Thursday, January 1, 2009
Training: Safety Watch
Aircrew coordination, cockpit resource management, cockpit coordination, cockpit communication management...these terms refer to the same basic principles of ensuring the sum of the members of an aircraft crew is greater than the individuals themselves. Computer-based training programs are great tools to enhance aircrew coordination training.
We don’t know how many accidents these programs have prevented. We do occasionally get stories from flight crews who survived mishaps as a result of poor aircrew coordination. I investigated several accidents where lack of crew coordination was a present and contributing factor to the mishap.
Unfortunately, all the efforts put into aircrew coordination training development will not prevent crew coordination-related accidents from occurring. Sometimes both pilots are focused inside the cockpit at a critical moment or the crew was overconfident in the pilot in command’s ability to take care of the situation and stopped coordinating.
Two of these incidents involving crew coordination failures resulted in catastrophic accidents. Aircrew interviews and digital recordings gave us indications that the crews encountered what any aviator would consider worst-case scenarios — engine failures. In one case, an engine failure in a single-engine aircraft, and in another, a single-engine failure in a multi-engine aircraft that was too heavily loaded to maintain altitude. The challenges these crews faced just to minimize the damage were significant; however, evidence indicates that the severity of the accident might have been lessened if the crews had better coordinated their efforts.
In the first case, two pilots in an OH-58D experienced an engine failure at terrain flight altitude. Pilots who fly Kiowa Warriors know there is no good place for an engine failure. With limited reaction time at low altitudes, engine failures can’t get much worse, and in this case, the pilot on the controls hesitated to respond to the failure. The digital collector indicates he misdiagnosed the failure and didn’t lower the collective for more than four sec. Interviews suggest the pilot not on the controls sensed what was happening but said nothing. This was going to be an accident from the time the engine failed, but the crew’s injuries might have been less severe if the pilot not on the controls had assisted the pilot on the controls.
In the second case, a multi-engine helicopter flying IMC experienced an engine failure. The crew initially responded well to the incident by crew-coordinating their immediate action steps. The pilot on the controls announced an airspeed that would have maintained the minimum rate of decent, made their emergency radio call and adjusted the flight controls to achieve that airspeed. Then something went wrong; neither pilot noticed the airspeed continued to drop until the maximum torque available was reached on the good engine and it no longer had the required power to maintain rotor speed. The circumstances indicate the crew failed to properly divide the duties in the cockpit. The pilot on the controls failed to maintain the briefed airspeed and the pilot not on the controls failed to cross-monitor his performance, thereby resulting in loss of aircraft control and the subsequent crash.
Every pilot must realize that coordination between aircrew members is critical to minimizing the severity of an accident.
The eight elements of crew coordination are: Communicate positively (sender directs and receiver acknowledges); direct assistance; offer assistance; announce actions; acknowledge actions (repeat critical parts); be explicit; provide aircraft control and obstacle advisories; coordinate action sequence and timing (request tail clear, receive clear acknowledgement and turn tail).
What can we do?
Ensure all aircrew members are trained and evaluated on the most current aircrew coordination training programs.
Conduct crew and passenger briefings religiously and meticulously using a leader-approved checklist as part of an SOP. Brief the actions and responsibilities of all aircrew members beforehand, so if an emergency does occur, there is a plan in place.
Ensure team rehearsals are conducted BEFORE a flight with emphasis on crew coordination, duties and responsibilities. Plan for the worst scenario.
Emphasize to aircrews the importance of continuing to "fly the aircraft," asking for assistance, offering assistance and continuing to communicate, especially when things start to go bad.
Conduct after-action reviews or debriefs after the mission and discuss crew coordination successes and deficiencies and how to improve.
Much of the communication in aviation is procedural and well structured, but unclear or ineffective communication remains a frequent contributor to mishaps. Sometimes a pilot has to disregard "excessive professional courtesy" where the least experienced crew member perceives the other pilot knows what he/she is doing and does not communicate. The atmosphere in the cockpit should be "sterile" especially during critical phases of flight. But proper training, a good crew briefing, knowledge of your responsibilities, and good communication during a flight will help you avoid mistakes that may be your last.
I would like to thank the United States Combat Readiness/Safety Center at Fort Rucker, Ala. for information contained in this article.