinates are expected to be more submissive .

In countries with lowerpower distance, such as the United Kingdom, Australia and Denmark, subordinates feel more comfortable about approaching superiors and, if necessary, contradicting them .

Medium Power Distance is considered to be desirable in multi-crew cockpits

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Individualism vs. Collectivism: Individualistic societies, such as the United Kingdom, United States and Australia, emphasize personal initiative and individual achievement.Collectivist societies, such as India, Brazil, Taiwan and Korea, emphasize the importance of group membership and cohesiveness of the group over individual achievement.

In collectivist societies, there is a tendency to avoid open conflicts.

A first officer from a collectivist society would be less likely to challenge a captain who is doing something that the first officer feels uncomfortable with.

CRM AT A TEAM LEVEL

POWER DISTANCE

INDIVIDUALISM

IndiaJapan

Greece

Korea

IndonesiaMalaysia

Spain

USA

Austria

Sweden

Costa Rica

Australia

DANGER ZONE

With high collectivism and high power distance the result is that a person with higher authority is not to be challenged, even if there is something that does not seem right, as it is deemed to be outside accepted cultural behaviour .

1+1 is less than 21+1 is less than 2

CRM AT A TEAM LEVEL

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The ethnical theory about aircraft accidents is due to two aircraft accidents (Colombian Avianca Flight 52 and South Korean Air Flight 801)

Flight 801 departed from Seoul-Kimpo International Airport at 8:53 pm (9:53 pm Guam time) on August 5, 1984 on its way to Guam. It carried 2 pilots, 1 flight engineer, 14 flight attendants, and 237 passengers,

There was heavy rain at Guam so visibility was significantly reduced and the crew was attempting an instrument landing. Air traffic control in Guam advised the crew that the glideslope Instrument Landing System (ILS) in runway 6L was out of service. Air traffic control cleared Flight 801 to land on runway 6L at around 1:40 am. The crew noticed that the plane was descending very steeply, and noted several times that the airport "is not in sight". At 1:42 am, the aircraft crashed into Nimitz Hill, about 3 nautical miles (5 km) short of the runway, at an altitude of 660 feet (201 m).

The NTSB Report said ‘..The captain also failed to follow a normal non-precision approach and prematurely descended to impact a hillside short of the runway. Contributing to the accident were the captain's fatigue, Korean Air's lack of flight crew training, as well as the intentional outage of the Guam ILS Glideslope due to maintenance. The crew had been using an outdated flight map, which stated that the Minimum Safe Altitude for a landing plane was 1,770 feet (540 m) as opposed to 2,150 feet (656 m). Flight 801 had been maintaining 1,870 feet (570 m) when it was waiting to land ’

Korean Airlines KAL 801 crash was the result of a succession of causal factors: (the long flight length, fatigue, bad weather) which made the pilot make a mistake that the co pilot was not able to correct for cultural reasons. ‐ In particular, the co pilot was unable or unwilling to express his opinion, in ‐other words he could not assertively communicate regarding crucial aspects related to the flight.This is due to the great importance that hierarchy has in Korean society.Quote “Korean Air had more plane crashes than almost any other airlinein the world at the end of the 1990s. When we think of airline crashes, we think, Oh, they must have had old planes. They must have had badly trained pilots. No. What they were struggling with was a cultural legacy, that Koreanculture is hierarchical. You are obliged to be deferential toward your elders and superiors in a way that would be unimaginable in the U.S. Boeing and Airbus design modern, complex airplanes to be flown by two equals. That works beautifully in low power distance cultures like the U.S., ‐ ‐where hierarchies aren't as relevant. But in cultures that have high power distance, it’s very difficult”.Therefore the aircraft accident was caused by several factors, and the high hierarchical distance between the captain and the co pilot was the most ‐important factor. 52

CRM AT A TEAM LEVEL

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Mangalore effect: DGCA emphasizes role of co-pilot in a crisisTNN, Aug 11, 2010, 03.52am ISTMUMBAI: If the commander of a flight doesn't respond to a situation, which demands that the aircraft should discontinue its descent for landing and pull up and do a go-around, then the first officer should take over the controls and do the needful.

There is nothing new in this norm, as it is already a standard operating procedure in airlines. What is new is that the Directorate-General of Civil Aviation ( DGCA) on Tuesday issued an operations circular to stress once again the particular role that a first officer needed to follow in such a situation.

Although the circular doesn't say it, it's apparent that this is one of the factors that led to the May 22 Mangalore air crash. The co-pilot called for a go-around but the commander ignored it and the co-pilot didn't take over the controls and the Boeing 737 eventually crashed.

CRM AT A TEAM LEVEL

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CRM AT A TEAM LEVEL

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2

!UNSTABILISED GO AROUND!!!

CRM AT A TEAM LEVEL

CONFLICT MANAGEMENT

You all agree with me, don’t

you?!!

i

CRM AT A TEAM LEVEL

CONFLICT MANAGEMENT WITH CREW WHO DISAGREE WITH YOU

• Complete the task first

• Listen to the input, show respect

• Focus on facts, not on crew’s behaviour

• Find what is right, not who is right

• Agree to debrief the problem when you have time

(e.g. after the flight)

CRM AT A TEAM LEVEL

I like it when the...

Captain … • Is professional

• Shows respect

• Shares workload

• Sets a good example

• Listens

• Keeps a good atmosphere

• Is a good teacher

First Officer …• Is professional

• Follows SOP’s

• Is disciplined

• Asks questions

• Is a good monitor

• Knows his / her limits

• Is well prepared

• Checks my actions

CRM AT A TEAM LEVEL

I like it when the...

Cabin Crew … • Are professional• Show respect• Report anything unusual in cabin• Are safety minded• Understand the cockpit’s overload• Are cooperative

Ground Staff …• Communicate• Are safety minded• Inform us of delays• Are well prepared• Respect captain’s authority• Are there when we need them

CRM AT A TEAM LEVEL

I like it when the pilots...

From the Cabin crew :• Are professional • Give a thorough briefing • Show respect• Help in the cabin when

needed• Understand the cabin’s

workload • Are friendly, cooperative

From the Ground staff: • Are professional• Provide precise information

in the log book• Are safety-minded • Understand my job• Are friendly, cooperative• Tell me when I’ve done a

good job

CRM AT A TEAM LEVEL

Good Followership qualities are:

1. Appropriate Behaviour:

• Supportive (when Pilot Monitoring)

“ Captain, landing checklist” (supply omitted actions/calls)

• Assertive: “Go around! (when safety is threatened)

Focused and persistent.

2. Communication: Exchanges relevant information pertaining to the flight.

But the thunderstormis still over the airport!


CRM AT A TEAM LEVEL

GO AROUND!

CRM AT A TEAM LEVEL

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Communication is • BOTH Transmit AND Receive• Builds shared mental model of problems• Enables shared problem solving & effective decision making

CRM AT A TEAM LEVEL

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Information has Four elements

2. Message

1. Sender (transmission) 3. Receiver

4. Feedback

(response)

CRM AT A TEAM LEVEL

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Sender (transmission)

Inquiry (ask)

“What does my crew know that I need to know?”

CRM AT A TEAM LEVEL

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Sender (transmission) Receiver

Advocacy(suggest)

Suggest to other crew: State Position Suggest Solution Be Persistent Give Timely Inputs

CRM AT A TEAM LEVEL

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Listen

Active Listening TipsDo not listen in parallel with performing concurrent tasks. Stop what you are doing, listen, and then resume.

Always use standard phraseology.

Read-back ATC instructions and listen out for any ATC correctionsIf in doubt - CROSS CHECK. If, even after a correct read-back, you feel that there is an ambiguity in the clearance, ask again

Query unclear or incomplete transmissions, especially if you suspect they may have been blocked.

CRM AT A TEAM LEVEL

Sender (transmission)Sender (transmission)

68

Inquiry (ask) Advocacy (suggest)

Listen

Conflict Resolution- Find what is right, not who is

right Keep an Open Mind Use a Predetermined “Key

Phrase” to show Non-Confrontational Discomfort “standby ,I’m not sure that’s correct”

CRM AT A TEAM LEVEL

Sender (transmission)Sender (transmission) ReceiverReceiver

Transmission: Wrong Perception of what is being said/ of the problem Inadequate Education- which determines

Tone and rate of speech Speech pattern Clarity Choice of words

Reception Intimidation- stops all communication.

Stems from Position/background (i.e Commanders, TRE/TRI/Check Pilots Pilot vs. Non-

Pilot Crew Personality type: Aggressive, child ego state etc Flight pressure (distracting events in the cockpit)

Body Language and Attitude- can stop or encourage good communication69

CRM AT A TEAM LEVEL

70

CRM AT A TEAM LEVEL

Fatigue: The cockpit voice recorder featured a capacity of 125 minutes. During the first 100 minutes of the recording there was no communication between the pilots however, all radio communication was done by the first officer. The captain's microphone occasionally recorded sounds consistent with deep breathing and mild snoring, at the later stages sounds of clearing the throat and coughing.

Poor Workload management: While the aircraft descended through FL295 an incomplete approach briefing was carried out, no standard approach briefing was conducted

Unprofessionalism: The aircraft continued to be high, intercepted the localizer beam and captured the false glideslope beam at double the correct approach angle (6 instead of 3 degrees descent). There was no cross check between actual altitudes/heights with the descent profile provided in the approach chart conducted by the crew

Conduct Take off and Approach briefings the way you intend to fly, and

fly the way the briefing is being done.

Fly using SOP so there are no surprises for other crew.

Empower crew to speak out-

“Call out clearly and precisely any abnormality or malfunction

affecting safety of the flight” is an SOP key phrase

Brief other crew to give two warnings, then escalate to corrective

action if needed

Adhere to “Sterile cockpit” procedure

71

CRM AT A TEAM LEVEL

72

1. Prioritise & address all tasks, with priority given to most critical

2. Delegate tasks to avoid task overload and receive acknowledgement

3. When in an abnormal condition, make time by joining hold/long radar

vectors.

4. Avoid ask fixation

5. Maintain communication receptivity during high workload phases

6. Use appropriate level of automation for phase and complexity of

flight.

7. Acknowledge all FCU changes and be aware of FMA at all times with

emphasise on FMA callouts.

8. Cross check with raw data at all times.

OPERAT-IONAL LEVELCRM

73

OPERAT-IONAL LEVEL CRM

Begins with Good Situational Awareness. Anticipate problems.

Evaluate Situation

What is wrong (Identify)?

What resources do you have?

How can the resources be best used (Action)?

Consider consequences of possible actions

Make decision, inform all involved

Evaluate decision, repeat as needed

74

Quick decisions aren’t always correct !

Management PhaseEvaluate the result, review decisions and modify solutions as required.

Manage the flight situation till a safe landing maintaining good teamwork and communication, using all available resources

75

Assessment PhaseDeliberate information gathering from all sources while maintaining flight path control using Aviate, Navigate &Communicate model of

task sharing. Evaluate all options openly

Assessment PhaseDeliberate information gathering from all sources while maintaining flight path control using Aviate, Navigate &Communicate model of

task sharing. Evaluate all options openly

Action Phase Choose the best options & inform all involved Implement that choice using ECAM/ EICAS/QRH/with awareness of time available. Detect

the changes that result from your decision

Action Phase Choose the best options & inform all involved Implement that choice using ECAM/ EICAS/QRH/with awareness of time available. Detect

the changes that result from your decision

76

Elements of Situational Awareness

1. Weather, Aircraft Condition and airline abilities

2. Flight Plan requirements: Track, Altitudes and speeds.

3. Airspace, Terrain, Traffic

4. Crew activities

77

1. FMA- F/D/AP MODES (A/T ,SPD, ALT and HDG/NAV AP modes)

2. FLIGHT PATH CONTROL: SPD, ALT and HDG/NAV parameters, TRP,FCU & FMS settings or manual control,

3. PROCESSED DATA-

1. Command pointers on NI gauge, Digital Thrust readouts,

2. Speed Tape, Altitude and heading readings on PFD

3. ND MAP display with PPOS and Required Track

4. Aircraft configuration

4. RAW DATA- N1 readings, pitch attitudes on PFD& Standby, FMS way point co-ordinates, RMI/HSI LOC and GS deviations, VSI and Aircraft configuration controls

78

Aircraft Condition: Aircraft Condition:

Failure to meet SOP/ATC flight path targets

Undocumented procedure or departure from SOP

Violation of airport minimums or aircraft limitations

No one flying the plane

No one looking out

Break down in communications

Un resolved discrepancies/ pre-occupation/distraction/confusion

79

1. Accomplish adequate pre-flight planning.

2. Set and accomplish flight targets

3. Stay ahead of the aircraft by being prepared for unforeseen contingencies

4. Use good communication to maintain situational awareness.

5. Recognise error chain clues and break links in the chain.

6. Recover situational awareness first and trouble shoot (what happened)

later.

7. Revert to last known safe position or configuration

80

1. Personality

2. Fatigue and Stress

3. Alcohol

4. Medication and Health

81

82

Bad enough on the ground…but in the air???

1. Loss of as little as one hour sleep begins a person’s sleep debt

2. Eight hours of disturbed sleep can produce effect of too little sleep

3. Only cure for sleep debt is to sleep

83

1. In human terms, stress is used to describe the body’s

response to demands placed on it

2. Three types of stress

1. Physical - environmental conditions, noise, vibration,

stages of hypoxia

2. Physiological - fatigue, lack of physical fitness, improper

eating

3. Emotional - social & emotional factors related to living

and intellectual activities

84

85

When performance drops due fatigue or stress consider using

1. Optimum levels of automation

2. Handing over controls

3. Additional crew members for flight watch

86

7- A THREAT & ERROR MANAGEMENT 7- A THREAT & ERROR MANAGEMENT MODELMODEL

Are defined as events or errors that are:

1. Not caused by aircrew ( external, come at the crew)

2. Increase the operational complexity of a flight

3. Require attention and management if safety margins of a flight are to be maintained

1.Environmental- Outside the control of the airline & include

•Terrain,

•Weather and

• Atc

2. Airline -

•Crew scheduling events

• Aircraft snags

•Ground /cabin crew errors

•Ontime performance pressures

• Crew / aircraft delays

UNFAMILIAR AIRPORT &

FATIGUE

TYPE Industry Average-4.2 /flight

Environmental

(43% in descent/ Aproach & Land Phases)

Adverse Weather (25%)

Thunderstorms, Turbulence, Poor Visibility, Wind Shear, Icing

Airport(7%)

Poor Signage, Faint Markings, Runway/Taxiway Closures, Inop Navaids, Poor Braking action, Contaminated Runway/Taxiways

ATC(25%)

Difficult to follow/changing clearances and restrictions*, re-routes, language difficulties, Controller Errors(*most problematic threat)

Operational Pressures

Terrain, Traffic, TCAS TA/RA, Radio Congestion

Airline

(73% in Pre-Departure/Taxi-out Phases)

Aircraft(13%)

System Malfunctions, MEL with Operational Procedures

Operational Pressure

On Time Performance Pressure, Delays, Late arrival Aircraft/Aircrew

Cabin Cabin Events and Cabin Crew Errors, Distractions and Interruptions.

Despatch / paperwork

Crew Scheduling events, Delayed or Erroneous Flight Plans and Other Documents, Load and Trim Errors

Ground/Ramp

Aircraft Loading Events, Fuelling Errors, Commercial Staff Interruptions, Improper Ground Support, De-icing

Maintenance Aircraft Repairs on ground, Aircraft Log problems, Maintenance errors

Manuals and Charts Missing Information or Document Errors.

Was there any external threat in the IX 812 accident?Was there any external threat in the IX 812 accident?

The first officer reported to Mangalore Area Control Center while overflying

waypoint IGAMA at FL370 and requested radar identification at which time he

was told that Mangalore's radar was out of service (starting May 20th 2010).

About 5 minutes later, about 130nm before Mangalore, the first officer requested

the type of approach to expect, was told to expect the ILS DME Arc approach to

runway 24, and requested descent. ATC denied the descent however due to

procedural control available only

The first officer reported to Mangalore Area Control Center while overflying

waypoint IGAMA at FL370 and requested radar identification at which time he

was told that Mangalore's radar was out of service (starting May 20th 2010).

About 5 minutes later, about 130nm before Mangalore, the first officer requested

the type of approach to expect, was told to expect the ILS DME Arc approach to

runway 24, and requested descent. ATC denied the descent however due to

procedural control available only

FOUR out of FIVE Pilot Errors that caused an ACCIDENT

occurred before the flight left the ground.

Every action we do in the air has a cascading effect so

we have to understand the long term results of our

actions. A wrong action or decision can kill hundreds.

90

ERRORS

• You make an error when

your action deviates from

your intention

• An error is not intentional

ERRORS & THEIR CONSEQUENCES

Are defined as action or inaction that:

1. Are caused by aircrew ( internal, come from the crew)

2. Lead to deviation fro m crew or organisational intentions or expectations

3. Are required to be detected and corrected if safety margins of a flight are to be

maintaiined

And are of three types-

1. Aircraft handling- associated with thrust, speed, altitude ,direction and configuration.

2. Procedural - deviations from sop, flight manual requirements or regulations

3. Communiation- between pilots, or between crew and atc, cabin crew and ground

personnel.

TYPE Industry Average-4.2 /flight

AIRCRAFT HAND -LING

Automation Incorrect autothrottle, speed, altitude and heading settings, mode selection or entries

Flight Control Incorrect thrust, thrust reverser, flaps/slats, speed-brakes, auto-brakes, anti-skid, parking brake and trim settings

Gnd Navigation Attempting to proceed on wrong taxi-way/runway. Missed taxiway/runway/gate.

Manual Flying Hand-flying vertical, lateral or speed deviations. Missed taxiway or runway hold short clearance(runway incursion), or taxi above speed limit.

Systems, Radio, Instruments

Incorrect Pack, altimeter, radio or fuel switch setting.

PROCE-DURAL

Briefings Missed items in briefing- omitted Departure, Takeoff, Approach or Handover briefing

Callouts Omitted takeoff, descent or approach callouts

Checklist Performed checklist from memory or omitted a checklist

Documentation Wrong Weight and Balance, fuel information, ATIS or clearance recorded. Misinterpreted items on paperwork.

PF/PNF duty PF makes own automation changes, PNF doing PF duty, PF doing PNF duty

SOP Cross-Verification

Intentional and unintentional failure to cross-verify automation inputs

Other Procedural Other deviations from government regulations, flight manual requirements or SOP

COMM-UNICA-TION

Crew to External Missed Calls, misinterpretation of instructions or incorrect read-backs to ATC, Wrong Clearance, Taxiway, gate or runway communicated

Pilot to Pilot Within crew miscommunication or misinterpretation

Was there any crew errors in the IX 812 accident?Was there any crew errors in the IX 812 accident?

Numerous EGPWS warnings ("Sink Rate!" "Pull Up!") were issuedNumerous EGPWS warnings ("Sink Rate!" "Pull Up!") were issued

The aircraft continued to be high, intercepted the localizer beam and captured the false glideslope beam at double the correct approach angle ..There was no cross check between actual altitudes/heights with the descent profile …by the crew

The aircraft continued to be high, intercepted the localizer beam and captured the false glideslope beam at double the correct approach angle ..There was no cross check between actual altitudes/heights with the descent profile …by the crew

an incomplete approach briefing was carried out, no standard approach briefing was conductedan incomplete approach briefing was carried out, no standard approach briefing was conducted

About 6 seconds after the brakes began operating and after the reversers were selected the captain announced "Go Around" - against Boeing standard operating procedures not permitting go-arounds after selecting reverse thrust -,

About 6 seconds after the brakes began operating and after the reversers were selected the captain announced "Go Around" - against Boeing standard operating procedures not permitting go-arounds after selecting reverse thrust -,

UNDESIRED AIRCRAFT STATES Undesired aircraft states are defined as ‘flight crew-induced aircraft position or speed deviations,

misapplication of flight controls, or incorrect systems configuration, Undesired aircraft states are defined as ‘flight crew-induced aircraft position or speed deviations,

misapplication of flight controls, or incorrect systems configuration,

UNDESIRED AIRCRAFT STATE (REDUCED SAFETY MARGINS)

MISMANAGED

INCIDENT/ACCIDENT

UN-ANTICIPATED, MISMANAGED THREATS

UNDETECTEDERRORS-THRUST, SPEED, ALTITUDE ,DIRECTION AND CONFIGURATION,PROCEDURAL,COMMUNICATION

HAZARDOUS ATTITUDESANTI- AUTHORITY, IMPULSIVITY, INVULNER-ABILITY,MACHISMO ,COMPLACENCY RESIGNATION

SYSTEM MALFU-NCTION

TURBULENCE,WIND SHEAR ,ICINGPOOR VISIBILITY

ATC ERRORSLANGUAGE DIFFICULTIESCHANGED/ DIFFICULT CLEARANCES

GROUND/CABIN DISTRACTIONS/CREW ERRORS

POOR SIGNAGE,FAINT MARKINGS, RUNWAY/TAXIWAY CLOSURE/,INOP NAVAIDS/POOR BRAKING ACTION / CONTAMINATED RUNWAY/TAXIWAY

TERRAIN

97

Undesired aircraft state

Incident / Accident

TEM: COUNTERMEASURES-1

Flight crews must use countermeasures to keep threats, errors

and undesired aircraft states from reducing margins of safety.

Examples of countermeasures are

• Checklists,

• Briefings,

• Call-outs

• COPs,

As well as personal strategies and tactics

TEM: COUNTERMEASURES-2

All countermeasures are necessarily flight crew actions. However, some countermeasures to threats,

errors and undesired aircraft states that flight crews employ build upon “hard” resources provided

by the aviation system. These resources are already in place in the system before flight crews report

for duty, and are therefore considered as systemic-based countermeasures. The following would be

examples of “hard” resources that flight crews employ as systemic-based countermeasures:

Airborne Collision Avoidance System (ACAS);

Ground Proximity Warning System (GPWS),

Standard operation procedures (SOPs);

Checklists;

Briefings;

Training;

Etc.

TEM COUNTERMEASURES-3

Other countermeasures are more directly related to the human contribution to the safety of flight operations. These are personal strategies and tactics, individual and team countermeasures, that typically include canvassed skills, knowledge and attitudes developed by human performance training, most notably, by Crew Resource Management (CRM) training. There are basically three categories of individual and team countermeasures:

AVOIDANCE Planning countermeasures: essential for managing anticipated and unexpected

threats (TRAP) ;

MITIGATE Execution countermeasures: essential for error detection and error response; Review countermeasures: essential for managing the changing conditions of a

flight.

101

Culture Behaviour Followership

Communication Leadership

Pillars of Pillars of TeamworkTeamwork Resource Management & Decision MakingResource Management & Decision Making

Attitudes & DisciplineAttitudes & Discipline

Personality and TurnoutPersonality and Turnout

Task sharing ,Time & Workload Management Automation

Threat and Error ManagementThreat and Error ManagementStress ManagementStress Management

Knowledge and Flying ProficiencyKnowledge and Flying Proficiency

CRM is a Tool for reducing Incidents & Accidents

Situational Awareness and ControlSituational Awareness and Control

Crewmembers are teams, not a collection of competent

individuals

Crew effectiveness should be enhanced through better

teamwork, which requires better behaviour within the

cockpit.

Practice training sessions are required

CRM is not just an emergency procedure but a part of

everyday behaviour.

102

A CASE STUDYA CASE STUDY

15 YEARS BEFORE THE MANGALORE CRASH, A SIMILAR INCIDENT TOOK PLACE..

Indian Airlines B-737 aircraft VT-ECS was operating flight IC-492 of 2.12.95 . The flight upto Jaipur was uneventful.

The aircraft took-off from Jaipur with 98+4 passengers and landed at Delhi at 1253 hrs. There was a NOTAM pertaining to airport closure at VIDP .

After landing the aircraft could not be stopped within the available runway length and went beyond the runway into overrun area. The aircraft was substantially damaged. There was minor fire. There were no casualties but six passengers received minor injuries.

DFDR analysis revealed that the crew made an un-stabilised approach and landed deep down the runway. The captain had forgotten to arm the speedbrakes and there were no deviation calls made by the PNF.

THREATS & ERRORSTHREATS & ERRORS

What are some of the What are some of the External ThreatsExternal Threats in the in the Delhi Accident?Delhi Accident?

?? ?? ?? ??

ExternalThreat

The Flight Crew was under pressure to land at DelhiThe Flight Crew was under pressure to land at Delhi hastily to

complete the flight in the inadequate time available before the

notified closure of Delhi airport for a VVIP flight, ..

ExternalThreat

There was one external threat: There was one external threat:


What are some of the What are some of the ErrorsErrors in the Accident? in the Accident? ?? ?? ?? ??

UnexpectedEvents/Risks

ExternalThreats


What are some of the Errors in the Delhi Accident?What are some of the Errors in the Delhi Accident? The dangerously unstabilised approach made by the Pilot-in- Command,

primarily due to his failure to decelerate the aircraft in time, The failure of the First Officer to call out significant deviations from the

stipulated approach parameters The failure of the Pilot-in- Command to carry out a missed approach in spite

of his approach being grossly unstabilised The inadvertent omission of the Pilot-in-Command to arm the speed brake

before landing, Touch-down of the aircraft at excessive speed and too far down the runway, Failure of the First Officer and Pilot-in- Command to monitor the automatic

deployment of the speed brake, and failure of the Pilot-in-Command to deploy it manually,

UnexpectedEvents/Risks

ExternalThreat

DGCA attributed the crash due to disregard of procedures, regulations and instructions


1. Lack of Technical and Flying proficiency

2. Indiscipline, Complacency & other Hazardous Attitudes

3. Emotional non-adult mental states

4. Intimidating other crew

5. Inability to communicate and a break down in teamwork

6. Hesitation to Speak Out

7. Hasty un-informed decisions

8. Loss of Situational Awareness

9. Fatigue

10. Overlooking of threats and crew errors

109

AVOID:

110

CREDITS:

OPERATIONS TRAINING DIVISION, MUMBAIAIR INDIA LTD.

MARCH 2011

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