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Crash Course VII

Cockpit Resource Management-Why It Is Necessary

by Leonard A. Phillips

LEXINGTON, MASS., 3/27/97 -. A panel of aviation safety specialists

presented ACONE's seventh annual safety seminar Crash Course VII on

Thursday evening, March 27 at Hanscom Field's Officers Club.

A distinguished panel of presenters addressed the packed Ballroom: Nancy

Risso, FAA Safety Program Manager, ATP Flight Standards (Bedford, MA);

Dennis Jones, NTSB Regional Director, Northeast Region Senior Air Safety

Investigator (Paramus, NJ), Major Aircraft Accidents, CFII, and former

airline pilot; Norm Komich, USAir Shuttle 727 First Officer and Crew

Resource Management facilitator and Airline Pilot's Association (ALPA)

safety representative; and Bruce Landsberg, Executive Director of the AOPA

Air Safety Foundation.

"This issue of Aviation Safety lists 57 accidents in January alone. Four

air carriers included. Fourteen involved continuing VFR into IFC

conditions, scud-running. And four involved fuel mismanagement." Our Panel

Moderator, TWA Captain (ret.), President of the US Society of Air Safety

Investigators and US Councilor of the International Society of Air Safety

Investigators, Jim McIntyre launched the Crash Course like a steam

catapult.


I. Nancy Risso: Continued Learning Is Essential

Introducing, the FAA Safety Program which she heads locally, Ms Risso

emphasized, "This business requires continuous learning." She told the

group that about 150 volunteer Aviation Safety Counselors make the FAA

program work, and they're always available for consultation. The Safety

Program is run out of the Boston FSDO; Risso is based at Hanscom Field.


II. Dennis Jones: "I Hope None of This Happens to You."

Jones, who worked on the investigation of the Space Shuttle Challenger

accident and was the first NTSB accident investigator at the TWA Flight 800

crash site, will soon be headed to South Africa to help teach accident

investigation to civil aviation authorities. He noted that 1996 was a

15-year low for general aviation accidents, but nonetheless, launched into

a broad spectrum of crash situations and lessons learned. "I hope none of

this happens to you," he said.


Choking Dog & Fat Pax

Jones delineated a number of grim cases the NTSB has worked on recently. A

few:

* Probable cause of the accident that killed the very young pilot, Jessica

Dubroff: an over-ambitious schedule that led the flight instructor to make

an improper decision to take off into deteriorating weather conditions in

an overweight aircraft flying at a density altitude with which the pilot

was unfamiliar. The message? There's no place you have to be...

* Carbon monoxide poisoning from a leaking exhaust manifold overcame the

pilot and then his mother, the passenger, on a Piper flying out of Long

Island, leading to a fatal crash. Keep a CO detector in your cockpit...

* Weight & Balance: A Cessna Cardinal taking off from Duanesburg, New York,

had two people aboard: a female weighing over 300 pounds, and a male pilot

weighing about 200 pounds; a pet dog was in the back. As the aircraft

reached the end of the runway, it went tail-down, pitched up abruptly,

stalled, and crashed. The dog apparently choked on a bag of food and in a

vain attempt to save her pet, the female shifted her position to the rear

of the aircraft, causing the stall.


Good Thinking; Good Advice

Jones discussed certain tight situations and what to do about them.

Samples:

1. What to use as pitch control if your elevator jams? Use your trim, but

in reverse. Or: if water in a C-172's tail cone freezes at altitude locking

elevator control cables, descend to a warmer, lower altitude and melt the

ice, restoring normal control.

2. "Be conscious of the passengers," he said. "If there's an accident, as

pilot you may not make it. They may need to know how to get out." In West

Virginia, a Cessna 1972 carrying four people crashed on a mountain,

inverted, killing the two men in front. The rear seat passengers survived

the impact but received severe frostbite. Had they known how to use the ELT

and how to start a warming fire using aviation fuel, they could have been

rescued sooner and in better physical condition.


Real Life Death Videos

Increasingly, people are taking videos of flights and subsequent accidents,

he said, sometimes filming their own deaths. He showed several

gut-wrenching examples. The most bizarre was a crash of a high-performance

Marchetti aircraft during a simulated combat flight, which killed a TV

reporter and the pilot. The entire event was filmed with a fully audible

voice track. The investigation discovered that the pilot was unlicensed and

was a Navy Aviation student washout. The lesson learned? Know your pilot's

credentials.


III. Norm Komich: "Human Error Is Inevitable."

Komich, a USAir Shuttle 727 First Officer and Crew Resource Management

facilitator with over 12,000 hours of flight time logged, including aboard

USAF C-133 transports, focused on human factors problems. Komich said that

about 70% of all airline accidents that occurred last year involved some

human error as the primary or a contributing factor. Despite the industry's

best efforts, "Human error is still inevitable," he said. (Controlled

flight into terrain is still the number one killer in all operations.)

B-52 Swallows Geese; Computer Crashes

A sampling of several illustrative scenarios he outlined:

* A B-52 flying low-level at 350 knots strikes a flock of geese, affecting

three of its engines. While the crew focuses on the engines, the plane

crashes.

* A Cessna 172 pilot on a sightseeing flight is caught in fog, runs out of

fuel, and crashes.

* An F-117 pilot flying into Baghdad ate a local delicatessen sandwich

before the flight, felt sick, but pushed on with the flight, and eventually

crashed.

* A 747-400 crew flying the Atlantic had computer problems, went off

course, and had a mid-air collision.

Komich noted that among his many examples the issues that faced all of

these flight crews affected the pilots' judgment, decision-making, workload

management, risk management, stress management, situational awareness, and

automation interface-all key human factors components. The goal of Cockpit

Resource Management (CRM) training is to enable the pilot and crew to

interact effectively to deal with emergencies, particularly to avoid,

reduce, or manage human error. He noted the importance of consensus among

the crew and double-checks of critical factors such as fuel quantity.

"A superior pilot uses superior judgment to avoid having to use superior

stick and rudder skills; good judgment comes from bad experience. Bad

experience comes from bad judgment."

What aspects of flight might trigger a situation where you need to exercise

judgment and decision making? Weather, mechanical abnormality, sick pilot,

crew member, or passenger, bird strikes, low fuel, ATC delays...

1. Accurately define the problem; be sure you have a problem.

2. Get all available information from human resources-including pilot,

crew, ATC, and other pilots-as well as written and mechanical resources.

3. Analyze alternative courses of action and their outcomes, and select the

best course.

4. Implement it and confirm it provides the desired results.


Set Limits Early; Have "Plan B"

Taking the specific and serious issue of fuel management, Komich described

a 4-part approach: 1) Set your limits as early as you can. 2) Have a viable

alternate game plan. 3) Do not go back. Once you begin the alternate game

plan, stick with it. 4) Do not plan to intentionally burn into reserve

fuel; in VFR allow reserve fuel sufficient for 30 minutes of flight time.

Komich concluded with a rapid-fire series of aphoristic statements: It is

true that flight is inherently risky, but everyone has their own threshold

of risk and we all fall into a different part of the risk spectrum. If you

find yourself rushing and looking at your watch, stop, wait a minute, and

ask yourself if what you are doing is appropriate under the circumstances.

Approach your flying professionally-ask yourself how an FAA flight examiner

on the jump seat would respond to what you're doing right now. If your game

plan differs from others, take another look. And one more thing: avoid

interpreting success as justification for doing it again.


IV. Bruce Landsberg: The Most Dangerous Game

Landsberg reported that the Air Safety Foundation held 300 safety seminars

in 1996, speaking with over 35,000 pilots. Landsberg reported that

according to ASF records, 1996 was the year having the lowest total number

of accidents since it began keeping score in 1938 and the lowest number of

fatals since 1952.

Then he rolled a video developed by the ASF for its safety seminars.

"Maneuvering flight. More accident sequences begin during this phase of

flight than any other. Cut the corners of this envelope, and you're playing

'the most dangerous game,'" noted Bennett Floyd, narrator. Last year low

altitude maneuvering flight was the number two producer of fatal accidents,

accounting for 57.


Wires

Among other reasons for keeping some altitude underneath the airplane, the

ASF recommends a minimum of 1,500 feet when flying en route because of the

prospect of wire strikes. About 75% of wire strikes result in severe damage

or destruction of an aircraft, and more than 70% occur at altitudes below

100 feet AGL. (Bad weather is not a primary cause of wire strike mishaps.)

Consult charts, fly a high altitude recon pass, and use a ground guide

prior to performing a low altitude pass. Look for supporting structures,

not the wire, and fly over the supporting structure, not the wire span, at

a low speed.


On Final: A Plea for Situational Awareness

"Flying is fun," reminded Capt. McIntyre. "Crashing certainly isn't fun.

Learn from your incidents," he concluded, "before they become accidents."


Thanks and Recognition

Crash Courses are organized by the program committee headed by Club

Secretary David W. Graham. Pilots who participate in Crash Course seminars

satisfy one requirement for FAA Pilot Proficiency Wings lapel pin and

Certificate; also required: 3 hours of dual instruction and a sign-off by

an instructor.

ACONE gratefully acknowledges the support provided for Crash Course VII by:

Aero Insurance, Nashua NH; Alpha Flying, Inc., Norwood Airport; Aviation

Electronics, Hanscom Field; Dorr Aviation, Inc., Marlboro Airport;

Executive Flyers, Hanscom Field; Attorney Gary Arber, Brookline, MA;

International Society of Air Safety Investigators (I.S.A.S.I.), Northeast

Regional Chapter, Boston, MA; and Jet Aviation, Inc., Hanscom Field. Dinner

sandwiches courtesy of Reese Dill.

Date Created: 08/08/97
Last Modified: 08/11/97

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