RSS

Cockpit Discipline Essential to Safety, Declares Safety Board Member

Tue, Jun 30, 2009 — David Evans

Articles, Featured

A statement regarding the reason for cockpit discipline ought to be posted in every crew ready room and provided in every company mailing to aircrews. The statement is buried on page 71 of a National Transportation Safety Board (NTSB) accident report, recently made available to the public. The report concerns a left engine fire immediately after take off from St. Louis on American Airlines flight 1400. The flight crew was able to abort the flight and return to the field, but while the passengers applauded the pilots for their competence, a senior member of the Safety Board, who also happens to be a former airline pilot, looked behind the cockpit door and found lapses in basic discipline. (See Aviation Safety Journal, “Emergency Landing the Result of Flawed Maintenance & Poor Cockpit Procedures”)

His is a look behind the stage, as it were, to frenetic and ill-considered activities offstage, which the passengers in the audience could not see. What Member Robert Sumwalt found was reminiscent of many other recent accident inquiries of the past couple years – gross violation of the so-called sterile cockpit rule.

Member Robert Sumwalt

Member Robert Sumwalt

In this investigation, the problem of cockpit indiscipline was bad enough to warrant a separate discussion in the investigative report. Herewith, extracts of that portion of the report:

“2.5.2 Nonpertinent Discussion and Cockpit Tone

“…. The pilots interrupted running the Before Takeoff checklist for about 38 seconds to engage in another nonpertinent conversation. Again, the captain engaged in and did not challenge the nonpertinent discussion. At 1311:01, the first officer contacted ATC without instruction from the captain while the airplane was still taxiing and before he had completed the Before Takeoff checklist, suggesting self-induced pressure or rushing on behalf of the pilots. Although calling ATC to announce that the airplane is ready for takeoff before arriving at the hold short line is not unusual, it is not good practice to do so before the Before Takeoff checklist items have been completed. The first officer resumed the Before Takeoff checklist at 1311:20 and completed it about 12 seconds later.

“The NTSB is concerned that the pilots engaged in nonpertinent conversations during airport surface navigation, which was not consistent with company guidance or Federal regulations that require a sterile cockpit during critical phases of flight to prevent redirection or degradation of pilot attention. The reasons why both pilots failed to ensure that standards were maintained and that procedures were properly performed cannot be determined definitely ….

“The NTSB has addressed issues related to nonpertinent conversation and cockpit discipline during several previous accident investigations. For example, in its report on the August 26, 2007, accident in which Comair flight 5191 crashed during takeoff, the NTSB concluded that the ‘flight crew’s noncompliance with standard operating procedures … most likely created an atmosphere in the cockpit that enabled the crew’s errors.’ ….

“The NTSB concludes that the casual atmosphere in the cockpit before takeoff affected and set a precedent for the pilots’ responses to the sitiations in flight and after landing, eroded the margins of safety provided by the SOPs and checklists, and increased the risk to passengers and crew.”

Sumwalt’s statement attests to the rationale for a sterile cockpit as a means of focusing on procedures – not crew discussions of the situation at the airline, impending retirement, crew scheduling, family matters, politics, alternate employment, what have you, which have been evidenced in numerous recent cockpit voice recordings of accidents. With the pilots concentrating on the business at hand, they are mentally ready for any untoward event, and prepared to implement requisite procedures. In other words, as far as Sumwalt is concerned, adherence to the sterile cockpit rule is essential to the business of being a professional aviator. His complete statement follows:

“Unfortunately, I, once again, find myself compelled to comment on the casual attitude of a flight crew. The fact is, time and time again, Safety Board investigations have revealed casual crew attitudes. Of significance is that in several cases, I believe that casual attitude either directly caused the accident or exacerbated factors leading to the accident.

“Granted, in the case of American Airlines flight 1400, the flight landed safely and no one was injured. Passengers applauded when the aircraft landed and, upon deplaning, passengers heavily complimented the crew’s performance. But, as the report points out, the process used to get to that landing (and after landing, for that matter) were fraught with crew-precipitated problems.

“As an airline pilot for nearly two-and-a-half decades, I recognize the difficulties this crew must have experienced in controlling the aircraft. Among others, they were dealing with an engine out; multiple caution and warning lights in the cockpit; the primary stabilizer trim was not working, leading to heavy control forces; no normal operation of rudder, which was exacerbated by the engine-out condition; intermittently failing Primary Flight Displays and Navigation Displays; a nore gear that would not extend; and a host of other problems associated with dual hydraulic and partial electrical system failures. On go-around, the captain had difficulty maintaining airspeed and climbing due to single engine performance with the two main landing gear extended. On landing, they could extend flaps to only eight degrees due to insufficient hydraulic pressure, and the actual flap position was unknown to the crew due to inaccurate gauges. They faced controllability issues on landing due to a combination of asymmetric thrust, to nose wheel steering and manual rudder operation. To compound all of this was high task loading, stress, and distractions associated with the cockpit door opening and dealing with multiple abnormalities.

Evidence of the engine fire that prompted the pilots to return to the field for landing.

Evidence of the engine fire that prompted the pilots to return to the field for landing.

“The Board affirmed the captain’s good decision to request the deadheading captain to come to the cockpit. And, as a professional aviator, I also applaud his decision to land on the longest available runway.

“One of the part submissions stated that the crew did not have ‘any formal flight crew training that addresses multiple system failures this complex.’ Perhaps that is true, but I note that the crew was trained and practiced engine fires at last annually. The crew was trained and practiced dealing with abnormal and emergency situations, and the crew was trained in workload prioritization and task association.

“I ask rhetorically: What is the best way to prepare yourself to deal with events that are unfamiliar to you – events where there are no established procedures? Based on my flying experience and aviation safety background, I firmly believe the answer is rigorous adherence to standard operating procedures (SOPs) and cockpit discipline on each and every flight. When you do this, you are preparing yourself for the unexpected.

“Sections 2.5.2 of the American 1400 report pertains to non-pertinent cockpit conversations and cockpit tone, and through this concurring statement, I would like to expound upon that discussion.

“In reviewing the cockpit voice recorder transcript, there were several things that pointed to a casual crew attitude. For example, after starting engines, the captain stated, ‘I’m ambivalent right now. I got six months to go.’ Although perhaps an offhanded comment, when combined with other behavior in the cockpit discussed below, I can’t help wondering if this comment was, in fact, a true indicator of how the captain approached his job on the day of the accident.

“The taxi checklist was conducted in a non-standard manner. For example, the captain simply stated, ‘…checklist and all that stuff when you’re ready…’ rather than calling for the checklist by name. The first officer did not reply to the captain’s statement but, instead, engaged in a personal conversation for a minute or so before initiating the checklist. Also telling was the way the checklist was conducted by the first officer. A flight deck checklist is to be accomplished crisply, using the precise checklist challenge and response. In this case, the first officer recited the checklist by adding unnecessary verbiage such as ‘how about flight instruments and bugs,’ ‘how about flaps and slats,’ ‘bout anti-skid,’ ‘and the APU,’ ‘alright crossfeeds,’ ‘and the packs,’ ‘all right, how about PA.’ Additionally, the first officer interrupted the checklist by engaging in non-pertinent remarks. The captain engaged in and did not challenge non-pertinent remarks, although in direct violation of FAA and company requirements to maintain a sterile cockpit.

“Taken in isolation, these individual deviations may seem insignificant. When viewed in totality, however, these remarks and deviations from SOPs before, during and after the emergency, paint a picture of a flight crew who may not have been mentally prepared to properly deal with the abnormal and emergency situations. The crew faced a critical emergency less than two minutes after takeoff and I believe that because of their relaxed and casual attitude, the situation caught them off-guard. Quite simply, they weren’t mentally in the ball game when the engine fire first manifested itself and this contributed to their critical delays in initiating and completing the appropriate checklists.

“Why does a professional aviator insist on strict adherence to procedures, including checklist usage and sterile cockpit compliance? It is not for the flights where everything goes right. Instead, it is for those flights when things go to hell and you need something to fall back on. You fall back on procedures, SOPs and discipline that have been practiced repeatedly over time. You insist on doing things this way so that when faced with an unfamiliar situation, you are mentally prepared to deal with it because you can fall back on procedures and discipline that are familiar to you.

“So how does the industry improve hallmarks of professionalism such as discipline and compliance? I believe the answer is through management and peer pressure, as well as through individual accountability and responsibility. Management and pilot associations must take a firm stance that sterile cockpit discipline, precise checklist usage and strict adherence to SOPs will be followed; to do anything less is unacceptable.

“Attitude change over time, but often these changes occur because of management, peer and societal pressures, along with knowing there will be consequences of not following the group norms. Examples of attitudinal changes that have evolved over time include contemporary societal views of smoking, drinking and driving, and seat belt usage. Those views have evolved because of laws, peer pressures and an awareness of consequences of non-conformity. In the case of improving pilot professionalism, the laws (regulations and company policies) are present. What is lacking are sufficient peer pressures, consequences, and in some cases, individual accountability and responsibility.

“I urge management and pilot associations to toe a heavy line on insisting on compliance. And I urge that individual pilots insist on this, as well. By addressing these issues through management and pilot association pressures, along with individual accountability and responsibility, needed changes will occur. To do anything less is simply unacceptable.”

One airline that has had a problem with sterile cockpit and basic discipline is Colgan Air, which lost an airplane on approach due to stall. The flight crew was caught by surprise, did not increase power to 100% and drop the nose – as a result of which the airplane crashed, and all aboard the Dash 8-Q400 were killed. At a recent NTSB hearing into the crash, a Colgan official expressed the intent to download a sampling of cockpit voice recordings to assess crew compliance with sterile cockpit. (See Aviation Safety Journal, “Crash Investigation Reveals Gaps in Airline Safety System”)

Sumwalt expressed discomfort over this plan, on the grounds that cockpit voice recordings are primarily for accident investigations, and they are not a potential tool to enforce sterile cockpits and compliance with SOPs.

Then again, such downloading and checking is about the only way the company has to verify compliance with procedures. Absent such randomized spot checking, sterile cockpit and procedural compliance is left to the professionalism of captains. Unfortunately, such professionalism has been absent in two many crashes the NTSB has investigated. If anything, procedures have had to be squeezed between non-pertinent conversation – which is to say safety has been a second order priority to personal chit-chat.


Comments are closed.

Nolan Law Group