UK Aircraft Accidents 1946 - 1970

[Pull what]

I am preparing a CRM lecture and instead of using the usual well known accidents of the 70s onwards as examples of poor CRM I am looking to include some earlier pre 1970 stuff. Can anyone suggest anything please other than Winter Hill, Aer Lingus DC3 1953 and BMA Stockport and the Comet accidents? Thank you

[Atcham Tower]

BAC 111 at Milan 1968 or 69. Good engine shut down and force-landed very successfully at night.

[Shaggy Sheep Driver]

Well there's that football team Elizabethan crash at Munich, and the Shadow Moss Rd Manchester BEA Viscount for two.

[Atcham Tower]

I totally agree with you Mr Scott. I realised the ambiguity just after I pressed Submit Reply. Duh!

A fellow trainee ATCO was also on the flight deck on a fam flight. Not quite what he expected ...

[Chris Scott]

Quote from Atcham Tower:
Good engine shut down...

Forgive me for pointing out that the above phrase is a classic example of unintentionally ambiguous communication: the kind of ambiguity that can lead to misunderstanding and possible accident.

Did the crew:
1) shutdown a "good" engine in error, or
2) perform an engine shutdown to a "good" standard?

What a pity that – if my experience was anything to go by – these easily made, but easily avoided errors in dialogue are never addressed on CRM courses, although amendments to standard R/T phraseology and standard calls (in some airlines) have helped.

[safetypee]

frontlefthamster, (re # 8 ?? time/post order errors)

Re (1), I would agree that most CRM discussions would benefit from clarity of the subject task, but there is little clarity in this ‘concept’. Thus providing a narrower view or specific aspects could help. Alternatively, a more abstract or generic description might be used, e.g. human behaviour.

Re (2), - ‘evidence’: This is a common (negative) terminating response to many difficult problems which defy definition, and have multiple contributing causes, are chaotic and where there may be unexpected self-generated outcomes without obvious solution.
CRM is a safety initiative which addresses aspects of the ‘human in aviation’ safety problem, and this problem stems from other problems ad-infinitum, thus neither a clear solution nor evidence of success will be available.

One view of CRM encompassing both (1) & (2) is that CRM is “the application of human factors”. This is useful as it describes a task or process to be explored without becoming entangled in problem definition or cause. Nor does it presuppose a solution, just activities to be undertaken in both training and daily operations.
Perhaps ‘CRM’ covers a few of those unusual training areas where there may be benefit from acting without too much forethought, i.e. no need for cause, problem definition, or predefined solution – no evidence of success, only of failure.

For Pull what, something more positive, but still challenging.
Examples of ‘every day’ incidents with positive outcome, but many contributing factors from the ICAO library. (www.icao.int/fsix/_Library%5CTAWS%20Saves%20plus%20add.pdf)

And perhaps a futuristic view of some ‘CRM’ aspects by Hollnagel, particularly ‘performance variability’. Human Factors From Liability to Asset. (www.vtt.fi/liitetiedostot/muut/HFS07Hollnagel.pdf)

[safetypee]

Pull what, the following might not help; but why, like the majority of the industry, focus on the negative aspects of safety?
Much of current CRM training appears to be concentrated on what not to do, as opposed to the objective of encouraging positive safety behaviour – examples of what individuals can and have done.

For every failure (incident, accident, etc), all rare occurrences, there is an inverse number of successes. Why not highlight these, explore situations where positive behaviour can be further improved or used in a range of different circumstances.
Try something new – a lecture on what goes right, why everyday operations are successful, why the majority of humans are able to manage safety. Look at the features of human behaviour and the contributing circumstances which occur day in and day out; these aspect might relate more with the audience than a negative approach.
And consider this; the audience might actually have more examples than the presenter in these areas. If so, presenting CRM might require the skill to bring out the examples and jointly explain (understand) the reasons and reinforce to key points.

Sorry to be so negative re your request.

[frontlefthamster]

Hmmm, for fear that this forum becomes infected with the CRM virus, perhaps I might ask Pull What for two things:

1. A meaningful definition of 'CRM'
2. Some evidence that 'CRM' has had a beneficial effect on aviation

[merlinxx]

It was as stated. G-ASJJ crew were, One Line Capt, one Check Capt (on jump seat) one Capt on final type check. Good engine shut down, not failed donk. I remember well, I was on duty that night in the Aero Club when the call came through:{ Check Capt departed BUA shortly afterwards. Article avbl on British Caledonian (BCAL) Reunited. The online portal to connect ex British Caledonian Employee's from around the world. (http://www.bcalreunited.co.uk).

Night folks

[Pull what]

Thank you all very much for all your inputs and suggestions


Pull what, the following might not help; but why, like the majority of the industry, focus on the negative aspects of safety?A good CRM course will teach you that everyones perception is different. You see an accident as a negative learning experience, I see it as positive one.

You will find a meaningful definition of CRM here

CRM Defined
2.1 CRM encompasses a wide range of knowledge, skills and attitudes including
communications, situational awareness, problem solving, decision making, and
teamwork; together with all the attendant sub-disciplines which each of these areas
entails. The elements which comprise CRM are not new but have been recognised in
one form or another since aviation began, usually under more general headings such
as ‘Airmanship’, ‘Captaincy’, ‘Crew Co-operation’, etc. In the past, however, these
terms have not been defined, structured or articulated in a formal way, and CRM can
be seen as an attempt to remedy this deficiency. CRM can therefore be defined as a
management system which makes optimum use of all available resources -
equipment, procedures and people - to promote safety and enhance the efficiency of
flight operations.
2.2 CRM is concerned not so much with the technical knowledge and skills required to
fly and operate an aircraft but rather with the cognitive and interpersonal skills needed
to manage the flight within an organised aviation system. In this context, cognitive
skills are defined as the mental processes used for gaining and maintaining situational
awareness, for solving problems and for taking decisions. Interpersonal skills are
regarded as communications and a range of behavioural activities associated with
teamwork. In aviation, as in other walks of life, these skill areas often overlap with
each other, and they also overlap with the required technical skills. Furthermore, they
are not confined to multi-crew aircraft, but also relate to single pilot operations, which
invariably need to interface with other aircraft and with various ground support
agencies in order to complete their missions successfully.

http://www.caa.co.uk/docs/33/CAP737.PDF

frontlefthamster (http://www.pprune.org/members/207985-frontlefthamster)
I cannot provide evidence of any training being beneficial in aviation, thats not my task but common sense tells me that when 70 - 90% of all public transport aviation accidents are 'error' based, training must be provided to try to reduce this figure and I am happy to take part.

[frontlefthamster]

Pull What,

Thanks for rising to the challenge.

One of the most fundamental weaknesses of CRM is that it's such a loose bundle of ideas it can't be defined in a few pithy words...

I, and others, argue that no benefit is discernable, because it has no benefit... Perhaps this isn't the place for a longer discussion, but I am very much afraid that CRM is simply snake oil, and the pyramid marketing of it benefits from the fact that those infected with it's charms are rapidly driven to addiction.

[safetypee]

Pull what, thanks, no disagreement, but - “CRM can therefore be defined as a management system which makes optimum use of all available resources - equipment, procedures and people - to promote safety and enhance the efficiency of flight operations” … is a bit like applying HF, applying all those things in the SHEL model – it's the process of managing.

Another view can be found here;
Crew Resource Management: An Introductory Handbook (http://handle.dtic.mil/100.2/ADA257441). There are references to some older accidents – the negative aspects, but interestingly, few if any in the time period which you seek. Perhaps this is because this period is pre CRM.
I would agree that human problems and variable behaviours might be found in older accidents matching those similarly labelled by today's CRM, but in either instance and with differing perspectives, the fundamental issues remain hidden by the absence of adequate investigation (understanding) of the perception of the actors in the accident, we don’t know what they thought.

As much as current CRM favours the negative, don’t forget the volume of information from normal operations and the enormous benefit of being able to ask people what they thought during periods of interest in normal operation, whereas in a fatal accident this is not so.

One of the challenges in CRM training is to construct a suitable argument to balance or adjust opinions such as given by frontlefthamster. The many differing viewpoints, difficulty in grasping the concept, or visualising effectiveness are indications of the complex nature of the problem space, and as such requires a change in the way in which we think about the constituent issues.
We should not be overly concern that there are differing views or possible alternative approaches for improving human performance, but at least we should be prepared to discuss them, and not write them off as unsolvable or of no benefit.
Those who see CRM in this contrary way provide a valuable insight into the processes of training; including aspects of instructor knowledge and ability – further aspects of human performance, which need adjustment in parallel with the overall safety task.

[frontlefthamster]

Safety pee,

This part of the discussion belongs elsewhere, of course...

It would be truly fascinating to review, academically, the way that CRM has grown into the monster that it is now. Certainly, part of the fertile ground for that growth came from a desire to reduce accident rates. Subconsciously, I'm fairly sure that part of it came about because CRM theory falls in step with blame culture, and is a way of trying to blame pilots before the event, often by using 'training' to show them they are wrong, before that wrongness translates into an accident.

I could go on and on. I'd still be very pleased indeed if someone could show that CRM has had some benefit. I am, by the way, a CRMI, but my work in the area sometimes leaves me feeling rather like Wonko the Sane. Wonko the Sane - Hitchhikers (http://hitchhikers.wikia.com/wiki/Wonko_the_Sane)

At it's worst, CRM training is an appalling waste of time. At it's best it provides a thought-provoking and informative day out from the office. Does it change behaviour? Very difficult to say. Does it reduce the accident rate? There is no sound evidence that it does.

Do we need to admit that the whole construct is false in order to move on to something that will have an effect? Perhaps. Would admitting defeat and stopping the programme help us towards some answers? Probably.

There is an interesting bifurcation in discussions about training and competence going on at present... On one hand, people point to loss of control accidents as a marker that better flying skills are needed (they seldom point out that technical malfunction is arguably more preventable and often the precursor to these events), on the other they argue that more and more complex attempts must be made to formalise pilot behaviours and modify them in the population. I wonder what we're losing in the middle ground?

[Pull what]

Very interesting views gentlemen and I can probably identify & understand why both of you have those views.

I worked for an airline who employed a guy to be in charge of CRM, a psycologist who knew nothing of multi crew operation. If you listened to him you would have thought he was a 20,000 hour pilot. Within a short period of time he became a laughing stock to such a degree that everyone was in a very negative frame of mind before they even got to the training centre, in fact I base my training on doing nothing that he did!

Personally I believe that only very experienced captains should deliver CRM. Airline flying is a very unique management discipline and pilots do not engage well with psychologists who enthuse about academic, non practical, mumbo jumbo.

Yes I certainly believe it works. Tenerife brought about less ambiguous RT. Tenerife Dan Air brought about more situational awareness in the area of the hold and questioning of ATC instructions. Kegworth brought about more involvement with cabin crew as team members and type difference training. The advantage of CRM training is that all this can be taught in the classroom rather than killing people down line! Training also give the opportunity to remind new pilots of these incidents and accidents, some of which happened before they were born.

[safetypee]

frontlefthamster, thanks for an enlightened post; I agree with views expressed.

(1) yes this discussion should be elsewhere, but I will persist. Perhaps the moderators could relocate the thread to Safety / CRM; that location might also result in more replies to the originating question.

(2) your view of CRM is increasingly common, which the industry should take note of. I agree with the perception and the need for action, but perhaps not all of the suggestions.
One response could be ‘the legal retort’ – “absence of evidence is not evidence of absence”, or in this instance effectiveness of some CRM activities.
However, this view does little to progress the interests of safety. ‘CRM’ is progressively being used like ‘error’, a general term of classification without substance, which may enable understanding, e.g. accident reports – “the crew exhibited poor CRM’. Yes this is blame, and there is often no detail as to what specific human aspect was ‘poor’ or what action could be taken to improve it.

It is probable that the industry’s current safety concerns stem in part from these historic changes in training and the (old) views of the human role, but equally they result from the success of the industry. We are safe – a high reliability industry, and as such the nature of problems and the means of maintaining safety require new views (Amalberti, Hollnagel).
There is growing interest in ‘error’, or the need for the term at all (Hollnagel et al); from this there are concepts of variable human performance, and problems of operating in complex, chaotic situations – functional resonance. In systems thinking, these problems are defined as ‘wicked problems’ which are not responsive to conventional analysis, problem definition, or solution; the details are in the references.
CRM, HF related safety is a ‘wicked problem’.

CRM, let’s call it human factors training, still has a part to play in future safety initiatives. It is a component of the triad (HF, technology, and organisation / operating situation), which may be amenable to further improvement to benefit safety.
The HF component may be the most problematical, it’s potentially powerful, but variable – “it’s difficult to change the human but you can change the conditions of work” (Reason).
Technology plays a major part, but change is slow and costly; the organisation could be adjusted, but this is plagued with other HF and commercial aspects; so we try to change the human!
The industry requires a broad view of safety, not necessarily to identify specific solutions, but to judge what each aspect might be capable of and how current processes might be adjusted – small changes in a chaotic system can have large (and often unexpected) results.

I agree with the views about training and competence. The attempts to seek ‘a solution’ to these and the associated problems of Loss of Control might be a catalyst for changing the way in which we think about safety and CRM, and be an opportunity to regain the middle ground.

Safe t p

The emperor’s new clothes (erik.hollnagel.googlepages.com/HESSDKeynote.pdf) or a short summary. (www.ida.liu.se/~eriho/HumanError_M.htm)

Systems Thinking. (www.demos.co.uk/files/systemfailure2.pdf)

Connecting the dots. (www.demos.co.uk/publications/connecting-the-dots)

Pull what - Vulcan B.1 XA897 London Heathrow 1 October 1956,– Plan continuation bias, peer pressure.

[Pull what]

Thanks for all your input
Anyone who doubts the need for CRM courses or training shoud read this:

Account of Kilwa Incident by Tommy Turk
Tommy was the First Officer on this flight and his unpublished account of the incident appears below. Tommy later went on to become a a Training Captain on the Comet 4 and a Senior Captain on the Super VC10.


"This story MUST start with why Captain Brokensha flew this, the second sector of that day's trip, which by normal custom, would have been flown by the FO. Checked proof of this fact was that the flight log had been made out by me for this sector, which was always filled in during the flight by the non-flying pilot, and records also showed that I, as the non-flying First Officer, had done the radio communications. "Captain.Brokensha, together with about 70% of the DC3 Captains, was a South African (SA). There had been, what we shall call an 'incident', in Dar-es-Salaam at the Government Hostel, where, at that time, all the crews stayed when flying the Southern Tanganyika routes. The 'incident' revolved around a New Zealand FO and an African air hostess. The 'incident' was reported to the Chief Pilot of the fleet by an SA Captain, who in turn was informed, that what the crew did when off-duty was none of the Chief Pilot's business.

"The SA Captains then decided to go on an anti-British FO campaign. ALL, except one FO, with a Kenya passport, were targeted. This included me, despite having lived in Kenya all his life and being a Hungarian. As a result of this harassment, many First Officers resigned. This led to the SA Captains being told by the operations manager to quit their harassment or resign. Some resigned their career in protest - would you believe?

"The harassment consisted of the SA Captains giving away NO flying and made the First Officers do air plots on longer sectors, which was not easy on DC3. The Captains also did their own on-ground and in-flight checks and totally ignored the rest of the crew, except when it was absolutely necessary for them to be spoken to.

"So back to the flight . . . . The second sector was now captained by Gene Brokensha. The approach was normal, right in the middle of the only runway and into the wind. A perfect three point landing, main wheels and tail wheel touching together, was then performed by the Captain.

"In all the DC3 training, it had been drummed into the pilots, that they must never do a three point landing, as the characteristics of the DC3 might cause the tail to swing, if there was even a hint of a cross wind, or if the aircraft did not touch down absolutely straight, or if the runway was cambered. This swing would be difficult, if not impossible to control. . . . Was the Captain simply showing off? Probably..

"The aircraft swung to the left. The Captain applied right brake to bring the aircraft back to the centre line, but very soon after that, the drum brakes faded from overheating. This particular aircraft had not yet been upgraded with the new, and, much more efficient disc brakes. The Capt then applied power to his side engine, to assist the fading brake, but by then the left wheel was running along the rough ground, off the runway.

There was a water table about a metre below the ground, off the edge off the runway, at that position. As a result, here the sand was extremely soft. This then caused a tremendous drag on the left wheel, and, despite massive power being applied to the left engine, the plane was dragged off the runway, until both wheels were completely OFF the runway. Within seconds, the aircraft came to a sudden stop, as both wheels sank in the soft sand, the aircraft belly touching the ground.

"Due to he impact, the Captain was thrown forward. As his hands were already on the throttles, the levers were both pushed to full power. The left engine revved up to full power. There was a crashing sound in the cockpit, with glass flying, and then . . . total silence.

"The Captain's seat had collapsed. I thought it was from the impact, but, it had actually been destroyed by the propeller. The Captain. was in a huddle on the floor, at an odd angle, holding his elbow, saying 'my arm, my arm'. The arm had almost been totally severed, just above the elbow. At that time I had no idea as to what had caused this particular injury. The Captain had been holding the control column right back, with his left hand, the propeller had found its mark there. Blood was spurting out from the injury. I thought, quick, apply pressure on the artery and stop the flow, I leaned over to pull the Captain up towards him so he could better apply pressure to the artery. Only then did I notice that the Captain's body had been sliced in half by the propeller. Within seconds the Captain lost consciousness and died from the massive blood loss.

"Still somewhat surprised at the chain of events, and not yet knowing what had caused this catastrophe I stood up in his seat, looked out of the cockpit windscreen, down the runway. About 80 metres away, in the middle of the runway, sat a propeller. Its blade tips bent back, and still attached to the massive reduction gear. 'Strange,' he thought, 'that shouldn't be there.' I looked out to his side engine: the propeller was still there. He looked out to the left engine, no propeller no reduction gear, just a messy ripped open engine. I looked around the cockpit and saw the finest cut mark, from the propeller blade. It had neatly sliced, through the cockpit from overhead, all the way down to the left, shattering the Captain's side window. Only then did it dawn on I what had transpired.
"On inspection of the runway the next day, the aircraft tracks showed that the plane had in fact started to come back onto the runway, despite one wheel running OFF the runway. But then the tail wheel had struck a cement runway edge marker, only a few inches high, which had again deflected the aircraft off the runway.

"The DC 3 flight manual states that in the event of a planned forced landing, the Captain must land the aircraft from the right hand seat, the First Officer's side, and that the First Officer must go back into the passenger compartment. The propeller 'walking' into the cockpit, after a crash, was a well documented fact.

"I went to the passenger cabin, and found that the African stewardess had fainted from the sight of bright red hydraulic fluid running down the cabin floor, from the sliced open damaged spare tin of fluid, carried near the cockpit, plus the Captain's blood. I disembarked the passengers with no steps necessary: they simply stepped onto the ground from the aircraft.

"After the crash I was advised by many pilots to get back in the air as soon as he could. Dutifully he went to the Aero Club, and flew around in the Tiger Moth, his initial trainer. Two weeks later . . . he went back on the line . . . more experienced, more hardened,

"Would this story have had a different ending had I flown that second sector, as was the norm? I believe so, as he would have done the mandatory 2 wheeled landing. He also he believes his flying was up to standard. as he went on to become a training Captain on the Comet 4, and later became a Senior Captain on VC 10s. He resigned in 1973, after being warned of the airline's imminent collapse, and had, by then, done 6000 flying hours in ten years with EAAC."

Thomas "Tommy" Turk (Vienna 2004)

Picture of the damage to the cockpit in link below where the story is reproduced from
East African Airways (http://www.mccrow.org.uk/eastafrica/east_arican_airways/East_African_Airways.htm)

[merv32249213]

Try Llubjana Sept 1st 1966 Britannia Airways , Britannia .93+ British lives lost.
It appears to have been airbrushed out of history books and very rarely recalled .

I still have vivid bad memories of trudging through the wreckage in Yugoslavia for clues with the Civil Aviation investigators and the late Geoff Parkins of Brits. Also coming home to Luton with the survivors .

[FlightlessParrot]

I have no experience of powered flying, but have spent a life time in teaching and training.

I understand the desire for positive examples, but that might imply accounts of routine events.

What might be attention-grabbing would be accounts of when good CRM avoided an accident. Especially, since the chief point seems to be to get Captains to exercise command without being arrogant sods, occasions when the FO has over-called a Captain. Shouldn't be about a culpable fault, but occasions when the FO has better information than the Captain.

Such anecdotes to come, of course, from Captains.