Study & analysis
Recently I was asked to participate in on-line Human Factors exams for the Aviation department of the Amsterdam University of Applied Sciences. It proved to be an exciting series of sessions where practical experience on my side mixed with the theoretical angle of the students.
The first year students of this University had to make a case study of a certain aviation accident and give a presentation analyzing the case based on which Human Factors contributed to the crash. In this case, the topic was the crash of the FlyDubai B737 in Rostov on Don, Russia. The students used the SHEL and the Wickens model to guide them in analyzing the accident. I used the Dirty Dozen as a reference. It was a lot of fun to watch (online) these bright young people sift through the data and give their take on things.
Always in the debriefing I came with one question; What, in this case, was the fatal step where it all went wrong? Some of them reasserted their findings but a few others said; ‘They should have never continued pressing on for the landing’. And there you have it; Get-Home-itis, or as some call it Press-On-itis. In my view the only huge danger still remaining that we cannot always be protected from. All the signs are red, all the ingredients screaming threats, but the crew presses on regardless. Stuck in their single minded tunneling mode.
The best equipment
Our modern jet and turboprop aircraft are equipped with the latest state-of-the-art Enhanced Ground Proximity Warning systems, weather radars, autopilots, triple redundancy on most all mechanical systems, Traffic Collision and Avoidance systems, you name it. But if the captain has a bout of Get-Home-itis, you are all in grave danger. Mortal danger, in the case of the FlyDubai jet.
So many crashes preceded this one and more will follow. The KLM-PanAm crash on Tenerife, the American MD80 in Little Rock, the TAME Embraer in Quito, Ecuador, the list goes on and on. All a result of pressing on against bad odds.
Hindsight is always twenty twenty as we know, but you wonder where the crew started missing all the warning signs, the red lights glaring. Mostly the crashes happen in very inclement weather, all other aircraft who at one time thought of continuing for an approach and landing, opted out and diverted (Rostov on Don e.g.) but one hangs on, presses on, and often that ends bad.
Such a small thing
The cause can be a very banal thing. The captain missed out on the last two soccer matches of his son and this is the season’s final and this one he will not miss! His wife had already shot accusing glances at him the last two times he came apologizing, his son was indifferent. Or the appointment with the chiropractor, which you end up paying for even if you don’t show. Which happened once or twice before.
Mostly though it is an operational decision. Diverting can mean running out of duty, everybody into a hotel in some strange place no one knows, further disruption of the schedule (the chiropractor appointment is definitely missed). Where operations should have an ear to the ground as to what conditions the plane/crew finds themselves in and maybe help them with guiding them to safer havens, they often exert pressure. Finish the flight, we need the plane for a lucrative charter after this trip etc.
Some flights during my career where I stood for a difficult decision I sometimes sought guidance by calling Operations but quite frequently they bounced the question back and said;’Well, what do you think, you are our ears and eyes on the ground there?’
Fair enough, you get paid all the money to make those difficult decisions, but sometimes a voice on the phone can give you an insight of the dangerous tunnel you might enter into and keep you from going in. For Operations that requires a good knowledge of the local situation; weather, alternate airports, entry requirements into other countries and what not.
Now, what I write suggests that the captain makes the decision alone, or in concert with Operations, but his/her first help, or barrier in case of tunneling, should be the First Officer and perhaps also the Purser. If they go along in tunneling then it gets dangerous very quickly. Here comes the CRM component looking around the corner. Is the captain an autocratic solo pilot or does she/he actively seek support from crew and company? This again hinges on how experienced and assertive the FO is, on company culture, training, the culture where one grew up in.
The required Vaccine
Thus Get-Home-itis remains the last hurdle. The solution is not always as simple as it sounds; when in doubt, back out!
In case of a difficult decision the captain should not have to make it alone, the operator has to be the wiser or at least help in collaborative decision making carried by all parties involved. And, the company should be supportive, not punitive. Being punitive is only increasing the chances of accidents. It will erase the trust of the crews when they are in a bind and have no one they can turn to for constructive support and confidence. As a result, they will become uncertain and this will hinder good decision making. Airlines and crews can battle this dangerous virus by working together, with safety as a starting point. If we have learned anything from all these unnecessary crashes then it should be that the costs and the immense grief always far outweigh the cost of backing out when you are in doubt.
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