This appendix illustrates the problems of changing embedded "cultural" attitudes within a single airline. The basic facts of the incidents are a matter of record but it must be emphasised that comments and interpretation are the author's own, and may be disputed by others looking from a different perspective.
A major airline experienced four near-disasters involving Controlled Flight Towards Terrain with one particular type of aircraft, over a period of some 23 years. The basic SOP on this fleet was the traditional PF/PNF “assisted flying” concept, and in each of the events the Captain was the pilot flying. In each case a catastrophe was averted more by good fortune than anything else.
These events are particularly interesting because they illustrate a number of common aspects to aircraft accidents, the organisational responses to them, and issues of entrenched airline “culture”. This airline's culture placed strong emphasis on each of its pilots demonstrating high levels of skill, which qualified them for membership of an elite group. Poor performance was therefore due to hitherto undetected flaws in individuals within the group, rendering those individuals unworthy of membership. This view supported by both management and line pilots, and was clearly self-reinforcing.
Because they involved no immediate injuries or major damage, all the crew members involved survived the events themselves, and thus were available to participate in the subsequent analysis.
Event 1.
In the early 1970s, a four engined wide-body descended to within 70 feet radio altitude of the ground, almost 7 miles from a high altitude airport. During an ILS approach, being flown by the Captain in instrument conditions, an altitude below that of the airport was mistakenly dialed into the altitude select, and an attempt was made to descend to it. A go-around was initiated when the ground was sighted.
This event was the subject of a full accident enquiry by the airline’s State Accident Investigation organisation, which concluded that amongst other factors which included crew sickness (the First Officer had been taking medication which may have reduced his performance and alertness), the fundamental causes were that the Captain’s planning and conduct of the approach gave himself and his crew too little time to monitor the progress of the flight properly.
His overall supervision of the approach was adversely affected by his personal preoccupation with the control of the aircraft, and the system of monitoring used by the company (i.e. monitoring by the junior crew members) did not function properly at a time when the cockpit workload was high. Accordingly, the national Accident Investigation Board recommended that the company should re-examine its allocation of crew duties and monitoring responsibilities during descent and approach, so as to enable the commander to exercise his supervisory function to greater effect.
The airline’s own conclusions however were that the fundamental problem lay with the inadequate performance of the individual crew members, rather than with the procedures laid down. The “rotten apple” was therefore removed from the barrel, and the Captain left the company. It is worth noting that since the incident had come to light as a result of the prompt and voluntary action of the Captain, the national investigation board commented that the company's actions "would be likely to discourage such responsible action in future".
At around this time the airline was involved in a rather acrimonious merger with another carrier which used the “delegated flying" PicMA philosophy. The recommendation that the procedures be reviewed “to allow the Captain more opportunity to supervise” was seen by many in positions of authority in the incident airline as an attempt to interfere in the internal negotiations over integrating the new merged airline, and the basic procedures remained unchanged
Event 2.
Eighteen months later, a similar four engine wide-body descended into treetops about two miles short of the runway during a non-precision approach at night in good visibility, and a go-around was made. Again, the event was the subject of a full accident enquiry by the airline’s State Accident Investigation organisation. This concluded that the incident was primarily caused by a poorly planned and executed approach by the Captain, and inadequate monitoring of the aircraft flight path by the crew.
Again it was recommended that the airline re-examine its crew procedures to establish whether a reallocation of crew duties and monitoring responsibilities would permit a greater degree of supervision. Once again this issue did not feature in the airline’s internal recommendations; it was concluded that the fundamental problem lay with the poor quality of the individual crew members rather than with the procedures laid down. More “bad apples” were therefore again removed from the barrel: the Captain left the company, the other crew members were disciplined, and the basic procedures remained unchanged.
During the merger-related negotiations that were still on-going at the time, the issue of SOPs and the appropriate "operational culture" was the subject of much heated discussion. In effect it became the subject of a vitriolic "turf war". At one stage this resulted in a high level management group submitting recommendations that unification across the airline should be based on PF/PNF “assisted flying”, and abandonment of the “delegated flying” PicMA concept.
This suggestion was eventually disregarded when it was shown that the recommendation had been based on “evidence” in which the position of other airlines had been misrepresented to support it - one of a number of actions which caused the group's sole non-airline-staff member to refuse to sign its report. However, this set the tone for the airline over the next twenty years. With no single operational philosophy across the entire organisation, two competing internal cultures existed. The credibility of its management in seeking to obtain adherence to its SOPs was damaged, as what was unacceptable on some types of aircraft was perfectly normal on others
Event 3.
Thirteen years later, a similar four-engined wide body made a badly controlled low visibility approach at its home base airport. During a go around, it descended to 75 feet radio altitude, in the vicinity of an airport hotel and other buildings which rose to 70 feet. Again, contributory factors included crew member sickness and experience levels. For various reasons the airline’s State Accident Investigation organisation did not conduct an investigation: it was left to the airline itself.
It is likely that given the circumstances which led to the event, an Accident Enquiry would have come to similar conclusions to that reached in the earlier events: that the Captain as pilot flying had become overloaded, his overall supervision and management of the flight had suffered as a result, and that inadequate monitoring had allowed an unsatisfactory approach to be continued to far too low an altitude.
But although a number of detail recommendations for changes were made, the fundamental conclusion was again that the problem lay with the poor quality of the individual crew members rather than with the basic procedures laid down. More “bad apples” were therefore again removed from the barrel: the Captain left the company, the other crew members were disciplined, and although numerous detail changes were made, the basic procedures remained unchanged.
Internal memoranda however noted that the State Accident Investigators’ recommendation regarding crew procedures in Event 2 was never adopted, nor featured in the company’s internal recommendations, and linkage of that accident to Event 3 could have proved embarrassing.
The internal report did not formally recognise the potential seriousness of this event. If the building in question had been only a few feet higher, the aircraft would have struck it, and the consequent crash could have been one of the worst civilian disasters in history. A full wide-body jet would have struck a large, fully occupied hotel, and the wreckage path would probably have destroyed the airport's fire station and emergency coordination facilities (police station etc), as well as closing the primary entrance routes to the country's principal airport, one of the busiest in the world.
The Captain was subsequently charged by the national aviation authority with criminal negligence in endangering people in the aircraft and on the ground. It is indicative of the inadequacy of criminal proceedings to deal with complex technical safety matters of this kind that he was found guilty of endangering his passengers but not guilty of endangering people on the ground - an incomprehensible verdict given that the people on the aircraft were in no more and no less danger than the building occupants on the ground.
The Captain was fined, lost his licence, and later committed suicide. Neither the company internal report nor subsequent criminal proceedings are available in the public domain but an article about the case which this author believes to be generally accurate is available.
Event 4.
Eight years later, a similar four-engine wide-body aircraft making a straight in ILS approach at night at an airport in a developing country failed to obtain the glide-slope signal. However the Captain, having had visual contact with the ground, elected to continue using DME data for altitude guidance. Unfortunately, altitude data for the wrong DME facility was used, and as a result the aircraft descended to some 350 feet radio altitude about 6 miles short of the runway, when a go-around was initiated.
For various reasons, no detailed investigation was carried out but a few months later the fleet procedures were changed to bring them into line with those used on the other fleets in the airline, i.e. replacing PF/PNF “assisted” flying with the “delegated flying” (PicMA) concept for all instrument approaches, and finally implementing the official recommendations arising from event 1, over 22 years earlier.
Lessons to learn?
Significant factors in these events appear to include these.
- In each event, sufficient information was available to the crew to have avoided the danger they encountered.
- In each event, an initially satisfactory situation deteriorated, as a number of individually containable events compounded on top of each other.
- In each event, it is possible to see with hindsight that the overall situation awareness of the pilot in charge had suffered because of his need to concentrate on a subset of detailed, aircraft handling, tasks.
- In each event, subordinate crew members had reservations about what was being done, but did not act forcefully enough or at an early enough stage to change the course of events.
- In two of the four events inadequate or misleading visual cues had been given preference over valid instrument cues.
In the first three events a “satisfactory” outcome (from the airline fleet perspective) was the eviction from their community of individuals whom events had proven to be inadequate. Although it recognised that some minor modifications to procedures were needed, the fleet’s membership (both in management and most of its line pilots) found it impossible to accept that its long established traditional methods could be at fault. In this culture, the ability to deal with difficult situations was seen as a test of individual worth.
All its members had, by definition, shown themselves to be “worthy” - until the moment when they failed. The fact that such individual failure might reoccur with massive loss of life was not a consideration: future recurrence could be avoided by ever more stringent “quality control” of the fleet's individual pilots. By the time of the fourth incident however, many of the personnel involved had changed. With more mixing across the entire airline and fuelled also by realisation of potential corporate vulnerability, change became possible.
For over 20 years, the organisation in fact exhibited all the “right stuff” individualistic characteristics of the pilot professional culture recognised as hazardous by CRM researchers. Strenuous efforts are made in CRM training to change the attitudes of Captains to accept that they might have misjudged a situation. From a different viewpoint, the reluctance of those with authority over an entire fleet to accept the possibility there could be a need for change could be seen as simply the same problem on a larger scale.