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CRM: THE MISSING LINK

 

On September 8, 1970, a Trans International DC-8-63F (Ferry Flight #863) crashed on takeoff at JFK. The NTSB found the cause to be:

"...loss of pitch control caused by the entrapment of a pointed, asphalt-covered object between the leading edge of the right elevator and the right horizontal spar web access door in the aft part of the stabilizer...an apparent lack of crew responsiveness to a highly unusual emergency situation, coupled with the captain's failure to monitor adequately the takeoff, contributed to the failure to reject the takeoff."

The elevator was jammed to almost the full-up position. The crew could not have known that, as they started the takeoff roll, because the plane was design-certified (incredibly) without a control indicator in the cockpit. However, they had adequate time to realize pitch control was lost as the plane began to rotate at a speed of 80 kts. The tail skid began dragging the ground at 91 kts. and could be heard on the CVR (cockpit voice recorder). The F/O (first officer) was flying and the planned Vr (rotation) speed was 124 kts. The tail skid left its marks on the runway, beginning at 1,550 ft. from the takeoff end and continued for an additional 1,250 ft. The plane left the runway (dry, with over 14,000 ft. available) at a point 2,800 ft. from the takeoff end. Twelve seconds after the unwanted pre-mature rotation and 11 seconds after the sound of the dragging tail skid, the captain words of "let's take it off" were recorded on the CVR. Two and one-half seconds later the F/O replied, "Can't control this thing, Ron." ("Ron" was the captain's name) One second later the sound of the stick shaker began.

They took off in daylight with a headwind and clear weather. Clearly, the captain made the wrong decision by deciding to continue the takeoff instead of aborting. It is also clear that if the F/O had overruled the captain and initiated an abort himself, when it became obvious that he had no pitch control, the plane would not have crashed and those 11 crewmembers would not have died.

On June 7, 1971, an Allegheny Airlines prop jet Convair 340/440 (flight #485) crashed into "the upper portions of three beach cottages at a height of approximately 29 feet m.s.l. (mean sea level),..." The plane was making a VOR (non-precision) approach to the Tweed-New Haven Airport in heavy fog. The MDA was 380 ft. The NTSB determined the probable cause

"...was the captain's intentional descent below the prescribed minimum descent altitude under adverse weather conditions, without adequate forward visibility or the crew's sighting of runway environment. The captain disregarded advisories from his first officer that minimum descent altitude had been reached and that the airplane was continuing to descend at a normal descent rate and airspeed. The Board was unable to determine what motivated the captain to disregard prescribed operating procedures..."

There was no doubt about the descent below MDA being intentional. The flight recorder revealed AL #485 had made 3 VOR approaches to the Groton Trumbull airport (the enroute stop prior to the Tweed-New Haven stop), when reported weather was well below that required to initiate the approach. The MDA for the Groton approach was 610 feet, yet the flight recorder showed a descent to 175 feet, for the first two approaches, before a missed approach was initiated. On the third approach, the plane descended to 125 feet, yet still failed to land. The captain finally landed at Trumbull by making the 4th try as a "contact approach."

In its "human factors" discussion of that accident, the NTSB noted both the Allegheny Airlines procedures relating to the responsibilities of a F/O and also the testimony of the surviving F/O:

"These procedures further state that:

'All crewmembers must realize that the captain is in complete command of the airplane and his orders are to be obeyed, even though they may be at variance with written instruction...'

"First Officer Walker, in response to a direct question, that at any time during the approach after passing minimum descent altitude did he consider taking over control of the airplane, the first officer replied that '...There was a thought in my mind..., It's better one man flying the airplane in perfect control, than than [sic] two men fighting over it...Had he been incapacitated in any manner, I mean, I would have, because that is the only time that I can take an airplane away from a captain.'"

"Considerable testimony was developed during the public hearing and during the interviews with the first officer. Much of this testimony was oriented toward the fundamental question: 'Why did the first officer not take more positive action or possibly take over control of the airplane when an extremely low and dangerous altitude was reached?'

"...The captain could also be classified as an authoritarian who enjoyed absolute command. By contrast, the first officer appeared to be the quiet, submissive type, not one who would question a superior or his authority."

"These personality profiles, combined with the apparent friendly relationship that existed between the captain and the first officer, would be conducive to a situation wherein the first officer would not challenge the judgment of the captain under virtually any operational circumstances."

"...The Safety Board fully appreciates the most difficult dilemma of the first officer in this case and recognizes the possibility of grave consequences in questioning the captain's command authority under a situation as developed in the case of AL 485."

"The Safety Board is concerned with the apparent delegation of authority for operational control to the Pilot-in-Command without a concomitant system to assess the effectiveness of how that authority is exercised in view of the air carrier operator's duty to perform the operation with the highest of safety [sic]."

"Inherent with delegation is a responsibility to assure that the delegation is effectively fulfilled. In this instance the Captain's deviation from the regulations governing the operation and the air carrier's operating certificate was one that the operator could not control at that moment."

"The concept of command authority and its inviolate nature, except in the case of incapacitation, has become a a [sic] tenet without exception. This has resulted in second-in-command pilots reacting differently in circumstances where they should perhaps be more affirmative. Rather than submitting passively to this concept, second-in-command pilots should be encouraged under certain circumstances to assume a duty and responsibility to affirmatively advise the pilot-in-command that the flight is being conducted in a careless or dangerous manner."

"...The second-in-command is an integral part of the operational control system in-flight, a fail-safe factor, and as such has a share of the duty and responsibility to assure that the flight is operated safely. Therefore, the second-in-command should not passively condone an operation of the aircraft which in his opinion is dangerous, or which might compromise safety. He should affirmatively advise the captain whenever in his judgment safety of the flight is a [sic] jeopardy."

"...The Board recognized that there is a dearth of guidelines regarding the circumstances and manner in which a flight crewmember should take affirmative action, which in turns leads to uncertainly [sic] in his mind when an actual dangerous situation [sic]. For this very reason, and in light of the circumstances of this accident, the Board believes that management and pilots' organizations should reexamine the relationship between the captain and flight crewmembers with a view toward enunciating the responsibilities in circumstances where the aircraft is being operated unsafely."

"The Board believes that it is incumbent upon the air carrier's management to devise and carry out a system that would enable it to continually assess the pilot-in-command's performance in executing the carrier's operational control responsibility which it must rely, to a great extent, upon the pilot-in-command to fulfill."

While it is not certain the plane would not have crashed, if the F/O had taken the controls and forced a climb back to a safe altitude (since the reaction of the captain, in that scenario, can only be speculated upon), it is certain the plane did crash because the captain was allowed to have his way.

On January 11, 1983, a United Airlines DC-8 freighter, crashed on takeoff at the Detroit airport, primarily because the stabilizer was mistrimmed. The takeoff warning horn did not activate because (incredibly) the plane was design-certified without the stabilizer position being tied into the warning horn system. The plane was destroyed and all 3 crewmembers died.

The NTSB also noted the captain allowed a non-qualified pilot (the second officer) to occupy the F/O's seat and make the takeoff (pilots refer to it as musical chairs). That second officer had failed to qualify as a DC-8 F/O and had lost his qualification as a 737 F/O and was permanently removed from all pilot duties, by mutual agreement with the company. The NTSB concluded the crash could have been prevented if the flying pilot had immediately applied nosedown trim and forward elevator when the plane began to over rotate -- a likely scenario, if the flying pilot was qualified and familiar with the normal control forces of the DC-8, which was not the case with the incompetent second officer.

It is likely, therefore, that the captain and F/O would have noted and corrected the stabilizer mistrim, during the running of the pre-takeoff checklist, had they not been distracted from their normal flow of duties by the seat swapping that occurred just one minute prior to takeoff. Or, if they had still failed to catch that error, after running the checklist, it is likely the highly qualified F/O would have immediately taken corrective action when he felt the plane rotating prematurely, if he had refused to relinquish his seat to the incompetent second officer.

On January 13, 1977, a Japan Airlines DC-8-62 freighter, carrying live beef cattle to Japan, crashed shortly after takeoff from the Anchorage, Alaska International Airport. The plane was destroyed and the three crewmembers and two cargohandlers aboard were killed. The NTSB determined:

"...the probable cause of the accident was a stall that resulted from the pilot's control inputs aggravated by airframe icing while the pilot was under the influence of alcohol. Contributing to the cause of this accident was the failure of the other flightcrew members to prevent the captain from attempting the flight."

The NTSB, once again, became very concerned about why the other crewmembers stood by and did not prevent the accident even though they must have realized they were getting into a very precarious position:

"In view of the overwhelming evidence of the captain's condition, the Safety Board must consider the lack of action by the other crewmembers."

"...It is extremely difficult for crewmembers to challenge a captain even when the captain offers a threat to the safety of the flight. The concept of command authority and its inviolate nature, except in the case of incapacitation, has become a practice without exception. As a result, second-in-command pilots react indifferently in circumstances where they should be more assertive. Rather than submitting passively to this concept, second-in-command pilots should be encouraged to affirmatively advise the pilot-in-command that a dangerous situation exists. Such affirmative advice could result in the pilot-in-command's reassessing his actions. The Safety Board has previously stated, and continues to believe, that the second-in-command is an integral part of the operational control of a flight, is a fail-safe factor, and has a share of the duty and responsibility to assure that the flight is operated safely. Therefore, the second-in-command should not passively condone any operation of the aircraft which might compromise safety. He should affirmatively advise the captain whenever, in his judgment, safety of flight is in jeopardy, particularly when the safety problem is detected before the flight is airborne. The Safety Board could not determine what transpired between the crewmembers before they boarded the aircraft, but there is little or no evidence that the second-in-command or the flight engineer expressed any concern about the safety of the flight. In addition, there is no evidence that they took any action to prevent the flight from proceeding as planned."

On March 27, 1977, the worst carnage in airline history occurred when a KLM captain insisted on commencing a takeoff at Tenerife, in heavy fog, without a takeoff clearance and with the knowledge that another 747 (Pan American) was taxiing down that runway and had not yet reported clear of the runway. Both the F/O and second officer knew they had not received clearance to takeoff and that they had not confirmed Pan Am had taxied off the runway. They tried to convey those concerns to the KLM captain, but he insisted on commencing the takeoff because he was concerned about running out of legal duty time for the flight crew.

Had the F/O jammed on the brakes and yanked the throttles back to idle, in direct defiance of the KLM captain, 583 people would not have suffered a terrible death by fire.

In 1990, a 747 relief F/O advised his captain they were departing the gate (starting the first leg of a long international trip) illegally as certain "no go" maintenance items had not been resolved. The captain refused to listen, even though one of the items was related to the takeoff configuration warning system.

As the conversation continued, it became clear the captain understood the takeoff warning configuration horn might sound when the throttles were advanced, because one of the unresolved maintenance items affected that system. It also became clear the captain intended to continue the takeoff, even if the configuration horn sounded. Such a decision, as well as the attitude behind it, was clearly wrong, dangerous, irrational and illegal. Few actions by a captain could be more threatening to the safety of an airliner and its passengers. The takeoff warning horn is an absolute "no go" item. No passenger aircraft can be operated without its functioning properly and no pilot can lawfully continue the takeoff if the warning begins below a safe abort speed.

The critical importance of the takeoff warning configuration horn is highlighted by past accidents:

March 21, 1968, at ORD, a United 727-QC freighter, crashed on takeoff because the flaps were not properly set. The takeoff warning horn sounded early in the takeoff roll but an abort was not initiated until after lift-off. The aircraft was destroyed. Two of the 3 crewmembers on board escaped without serious injury, while the captain did require hospitalization. "The Safety Board determines that the probable cause of this accident was the failure of the crew to abort the takeoff after being warned of an unsafe takeoff condition."

December 26, 1968, Anchorage, Alaska, a Pan Am 707-321C freighter, crashed on takeoff because they failed to extend the flaps. The takeoff warning horn was not activated because the temperature was so cold the throttles were not pushed forward enough to engage the switch (the colder the air, the more thrust for a given throttle position). The aircraft was destroyed and all three crewmembers died.

August 16, 1987, at Detroit, a Northwest MD-82, crashed on takeoff, killing 156, because the flaps were not set to a takeoff position. The warning horn failed to activate, because the pilots or maintenance personnel had deliberately opened the circuit breaker, or because the circuit was automatically tripped by a brief overload, or because the circuit breaker itself was faulty.

August 31, 1988, at DFW, a Delta 727-232, crashed on takeoff because the flaps/slats were not properly configured. The takeoff warning system failed to activate, probably because of a faulty switch. Eleven passengers and two flight attendants died and the aircraft was a total loss. The NTSB said:

"Contributing to the accident was Delta's slow implementation of necessary modifications to its operating procedures, manuals, checklists, training and crew checking programs, which was necessitated by significant changes in the airline...

"Contributing to the accident was the lack of sufficiently aggressive FAA action to have known deficiencies corrected by Delta and the lack of sufficient accountability within the FAA's air carrier inspection process."

That relief F/O subsequently reported the incident to the head of the 747 training department for that airline. That department head responded with anger; not at the offending captain, but at the F/O making the report. He simply did not want to hear or believe that one of his captains could have been so irresponsible. He refused to accept the report or to investigate and take appropriate action, despite the fact that the airline's flight operations manual (an FAA required and approved document) stated:

"In order to maintain the highest level of safety and to permit the Company to initiate follow-up action, it is the obligation of all crewmembers to report any areas which could be detrimental to safe operations. This includes, but is not limited to, items such as mechanical problems, weather, crew proficiency, and airport or ATC problems."

Early in 1991, that relief F/O sent a 15-page letter to the head of that airline's flight operations department, documenting the specific details of the incident, his verbal report to the 747 department head and the requirements in the 747 maintenance manual and flight operations manual. He concluded the letter with analysis and recommendations. Excerpts:

"I believe that the accidents I have cited (as well as the one where a JAL captain deliberately crashed a DC-8 and killed passengers -- because he was mentally ill), demonstrates that, as a simple matter of logic, there are times -- extremely rare though they may be -- when it is right, proper and necessary for another cockpit crewmember to overrule a captain's decision and even take control of the airplane away from him if he fails to respond in a rational manner. My [cockpit resource management] training teaches me that; the admonitions of the NTSB teaches me that; my own rational mind teaches me that..."

"That management devise a program or system to implement what the NTSB has been advocating for almost 20 years:" [He then quoted the NTSB's commentary -- see above -- from the 1971 Allegheny accident report]

"Such a system should encourage cockpit crewmembers to make written reports to management when they observe a pilot-in-command making decisions that clearly endanger the safety of the operation. And that system should provide for positive follow-up so that [the airline's management] duty to provide the highest degree of safety is not short-circuited by a captain who continues to make dangerous and irrational decisions."

"That [cockpit resource management] training be expanded to include a thorough discussion of the responsibilities and proper actions of cockpit crewmembers who observe a captain making dangerous decisions. The "human factor" accidents, described above, should be required knowledge of all pilots and guidelines should be established as to how and when control should be taken away from a captain so as to prevent an accident."

"Without such guidelines, the danger continues to exist that we will have more accidents that could have been prevented, like the ones enumerated above; or, that improper actions might be taken by a crewmember, who is legitimately concerned about the safety of the operation, because of the stress of the moment and the lack of clear training."

Copies of that letter were sent (all via certified mail with return receipt requested) to the following:

1. Mr. Samuel Skinner, Dept. of Transportation, Washington, D.C.

2. Mr. James Busey, F.A.A., Washington, D.C.

3. Mr. James Kolstad, NTSB, Washington, D,C.

That relief F/O never received a written reply from any of the above. The only feedback he got was via the verbal grapevine: the management of the airline he worked for wanted to fire him. They didn't, of course, because all the rules required him to make that report and it was quite proper for copies to be sent to government agencies that are charged with responsibility for airline safety.

Cockpit resource management training (referred to as CRM or CLR) is one of the most valuable safety tools we have today. It has contributed significantly towards the prevention of "pilot error" accidents; it has saved airplanes and lives. But there seems to be great reluctance to even discuss the idea that there are times when the captain's authority must be countermanded. It is clear, from the accidents noted above, crashes could have been prevented if the second-in-command had overruled the captain.

CRM training should, therefore, be expanded to highlight that issue. The cited accidents should be known and thoroughly discussed by all pilots, and specific guidelines set out so that they will know when and how to act, if a captain makes decisions which are clearly irrational and dangerous. Such training will, in itself, probably prevent most future incidents because captains will know they will be countermanded if they attempt to take a course of action, which endangers the lives entrusted to them.

See also, the guest editorial on CRM.

November, 1997

[All bold emphasis in this editorial is that of the author]  

Robert J. Boser    
Editor-in-Chief 
AirlineSafety.Com


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The Editor of this Web Page, now retired, was an airline pilot for 33 years and holds 6 specific Captain's type-ratings on Boeing Jet Airliners.


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