Safety Briefings

The Capacity to Stand Defeat (Part 2)

by Charlie Marais
2014-08-01

RESEARCH FOUNDATION

Research quoted results were derived from accidents where there were no mechanical failures and could be attributed to human shortcomings only.  These accidents were randomly selected over a period of three years from the accident investigations of the Flight Safety Foundation.  A further commonality was that all the case studies were classified as CFIT accidents.  The four areas measured as direct contributors to the accidents utilised were knowledge, skills, attitude (discipline) and human design.

RESEARCH RESULTS

The following results were obtained:

Knowledge:  The first building block towards sound decision making is knowledge.  The lack of knowledge has shown in my research to have a direct influence on 6% of the accidents.  Without the correct knowledge, a sound decision is not possible.  When knowledge of the problem and its building blocks are not known, decision making is said to be calculated.  The true facts, the understanding of concepts, the knowledge of SOP's, to know something from experience and to be fully aware of the problem, its development and consequences, are all supplements to knowledge required when an informed decision has to be made.  The risk then becomes more truly calculated.

Skills:  We need to be skilful in many ways to be able to transform our knowledge of the problem into an effective antidote.  Motorised, verbal, cognitive, emotional and people skills are but a few essentials to move from knowledge to action in resolving the problem though sound decision making.  My research has shown that the lack of skills have had a direct influence on 20% of accidents.

Attitude:  Our attitude is merely a measure of how well we are aligned with the norms, truths and values of our environment.  When we knowingly and willingly deviate from those standards, we are said to be ill disciplined.  This lack of discipline by aviators has shown to contribute as many as 24% of accidents.

Human Design:  My research has shown that at least 50% of the accidents due to human error were due to the nature of our design.  Our ability to compute information, to become aware of deviations from the required norms, our gradual acceptance of high risk areas where no adverse effects have materialised and our ability to perform when stress levels are extremely high, are amongst the factors affecting sound decision making.  It is in this last area of human factors that I would like to focus the presentation on and more specifically that of the human's ability to perform under adverse conditions when the possibility of being defeated is very high.

FACTORS INFLUENCING THE CAPACITY TO STAND DEFEAT

As discussed in the previous paragraphs, in order to make good solid decisions one needs to be well developed in the various fields of knowledge, skills and attitude.  The one part that seems to be a bit unfair, the human design part, is where understanding of human functioning, especially under trying circumstances, needs understanding.  We need to understand the potential shortcomings so as to equip us with an early warning system to proceed with caution.

ENHANCING THE CAPACITY TO STAND DEFEAT

It is clear that we can do something about our present situation of human related accidents.  We should remind ourselves that many technical problems also start with normal human oversight that could be addressed through the same training programs developed for flight crews.  Any person that forms part of a crew to perform their duty should be involved.  Single crew operations also need to be addressed in the training programs as they also have to communicate with other services and thus form a detached crew to complete an operation safely.  They are also team players.

Knowledge is power.  Knowing how to equip oneself for the ultimate test is something valuable only when action is brought to this concept.  The following areas are identified as areas that need attention in the most practical possible way:

Knowledge:  We can expand the knowledge base of our crews, or at least ensure that our crews have complete knowledge of their operational environment.  The 6% of accidents found in the research is avoidable and as a contributing factor to the causation of accidents needs our attention.  Knowledge must be expanded as an ongoing process through:

 o  Continual Learning:  You need to know more about your environment as covered through the five M's.  It is said that you stop learning when you die and you die when you stop learning.

 o  Exposure:  The "real thing" is more valuable than any simulation.  We cannot force this kind of exposure, but to operate in tough conditions gives first hand knowledge.  There are tougher routes to fly.  We must expose our crews, under supervision, to all the situations we possibly can without risking the operation.

 o  Simulation:  The dynamics of an adverse condition is something to be understood.  It is not just the problem facing you, but the total package.  Studies have shown that problems are normally ill-structured and a single cause could have multiple negative results to consider.  Defining the problem still stays the main concern.  Should one be able to define the problem perfectly, its complexity would immediately reduce.

 o  Testing:  Knowledge on such items as letdown plates and approach procedures also need testing.  Technical knowledge and knowledge of the mission needs to be tested from time to time and in a structured way.

Skills:  The accident rate of 20% due to skills shortage is something unacceptable in our modern flight environment.  Although we pay a lot of attention to motorised skills, we still need a lot of advancement in the cognitive environment.  We must teach our crews to think, to become innovative and to be able to contain stress to such a level where thinking is still possible.  We must teach our students to pick up the tell-tale signs of when things are starting to go wrong.  The anomalies must trigger cautious behaviour.  In the area of skills, the following should be addressed:

 o  Simulation:  Simulation of ill-structured situations the crew might face will teach innovation.  To let the crew face the impossible under simulated conditions will lead to thinking far advanced from the normal mundane scenarios used session after session.

 o  Decision Making Exercises:  Even with all the knowledge of a situation one could still lack logic.  The application of logic is an art and a skill that could be practiced, but demands solid knowledge of the task environment.  Should fewer facts be known in a situation, assumptions need to take the place of those hard facts not available.  The logic of assumptions is a skill that needs development.

 o  Risk Calculation:  Outcome based decision making requires the ability to predict and allocate a risk factor coupled to a specific decision made.  This is another skill that could be practised under simulated conditions in the class room.

 o  Communication:  The ability of a crew to communicate freely and relevantly in any situation leads to synergy.  We are reminded that it is not only the language such as English, but it is also the language and knowledge of the medium, machine, management and mission that requires practise.  We must be able to communicate with people and things!

 o  Cross Training:  A pilot that is technically minded has an advantage of communicating the problem experienced to technical crews.  If both the pilots are technically minded or have a fair knowledge of the technical side of the operation, decision making is immediately enhanced when faced with a technical problem.  However, the technical crew does not understand pilot and cabin crew language.  Cross training is essential not only between cockpit and cabin crew, but also between all the other parties such as operations, ground crew, ATC, management and other relevant role players.  ATC for instance has direct access to the cockpit and can induce stress into this environment due to a lack of CRM training as well as a lack of technical knowledge of the aircraft capabilities under certain operational conditions.

Attitude:  Poor discipline must be stamped out.  24% causation in non-technical accidents is simply not acceptable.  If poor discipline is the result of human design or human normal functional failure, it could be understood, but when poor discipline is the result of wilfully and deliberately deviating from the norm, action must be taken.  I suggest a tougher approach towards cases where neglect is premeditated or where neglect has no excuse other than sloppy workmanship attributed to an over casual approach.  Discipline is something we demand from our crews, be it air or ground, but when there is a mishap, we tell crews that as long as they own up to the problem we will not prosecute them.  The information is only required to avoid similar accidents in future.  Well, how will we ever stop poor discipline causation if we are merely collecting data with it?  How can we stop bad discipline if we will never discipline those that require discipline?  The following actions are recommended:

 o  Discipline Culture:  Ill discipline is not OK!  This message must be preached and practised.  This is a top down approach through example of excellent behaviour.

 o  Train Discipline Behaviour:  Only when we have been tempted to stray from the norms will we find out what it takes to stick to the norms.

 o  Punitive Action:  If discipline is not appropriately rewarded, positive or negative, your discipline accidents and incidents will never change for the better.  Negative behaviour must not be left alone or ignored.  This is like silent consent.  Discipline needs to be enforced through a disciplined approach.

 o  Good Relationships:  There must be good relationships between co-workers, air and ground, between management and crews, between support structures and the cockpit.  Good relationships are based on good behaviour, honesty and putting your company first.  After all, it is where you earn your living.

Human Design:  A whopping 50% of accidents due to our design shortcomings are neither a doomsday call nor a reason to be resigned to the inevitable.  There are clear tell-tale signs when we enter into a situation where we are prone to become less functional, rational or effective.  If we understand how we function under stress, we could be taught what the signs are to look out for.  We must learn what triggers a set of events that will lead to disaster.  In most accidents we pick it up in the investigation and we stand in amazement that the set of events did not trigger a different set of behaviour.  We might know enough of human design but we are still short in training these factors to crews under realistic (chaotic adverse conditions preceding an accident) conditions so as to equip them to recognise the symptoms and to react to them.  There are so many facets to human design or human factors involved in the way decisions are made.  The following are but a few highlighted for this particular discussion:

 o  Individual Stress Behaviour:  Each one of us will have a different capacity to handle stress.  Should we be able to discover the individual's stress behaviour, we would be able to address possible shortcomings and train to overcome certain anxieties.

 o  Understand Human Shortcomings:  It is important for crews to understand their own as well as the general human shortcomings in order to recognise the early signs of being sucked into a trap for which our design cannot cater.

 o  Develop SOP's:  Where possible SOP's to govern behaviour under certain stressful conditions should be researched and developed.  These SOP's would govern human behaviour under certain conditions and not the machine or environment.

 o  Train Adverse Condition Decision Making:  Crews should be subjected to extraordinary circumstances in which their decision making skills are tested.  Simulations in terms of motorised skills are well defined and tested, but the human mind's ability to bring order to a chaotic situation is what should be challenged and developed.

 o  Crew Composition:  If we know our crews better, we would be able to pair complimentary crew.  The ability to partner the most suitable crew is an art that should be developed.  The operational nightmare of attempting such a roster would indeed be more than challenging. However, one could start with broader spectrum experience versus newcomers.  Known stress behaviour could become criteria in the pairing of crews.  This field is still wide open for research and development to make crew synergy an optimal tool.

CONCLUSION

Even if the research is 50% off the mark, we still have a chance to enhance our chances should we understand the dynamics of our environment.  We must do more research, discover individual behaviour at the next level, develop the ability to understand when we enter into the beginning stages of ineffectiveness, formulate SOP's to restore some order in the chaos preceding an accident and condition rational thought under extreme stress conditions.  We must not tolerate deviations from the norms and values set by the company and the aviation family.  We have a better chance than the one we are giving ourselves at this moment.

Yes, we will meet resistance, but the challenge is clear.  Either we invest in human development with less stinginess, or we continue to pay the price.  As a paying passenger I would rather be safe than just feel safe.

Safety can manifest itself only through dedicated and diligent action, but never through a façade of non-action talk and written communication.  We must walk the talk and live the vision!

DIAGRAM 1:


CHALLENGE

The challenge to this forum is quite clear.  It is time to finance research in a co-ordinated and focused effort.  Human related accident contribution needs a holistic approach in order to determine the way forward in a most professional way.  It is time that efforts are combined to tackle the challenges of the future cockpit.  It is time that single man research teams are incorporated into the bigger organ to enable diverse, but co-ordinated efforts in finding training solutions to our increased challenge of:

See DIAGRAM 1 (above)



SOURCE
FLIGHT SAFETY FOUNDATION JULY 2003

ACCIDENT DESCRIPTION
B-737 CREW'S UNSTABILISED APPROACH RESULTS IN OVERRUN OF A WET RUNWAY

SHORT DESCRIPTION OF EVENTS LEADING TO THE ACCIDENT
Twilight visual meteorological conditions prevailed about 1811 local time on March 5, 2000, when a Boeing 737-300, being operated as flight 1455 by Southwest Airlines, overrun the departure end of runway 08 during a landing at Burbank Glendale-Pasadena airport.  The airplane struck a metal blast fence and an airport perimeter wall.  Air traffic control instructions caused the Boeing 737 to be high, fast and close to the runway when the crew conducted a turn to establish the airplane on final approach.  Two passengers received serious injuries, 41 passengers and the captain received minor injuries, and 94 passengers, three flight attendants and the first officer received no injuries.  

NTSB FINAL REPORT
The probable cause of the accident was the flight crew's excessive airspeed and flight path angle during the approach and landing, and the crew's failure to abort the approach when stabilised approach criteria were not met.  The flight crew's only safe option at the time was a go-around.

CONTRIBUTING FACTORS
The controllers positioning of the airplane in such a manner as to leave no safe options for the flight crew other than a go-around manoeuvre.



SOURCE
FLIGHT SAFETY FOUNDATION JUNE 2002

ACCIDENT DESCRIPTION 
COMMUTER AIRCRAFT STRIKES TERRAIN DURING UNSTABILISED, HOMEMADE APPROACH

SHORT DESCRIPTION OF EVENTS LEADING TO THE ACCIDENT
At 2357 local time Aug 12, 1999, a Raytheon Beech 1900D operated on a scheduled flight by Regionnair struck terrain one nautical mile from runway 31 at Sept-Iiles airport during an approach in instrument meteorological conditions that included a 200 foot ceiling and 0.25 statute mile visibility.  The crew used self-programmed GPS waypoints for navigation during a night approach, with weather conditions below minimums for the published non-precision approach.  The captain was killed, the first officer received serious injuries and two passengers received minor injuries.

NTSB FINAL REPORT
The pilot flying (first officer) did not establish a maximum performance climb profile, although required b y the company's SOP's, when the GPWS warning sounded during the descent in cloud, to the NDB, 4.1 nm from the runway.

The pilot flying did not fly a stabilised approach, although required by the company SOP's.  The crew did not carry out a go-around when it was clear that the approach was not stabilised.

The crew descended the aircraft well below the safe minimum altitude while in  IMC.

Throughout the approach, even at 1000 feet above ground level, the captain asked the pilot flying to continue the descent without having established visual contact with the runway environment.

After the GPWS voice activation at 100 feet AGL, the aircraft rate of descent continued at 850 feet per minute until impact.

The crew conducted in cloud and low visibility, a user-defined GPS approach to runway 31, contrary to regulations and safe practice.



SOURCE
FLIGHT SAFETY FOUNDATION NOVEMBER 2002

ACCIDENT DESCRIPTION
REDUCED VISIBILITY, MOUNTAINOUS TERRAIN CITED IN GULFSTREAM III CFIT AT ASPEN

SHORT DESCRIPTION OF EVENTS LEADING TO THE ACCIDENT
About 1901 local time on March 29, 2001, a Gulfsteam III operated by Avjet Corp struck terrain approximately 2400 feet from the runway threshold during a non-precision approach in IMC.  As darkness increased and weather conditions deteriorated, the pilots continued the non-precision approach below minimums without adequate visual reference.  The two pilots, the flight attendant and the 15 passengers were killed.  The airplane was destroyed.

NTSB FINAL REPORT
The probable cause of the accident was the flight crew's operation of the airplane below MDA without visual reference of the runway.

CONTRIBUTING FACTORS
The FAA unclear wording of a March 27. 2001, NOTAM regarding the night time restrictions for the VOR/DME approach to the airport and the FAA's failure to communicate this to the Aspen ATCT.

The inability of the aircrew to adequately see the mountainous terrain because of darkness and the weather conditions.

The pressure on the captain to land from the charter customer and because the airplane's delayed departure and the airport's night time landing restriction.



SOURCE
FLIGHT SAFETY FOUNDATION APRIL 2003

ACCIDENT DESCRIPTION
SABRELINER STRIKES MOUNTAIN RIDGE DURING NIGHT VISUAL APPROACH

SHORT DESCRIPTION OF EVENTS LEADING TO THE ACCIDENT
On May 10, 2000, the crew of a Rockwell Sabreliner 65 cancelled their IFR clearance during a non-precision instrument approach to Molokai Airport and conducted a visual to the airport in VMC.  The aircraft struck mountainous terrain 3.3 nm southwest of the airport.  The captain, co-pilot and four passengers were killed by the impact and post impact fire.

NTSB FINAL REPORT
The NTSB said that" inadequate crew co-ordination led to the captain's decision to discontinue the instrument approach and initiate a manoeuvring descent solely by visual reference at night in an area of mountainous terrain."

The crew failed to review the instrument approach procedure, and the co-pilot failed to provide accurate information regarding the terrain clearance and let-down procedures during the instrument approach.



SOURCE
FLIGHT SAFETY FOUNDATION JANUARY 2002

ACCIDENT DESCRIPTION
CARGO AIRPLANE STRIKE FROZEN SEA DURING APPROACH IN WHITE-OUT CONDITIONS

SHORT DESCRIPTION OF EVENTS LEADING TO THE ACCIDENT
On March 19, 1999, a de Havilland DHC-6-300 Twin Otter on a cargo flight, was destroyed when it struck the frozen surface of the Labradir Sea during a NDB approach to Davis Inlet Airport.  The pilots descended below minimums during the NDB approach.  They were heads-up, seeking visual references, when the airplane struck the ice in a controlled descent.  The captain received serious injuries and the first officer was killed.

NTSB FINAL REPORT
The captain decided to descent below MDA without the required visual references.

After descending below MDA, both pilots were pre-occupied with acquiring visual contact with the ground and did not adequately monitored the flight instruments, with the consequence of the airplane striking the ice.



SOURCE
FLIGHT SAFETY FOUNDATION JUNE 2001

ACCIDENT DESCRIPTION
RUNWAY OVERRUN OCCURS AFTER CAPTAIN CANCELS GO-AROUND

SHORT DESCRIPTION OF EVENTS LEADING TO THE ACCIDENT
At 2247 local time Sep 23, 1999, a Boeing 747-438 was landed beyond the touchdown zone on runway 21L at Bangkok International Airport, hydroplaned on the wet runway and ran off the end of the runway.  The aircraft was configured for a dry-runway when heavy rain occurred on final approach.  The captain told the first officer (the flying pilot) to go around but then retarded the throttle levers when the main landing gear touched the runway.  The airplane was substantially damaged.  The occupants successfully evacuated the airplane with no injuries sustained.

ATSB FINAL REPORT

Unsafe acts and active failures:
- The aircrew did not use an adequate risk management strategy for the approach and landing.
- The first officer did not fly the aircraft accurately during the final approach.
- The captain cancelled the go-around decision by retarding the thrust levers.
- The flight crew did not select (or notice the absence of) idle reverse thrust.
- The aircrew did not select (or notice the absence of ) full reverse thrust.
- The flight crew did not consider all relevant issues when deciding not to conduct an immediate evacuation.
- Some crew members did not communicate important information during the emergency period.

Other significant failures:
- The runway surface was affected by water.
- The cabin interphone system and passenger address system became inoperable.

Significant latent failures company related:
- Company published information, procedures and flight crew training for landing on water-affected runways were deficient.
- Flight crew training in evaluating the procedural and configuration options for approach and landing was deficient.
- Procedures and training for cabin crew in identifying and communicating relevant information during an emergency were deficient.
- The processes for identifying hazards were primarily reactive and informal, rather than proactive and systematic.
- The processes to assess the risks associated with identified hazards were deficient.
- The processes to manage the development, introduction and evaluation of changes to operations were deficient.
- The design of operational procedures and training were over-reliant on the decision making ability of company flight crew and cabin crew, and did not place adequate emphasis on structured processes.
- Management culture was over-reliant on personnel experience and did not place adequate emphases on structured processes, available expertise, management training and research and development when making strategic decisions.

Significant latent failures CASA related:
- The regulations covering contaminated runway operations were deficient.
- The regulations covering emergency procedures and emergency procedures training were deficient.
- The surveillance of airline flight operations was deficient.

Aircraft related latent failure:
The redundancy provided by the normal and alternate cabin-interphone and public address systems in the B747-400 was significantly reduced because components for both systems were co-located in the same damage-prone position in the lower fuse3lage aft of the nose wheel.



SOURCE
FLIGHT SAFETY FOUNDATION JUNE 2003

ACCIDENT DESCRIPTION
FAILURE TO MAINTAIN SITUATIONAL AWARENESS CITED LEARJET APPROACH ACCIDENT

SHORT DESCRIPTION OF EVENTS LEADING TO THE ACCIDENT
At 1005 local time on Dec 24, 1996, a Learjet 35A struck mountainous terrain at 2300 feet during a VOR approach in IMC to runway 25 at Lebanon Municipal Airport.  During the approach the crew was unaware of a 40-knot wind that led to the accident.  At the time no locator transmitter was required on the turbojet.  The site was not located until nearly three years after the aircraft was reported missing.

NTSB FINAL REPORT
The captain's failure to maintain situational awareness, which resulted in the airplane being outside the confines of the instrument approach, and the crew's misinterpretation of a step-down fix passage, which resulted in an early descent into rising terrain.

- The captain misread the approach procedure.
- The crew rushed which resulted in an incomplete instrument approach briefing.
- The crew's failure to use additional, available navigational aids.
- The crew failed to account for the winds at altitude.



SOURCE
FLIGHT SAFETY FOUNDATION NOVEMBER 2001

ACCIDENT DESCRIPTION
DOUGLAS DC-3 STRIKE HILL DURING NIGHT CARGO FLIGHT

SHORT DESCRIPTION OF EVENTS LEADING TO THE ACCIDENT
At 0633 local time Jan 13, 1999, a Douglas DC-3C on a night VFR cargo flight from Vancouver to Victoria, struck a hill on Mayne Island, about 14 NM north of Victoria international Airport.  The impact occurred at about 900 feet.  The airplane then descended into the valley, struck ground and burned.  The flight crew is believed to have conducted a night VFR operation beneath a low ceiling and below Canadian OCH requirements.  Both pilots were killed.

NTSB FINAL REPORT
The Canadian TSB concluded as follows:

- The flight was not conducted in accordance to OCH requirements.
- The Kelowna flight company operations manual did not reflect the restrictive conditions imposed on night VFR flights according to the applicable Canadian air regulation.
- AS the airplane approached Mayne Island it encountered a low cloud ceiling that was based about 800 feet and that reduced visual reference with the surface.
- When the aircraft struck trees, it was being flown in controlled, level flight at an attitude below the surrounding terrain.
- The aircraft was not equipped with a GPWS or any other similar device (nor required by regulations).
- Kelowna Flightcraft flight operations personnel were not aware that most of the DC-3 flights were being conducted under VFR.
- First responders were not aware of the presence of dangerous goods on board and were at greater than normal risk.
- Canadian transport officials responsible for monitoring the this operation were not aware that most DC-3 flights were conducted under VFR conditions and below required OCH.



SOURCE
FLIGHT SAFETY FOUNDATION DECEMBER 2002

ACCIDENT DESCRIPTION
NON-ADHERENCE TO STANDARD PROCEDURES CITED IN AIRBUS A320 CFIT IN BAHRAIN

SHORT DESCRIPTION OF EVENTS LEADING TO THE ACCIDENT
About 1930 local time on Aug 23, 2000, an Airbus A320 struck water in the Arabian Gulf about three NM northwest of Bahrain International Airport, during an attempted go-around in night VMC.  The crew likely developed acute special orientation during the go-around.  The GPWS generated nine warnings before the aircraft struck the sea.  All on board were killed.

NTSB FINAL REPORT
he Bahrain Accident Investigation Board attributed the accident to the following individual contributing factors:

- Non-adherence to SOP's by the captain.
- The first officer did nit draw the attention of the captain to the deviation of the aircraft from the standard flight parameters and profile.
- Spatial disorientation and information overload was experienced by the flight crew.
- The aircrew were non-responsive to the GPWS warnings.

CONTRIBUTING FACTORS
- A lack of CRM training, inadequacy in some of the airline's A320 flight crew training program.
- Problems in the airline's flight data analyses system and flight safety department.
- Organisational and management issues.
- Safety oversight factors by the regulator.

CFIT ACCIDENT COMMONALITIES
- Night Approaches. (Environment)
- Night with marginal weather conditions. (Environment)
- Night VFR followed, or during the final stages of the approach change from IFR to VFR. (Man, judgement)
- When time constrained, a rushed approach results. (Man, Emotional)
- No review of the approach plate, especially with reference to sector safety altitudes for terrain clearance. (Man, PJ, Attitude)
- Non adherence to company SOP's. (Man, PJ, Attitude)
- Flight not stabilised at approach gate. (Equilibrium point)
- Commercial pressure. (Man, Emotional)
- Flight below published minimums (MDA, MDH, OCH) without adequate visual references. (Man, Judgement, Human Factors)
- Lack of appreciation of the "black hole" phenomena. (Man, Knowledge)
- Pre-occupation with finding visual contact when visual contact not possible. (Man, Emotional)
- Loss of situational awareness or special disorientation. (Man, Human Factors)
- Crews are caught up in the moment, which results in poor procedural performance. (Man, Human Factors)
- Failure to communicate with the aircraft. (Man machine interface, Knowledge of Machine)
- Not efficient crew cross-reference and cross-checks. (Man, Human Factors)
- Non adherence to GPWS warnings. (Man, Emotional)

Environment   12,5%   (Knowledge)
Man EQ   25%   (Human Design)
Man Poor Judgement   25%   (Attitude)
Man Human Factors   25%   (Human Design)
Man Machine Interface   6.25%   (Knowledge and Skills)
Man Knowledge   6,25%   (Knowledge)
Man contribution overall   87,5%
Environment Contribution Overall    12,5%
Skills   6,25%
Knowledge   18,75%
Attitude (Discipline)   25%
Human Design   50%