The Cockpit: Where Custom & Tradition, Technology and Humans Collide

The Probable Cause summation at the end of an aircraft accident investigation report is the official determination of why an accident occurred. Common threads are pilot error and equipment failure. Beyond structural failure, the clash between technology and humans was evident in the case of an American Airlines flight at Cali, Columbia.1 The third factor is more difficult to identify and document. It is the failure of the system, a situation that does not allow for the full utilization of all the occupants in the cockpit for whatever reasons. The cause for this condition can be overlooked when the investigators attempt to put all the pieces back together again during an accident investigation. This is especially true when a plane crashes without mechanical problems. Several factors could be involved such as target or goal fixation, losing situational awareness and being overly cautious to the extreme. Over-confidence and arrogance are not usually noted in an accident report but crew-members at any base will know the cockpits where they can be found.

Around 1978-1980, airline companies began to realize that their flight commanders might be becoming overloaded with the management of large crews and complex aircraft. To address the issues they piled on more automation and added Crew Resource Management courses to the recurrent training curriculum for the pilots. CRM was thought to be the cure but it wasn’t the panacea which it was originally thought to be because it focused only on how the captain would manage the crew. It was a start but the problems remained. They really didn’t know how to handle the command supremacy issues in the cockpit. Nor was there a way to question or eliminate the technical mistakes made by the experts who wrote the bible. Bad procedures written into the aircraft operating manual are approved by the FAA and become like biblical commandments cast in stone. Those pilots that ignore the bible are considered careless rogue pilots; those who write the bible are called experts. Neither statement is true 100 per cent of the time.

Crew Resource Development might be a more effective undertaking. This becomes apparent when a subordinate crew member does not respond to a developing situation because of reticence, attitude, lack of training, or fear of insubordination. The fix is impossible to achieve on a moments notice when the aircraft is plunging to earth. The further along the technology scale we progress the more subtle the clash between it and humans.

The following three airliner crashes involved U.S. aircraft and those crashes resulted in 983 fatalities. The probable causes listed in the accident reports are only told part of the story.

KLM and Pan Am B-747’s collision at Tenerife Airport Spain on 27 March 1977, 583 fatalities.2
American Airlines DC-10 crash at O’Hare Airport, Chicago, IL, 25 May 1979, 273 fatalities.3
Delta Airlines L-1011 crash at DFW Airport, Texas, 2 Aug 1985, 137 fatalities.4

Interestingly, both the crashes at Tenerife and at DFW Airport, Texas, involved three perfectly good airplanes with no malfunctions. The other crash at Chicago’s O’Hare Airport involved an aircraft with a demanding emergency but it occurred in excellent weather and the aircraft was later determined to be very flyable; indeed, it was flying and climbing just as it was supposed to be doing until the pilot flying changed his flight profile to conform to the recommended and approved procedures. What could have gone so wrong as to have caused the worst aircraft accident in aviation history at Tenerife, the worst aircraft crash in U.S. history at Chicago, and the equally tragic and preventable L-1011 accident at DFW Airport, Texas?

One or more of the following could be considered as probable causes in the three crashes; command structure, infallibility of the captain, a reluctance of the co-pilot to step forward, and unwarranted blind faith in procedures. The aviation community gives command structure lip-service but the supremacy and infallibility of the aircraft commander is alive and well. A co-pilot is like a secretary in the business world, taking orders and doing paperwork but not making decisions for the company. When a corporate CEO falters the board of directors provides another leader. When a captain falters there is a possibility of a great void developing; a void propagated by the system. When a bad procedure is discovered, usually after a crash, the flight manual is simply changed. Rogue pilots were probably already using some sort of a modified procedure.

In the Tenerife accident, seven people watched the sequence of events fall into place that preceded the wreck with only a few low-keyed inputs. Basically, the KLM airplane took off directly into the path of the Pan Am airplane that was taxiing in an opposite direction on the same runway in very foggy conditions, but it was not quite so simple. There was more involved. Those seven that were involved in the accident included the airport’s control tower operator, the three cockpit crew members of the Pan Am airplane and the three cockpit crew members of the KLM plane. In reality, only the tower operator and the two captains were making decisions but what about the second-in-command and the other crew members in both airplanes?

Both custom and tradition can elevate a skipper to lofty heights and if the commander is further renowned by war records, professional position or special talents, he or she can become almost infallible. Such ascendancy has a certain amount of military heritage where the mere mention of a great warrior’s name can bring a hush over an entire group. When a flight commander becomes unaccountable and blinded by self-importance, the ability to use common sense and good logic in the thought process becomes impaired. Not a good thing in the aviation world where things can happen at a blinding pace; especially bad things.

The KLM pilot was obviously more than just a pilot, at least in the company structure.5 He was their most senior captain as well as a training pilot. As the company’s senior training captain he had probably trained most, if not all, current KLM pilots, a living legend. He was obviously highly regarded in the tight circle of upper management. His photograph was used in company publications with his image looming large, front and center. While holding such a large part of the big picture he was perhaps thinking beyond his local environment as a line pilot on this particular trip. If he had been a manager at company headquarters he might have been thinking about saving hotel expenses, contract negotiations, scheduling problems and the like, things that an ordinary line pilot might not worry about. But on this day he was not at headquarters; he was out of his element. He had spent most of his recent career as a training pilot in flight simulators where a crash results in an innocuous thump on the bottom of the simulator. Another insidious factor was in place; in a flight simulator, the training captain doesn’t ask for take-off clearance; he gives the clearance. There is no control tower operator involved.

Could it be that on this foggy day in March, he momentarily forgot where he was? From the recording left on the cockpit voice recorder he hadn’t forgotten who he was. From all indications, the captain virtually disarmed with his demeanor, his most vital safety link, his co-pilot, the second-in-command.

At numerous points along the short trip from the parking spot to the collision any member of the two crews could and should have interceded with a forceful protest or offered an alternate plan of action. Of course, the control tower operator could have held the Pan Am airplane short of the runway until the KLM plane had taken off. What the control tower did was not illegal and was probably done everyday at that airport with a single runway and no taxiways available. Another last-ditch effort would have been for the KLM co-pilot to have applied the brakes on his plane or he could have pulled the throttles back on the big KLM 747. But how do you pull the throttles back on god?

Two years and two months after the Tenerife crash, a DC-10 takes off from Chicago’s O’Hare Airport and loses an engine, not just power, but the engine actually fell off the plane.6 As the plane lost its engine, it also lost one of the three hydraulic systems that operate the flight controls. However, on the DC-10, only one hydraulic system is needed to sustain flight and both #2 and #3 systems were operating normally. The engine that was lost also took its hydraulic pump with it, the heart of the #1 system. Concurrently with the loss of the engine and its hydraulic system, without a cockpit indication, the wing slats retracted on the left side of the airplane thus reducing the stall speed on that wing.

It was a demanding emergency to be sure but a three-engine aircraft will fly on two engines and it did, until the pilots changed to the approved flight profile that was written by the hands of god, the authors of company aeronautical canon. The engine-out procedure called for the climb profile airspeed to be no more than V2+ 10 knots, which was about 6 knots below the stall speed for their abnormal, but unbeknownst to the pilots, wing-slats configuration. Never mind that they were already flying beyond that speed at 172 knots and climbing nicely; one must conform as closely as possible to approved procedures. As their speed was reduced toward the procedural target airspeed the airplane’s left wing stalled; the airplane rolled over on its back and crashed into the ground.

In most abnormal conditions of this type, a pilot is wise to maintain whatever airspeed that has been achieved. In the case of this crippled DC-10 airspeed was critical. Giving up airspeed to satisfy a procedure was not a good idea. However, once the procedure was printed in the company’s operating manual it became the gospel, the printed word of god, the bible. After the crash the flight profile was changed in the operating manual; so much for the written word.

On a hot summer day of 1985, a Lockheed L-1011 jumbo jet is making an approach to the south at DFW Airport.6 As they begin to turn in toward the airport an active thunderstorm sits right in its flight path. One of the crew points out that there is lightening flashing out of the storm just ahead; a clear indication that evasive action is necessary, immediate evasive action. The plane continues on its intercept heading. The ultimate authority in the cockpit was about to do battle with Mother Nature, an angry mother on this day. The other two crewmen watched. Seemingly, there was no plan of action on how to avoid the obvious hazard directly ahead. The surrounding area was clear of storms and there were at least three alternate airports within a few miles where they could have landed had fuel been an issue. Indeed, the other side of the airport was in the clear. Without so much as a second thought, they drove straight into a devastating micro-burst, a severe downdraft of unbelievable power. If you can see storm clouds with visible lightening, you don’t fly into the storm. It is not a good idea and bad things will likely happen.

It appears that the second-in-command who was at the controls, was either intimidated into submission or was inadequately trained to do his job. That job was to protect his aircraft, passengers and crew to the best of his ability. To do that, he most assuredly would have had to go against the captain’s will.

Perhaps the most difficult task a second-in-command pilot will ever face is how to terminate a potentially dangerous action when it is being directed by god, the captain. This action has to be trained for and allowed to flourish. At the same time, flight commanders should be trained on how to accept disputes from subordinates. Could the helmsman on the Titanic have counseled the captain that running through iceberg infested waters at full-speed, in the dead of night, was maybe not a healthy thing to do? Not a chance.

On the night of April 14, 1912, Captain John Edward Smith, the White Star Line’s most prestigious captain, was commanding officer of the most technologically advanced steamship in the world, the Titanic.7 On that night, the Titanic was sailing the North Atlantic under heavy clouds of unbridled, supreme arrogance. Other lesser ships in the area had shut down for the night as icebergs had been reported in that part of the dark Atlantic Ocean. The KLM Boeing 747 was like the Titanic except that it was traveling at about 150 miles per hour when the iceberg was sighted, a few hundred feet dead ahead.

In past years during training, a co-pilot did not have to perform all the maneuvers that a captain was required to perform yet if the captain became incapacitated the co-pilot might have to perform any one of those exact maneuvers single-handed, without being trained to do so. It would make sense that the second-in-command be trained and fully rated as a captain. On a day-to-day basis, only the captain is allowed or required to do certain things and herein is a problem. Only the captain signs the flight plan, starts the engines, taxis the airplane and sometimes, makes all the landings. A competent and fully engaged co-pilot can do all those things. However, after years of being underutilized it is no wonder that usefulness of the co-pilot is diminished. Incidentally, incapacitation almost never gets reported unless a crew member actually dies or physically has to be assisted leaving the cockpit.

A review of the command structure, i.e., eliminating the god-mentality in the cockpit, and developing a more comprehensive training of the second-tier managers might be in order. The not-uncommon practice of manning the cockpit with simulator pilots when peak demands arise likewise has obvious implications. Bad procedures can produce equally devastating results. It is apparent that the engine-out procedure in place at the time of the Chicago crash was inappropriate for the situation and once it was applied at low altitude there was not time for experimentation to find out what would work. Blind faith in the bible and its authors did not serve the passengers and crew well that day.

Standardization and a command structure usually makes for an easy flowing routine but there are times when neither is appropriate for the situation at hand. These accidents could have been prevented if someone had stepped outside the box. However, human nature apparently doesn’t allow a person to work inside the box for extended periods of time and then to suddenly step out and deliver a command-performance. Crew Resource Management training was an attempt to address the situation but never quite achieved a solution because of the complexities of human nature and years of authoritarian training. Crew Resource Development might provide relief from the dark void that can sometimes kill.

A healthy cockpit is where two people are working together to make the sum greater than the two parts. An unhealthy cockpit is a place where only one voice is heard and the other person is unable to act because of unrealistic perceived consequences. While technology has progressed at an exponential rate, human engineering has eluded perfection.

All the crewmen in the previously mentioned accidents were experienced and qualified; they became victims with their passengers when fate interrupted their journey as technology and humans collided and custom and tradition hobbled their performance.

Charles Foerster is a graduate of the University of Houston, a former U.S. Naval Aviator and a retired commercial pilot. He and his wife currently live in West Texas. ©2009

Notes:
1 Aviation Safety Network, http://aviation-safety.net/database/record.php?id=19951220-1

2 Subsecretaria de Aviacion Civil, Spain, http://www.pan-american.de/Desasters/Teneriffe3.html

3 NTSB/AAR-79-17, http://www.airdisaster.com/reports/ntsb/AAR79-17.pdf

4 Project-Tenerife, http://www.project-tenerife.com/engels/

5 Project-Tenerife, http://www.project-tenerife.com/engels/

6 NTSB Accident Report, Delta Airlines, http://www.ntsb.gov/ntsb/brief.asp?ev_id=20001214X37434&key=1

7 Titanic-Titanic, http://www.titanic-titanic.com/captain_smith.shtml