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BEYOND ACCIDENT ANALYSIS

Lessons are Painful. Many airlines have had to face the fact that their procedures and culture were contributing to accidents.United; Delta; JAL; USAir; Korean; AmericanJust some examples. Most airlines, if they are honest with themselves would conclude that they either were or still are at risk..

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BEYOND ACCIDENT ANALYSIS

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    1. BEYOND ACCIDENT ANALYSIS What can we do to learn the lessons? Capt. Paul McCarthy, DAL (ret.) IFALPA Representative to ICAO

    2. Lessons are Painful Many airlines have had to face the fact that their procedures and culture were contributing to accidents. United; Delta; JAL; USAir; Korean; American Just some examples. Most airlines, if they are honest with themselves would conclude that they either were or still are at risk.

    3. What is the RISK? Aircraft are imperfectly designed Aircraft are imperfectly maintained Aircraft are imperfectly dispatched Aerodromes are imperfectly designed Aerodromes are imperfectly maintained Aerodrome deficiencies are imperfectly notified Air traffic control is imperfectly carried out Weather presents difficulties Other things go wrong

    4. What is the RISK? Usually, the operating crew responds to each and every challenge in a way that saves the aircraft and all who are aboard Sioux City Iowa, USA (United 232)

    8. What is the RISK? Almost everything went wrong and yet the crew got the aircraft to an airport and saved many onboard So, the imperfections in the aviation system are not risks IF

    9. What is the RISK? The crew manages their resources in a way that allows them to control the challenge. If the challenge is not controlled, bad things happen. The single best chance of controlling any problem is through procedural discipline and EFFECTIVE CRM

    10. “déjà vu all over again”- yogi berra Delta 191, Dallas, 1985 “Summer of ’87” Delta 1141, Dallas, 1988

    11. DELTA 191

    12. DELTA 191 The aircraft crashed while on final approach to Dallas after encountering severe windshear. The plane landed in a field, careened across a highway crushing a car, and bounced onto the airfield where it hit two 4 million gallon water tanks The crew was well aware of the weather but chose to continue the approach

    13. SUMMER of ‘87

    14. SUMMER of ‘87 In June 1987, the pilot of a Delta jet inadvertently shut off the engines of his plane, causing it to plunge 1,100 feet before power was restored. A week later, a flight approaching a Lexington, Ky., airport mistakenly landed at the wrong airport 20 miles away.

    15. SUMMER of ‘87 The next week, a Delta jet strayed 60 miles off course over the Atlantic Ocean and nearly collided with another aircraft. And just a few days after that, a Delta flight landed on the wrong runway of the Boston airport.

    16. SUMMER of ‘87 From the NY Times report of Delta 1141 crash – “Determining that the 1987 incidents all resulted from pilot error, the company last September began bringing all of its pilots in for retraining. “

    17. DELTA 1141

    18. DELTA 1141 August 31, 1988 Two facts were primarily blamed for the incident: The crew had not ensured that the wing's flaps and slats were properly positioned for take-off, and the plane's takeoff warning horn, designed to alert the crew if the engines are throttled to take-off power without the flaps and slats being correctly set, was not operating correctly.

    19. DELTA 1141 The airplane did not gain sufficient speed to climb in a flaps and slats retracted condition, causing a loss of lift and subsequent collision with equipment pertaining to the ILS (instrument landing system) at the departure end of the runway. 14 people died

    20. “déjà vu all over again”- yogi berra We (the Delta pilots) proved that our flight deck procedures were flawed, badly flawed We (management, pilots, government) had to act or lose the airline

    21. “déjà vu all over again”- yogi berra Delta initiated an outside contractor to provide effective CRM training at significant expense Delta Pilots union not only supported the training but said so in a very public way The FAA allowed us to self correct in a non punitive, just culture environment

    22. KOREAN AIR 801

    23. KOREAN AIR 801 The airplane had been cleared to land on runway 6 Left at A.B. Won Guam International Airport, Agana, Guam, and crashed into high terrain about 3 miles southwest of the airport on August 6, 1997 It was determined that the captain's failure to adequately brief and execute the nonprecision approach and the first officer's and flight engineer's failure to effectively monitor and cross-check the captain's execution of the approach were primary causes. Contributing to these failures were the captain's fatigue and Korean Air’s inadequate flight crew training.

    24. KOREAN AIR 8509

    25. KOREAN AIR 8509 December 22, 1999- Collision with ground after take off killing all 4 crew. On impact, the aircraft was assessed to be pitched approximately 40· nose down and banked close to 90· to the left; the speed was high in the region of 250 to 300 kt. Indications are that the aircraft was structurally complete at impact.

    26. KOREAN AIR 8509 Inadequate airmanship combined with inadequate maintenance troubleshooting of an ADI problem led to the accident The case prompted numerous changes at the airline in three key areas: basic flying skills in partial-panel situations, crew resource management, and maintenance trouble-shooting

    27. “déjà vu all over again”- yogi berra Cockpit resource management (CRM) training has been strengthened. The AAIB urged that it be strengthened further to "ensure adaptation of imported material to accommodate the Korean culture." The godlike authority invoked in the captain, a manifestation of traditional Korean structure, has sometimes been criticized as an impediment to good CRM.

    28. WILL IT WORK HERE? every culture is different- but the airplanes, airspace and aerodromes are the same everywhere and the laws of physics always apply But our culture is different- Properly implemented CRM addresses culture The culture question must be resolved

    29. Garuda 200 - Jogjakarta, March 2007

    30. Garuda 200 - Jogjakarta, March 2007 What happened? NTSC Factual Report: There was no evidence of any defect or malfunction with the aircraft or its systems that could have contributed to the accident.

    31. Garuda 200 - Jogjakarta, March 2007 The Yogyakarta Air Traffic Controller advised the crew: • QNH10 1004 millibars • Surface wind calm. The crew informed the investigation that they were conducting an Instrument Landing System (ILS) approach to runway 09 (Figure 2), in visual meteorological conditions

    32. Garuda 200 - Jogjakarta, March 2007 23:57:34 The flaps reached the five degrees position when the speed was 248 knots, at 1,088 feet pressure altitude or 473 feet above aerodrome elevation. 23:57:41 GPWS sounded the ‘WHOOP, WHOOP, PULL UP’ warning twice until 23:57:45. At 23:57:45 the terrain closure rate was 1,517 feet per minute, and the aircraft was 153 feet above the aerodrome elevation. 23:57:43 Pressure altitude 832 feet, or 185 feet above the aerodrome elevation, airspeed 240.5 knots, and wind direction from 170.2 degrees at 23:57:41 to 049.2 degrees at 23:57:45, speed constant at 5 knots. The copilot called ‘Wah Capt, go around Capt’.

    33. Garuda 200 - Jogjakarta, March 2007 The aircraft was destroyed by the impact forces and an intense, fuel-fed, post-impact fire. There were 119 survivors. One flight attendant and 20 passengers were fatally injured. One flight attendant and 11 passengers were seriously injured. The investigation determined that the flight crew’s compliance with procedures was not at a level to ensure the safe operation of the aircraft.

    34. Garuda 200 - Jogjakarta, March 2007 Compliance? How about resource management?

    35. Adam Air 574 - Makassar strait, January 2007

    36. Adam Air 574 - Makassar strait, January 2007 What happened? NTSC Factual report: The DFDR analysis showed that the aircraft was in cruise at FL 350 with the autopilot engaged. The autopilot was holding 5 degrees left aileron wheel in order to maintain wings level. Following the crew’s selection of the number-2 (right) IRS Mode Selector Unit to ATT (Attitude) mode, the autopilot disengaged. The control wheel (aileron) then centered and the aircraft began a slow roll to the right. The aural alert, BANK ANGLE, sounded as the aircraft passed 35 degrees right bank.

    37. Adam Air 574 - Makassar strait, January 2007 The DFDR data showed that roll rate was momentarily arrested several times, but there was only one significant attempt to arrest the roll. Positive and sustained roll attitude recovery was not achieved. The pilot did not roll the aircraft’s wings level before attempting pitch recovery in accordance with standard operating procedures. The recorded airspeed exceeded Vdive (400 kcas), and reached a maximum of approximately 490 kcas just prior to the end of recording.

    38. Adam Air 574 - Makassar strait, January 2007 Flight recorder data indicated that a significant structural failure occurred when the aircraft was at a speed of Mach 0.926 and the flight load suddenly and rapidly reversed from 3.5g to negative 2.8 g. This g force and airspeed are beyond the design limitations of the aircraft. The aircraft was in critically uncontrollable state.

    39. Adam Air 574 - Makassar strait, January 2007 The PIC did not manage task sharing and crew resource management practices were not followed. There was no evidence that the pilots were appropriately controlling the aircraft, even after the BANK ANGLE alert sounded as the aircraft’s roll exceeded 35 degrees right bank

    40. Adam Air 574 - Makassar strait, January 2007 There were 102 people on board; two pilots, 4 cabin crew, and 96 passengers comprised of 85 adults, 7 children and 4 infants.

    41. What is the RISK? This is important! “CREW RESOURCE MANAGEMENT PRACTICES WERE NOT FOLLOWED”. That is the risk! But, are these isolated examples or do they speak to Indonesian aviation culture?

    42. CRM When, within three months there are two such accidents, It seems fair to draw the conclusion that there may be a general problem with the application of CRM in Indonesian Airlines. This is true even with the existence of some formal CRM training. Is the training effective?

    43. CRM Possibly not: GA200 demonstrated a PIC that would not take guidance from the F/O and an F/O that did not feel empowered to take command, even with “company policy” to the contrary

    44. CRM Adam Air 574 demonstrated that both crew members can become so involved with a minor technical fault that both forgot to ‘fly the airplane” When they did take control, their actions were inappropriate to the situation

    45. WILL IT WORK HERE? Our culture is different- but the airplanes, airspace and aerodromes are the same as everywhere else and the laws of physics still apply But our culture is different- Properly implemented CRM addresses culture The culture question must be resolved

    46. WILL IT WORK HERE? Recall that the airline, aircraft, aerodromes and air traffic service may let you down, but that is almost never a reason for the loss of the aircraft The flight crew is the last defense in the air transportation system and CRM is their best weapon

    47. QUESTIONS, COMMENTS, BRICKS? Thank you for your kind attention

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