Discounting our resident Fountain of All Knowledge and the usual bevy of instant blame-finders, this is a very interesting thread.
In
addition to the excellent summing up by PantLoad of the importance of SOPs, did CRM also play a role here?
The core of the fifth phase of CRM is the principle that human error is both inevitable and a valuable source of information as well. Since error is inevitable, CRM can be seen as a set of error antidotes with three lines of defense.
The main cause of this incident appears to me to be a failure in communications between cockpit and cabin crew. This vital communication seems to have failed in two, possibly three instances.
Main comms failure:
The SCCM returned to the flight deck to update the commander, and while the flight crew acknowledged her presence, she did not convey her concerns on the need to evacuate the passengers as the flight crew were busy dealing with the incident.
When effective communication is at work, what the receiver decodes is what the sender sends. A breakdown in the communication process may occur if the intended message was not encoded or decoded properly. There may also be barriers in the transfer process including: noise, vibration, radio clutter, cultural differences, distractions, fatigue, stress and incomplete messages. Lack of common experience is a major cause of communication breakdown in a cockpit. A communicator’s words cannot communicate the desired meaning to another person unless the listener or reader has had some degree of experience with the objects or topics to which these words refer. The English language can be very confusing; due to the fact that several words in the language mean different things to different people. This is the cause of confusion between what is said being received differently from what is really meant to be interpreted by the receiver. This hurdle to the communication process can be attributed to the pairing process, and specifically the cultural differences between crewmembers. Both verbal and non-verbal communications may be interpreted differently, and this may cause problems during flight, particularly in high-workload situation.
Power Distance (PD) is the distribution of “power” among individuals and groups in a society, and how inequalities in power are dealt with in these societies. Societies with a low PD believe that, inequality should be minimized, all people should be interdependent, and hierarchy is an inequality of roles. In practical terms, PD reflects that there is an unequal power relationship in the cockpit, and a subordinate should not question the decisions or actions of their superiors. The results of a cross-cultural study conducted in 2001, showed that in cultures with a high PD safety might suffer from the fact that insubordinates may not have the ability to speak up when they should, or are unwilling to make inputs regarding leaders’ actions or decisions (Baron, 1997).
There was a clear failure of communications when she stepped into the cockpit, with the result we are now discussing.
Cockpit and cabin crew can be said to hail from different cultures. They use language differently, they deal with completely different realities & challenges in their day to day work, and have different skill sets.
How much training in cross cockpit-door communications does this operator provide for its cockpit and cabin staff? Are its pilots and CC aware of their different communication styles and have they been trained in effective two-way communications under stressful circumstance?
A proper awareness of, and respect for, the chain of command is essential for a safe operation. Too much "respect"
may in this case have led to a failure of communicating forcefully with clearly busy pilots.
When she returned to the cabin she announced, in a calm manner, over the passenger address system: “Please evacuate the aircraft as quickly as possible. Leave all hand baggage behind.”
In a non-standard situation you may need to use non-standard phraseology. Is the possible need to use non-standard phraseology something that gets discussed during the training at this operator, or is there an exclusive focus on the use of standard commands?
From the report´s "... she would again consider initiating an evacuation." it
seems but is not entirely clear that she intended to initiate an evacuation. If so, why did she not use the company´s standard command?
When cabin crew perceives a situation on the ground to be imminently life threatening, and they are certain the engines are not running, they are obliged to start an evacuation and to inform the pilots that they are about to do so. This SCCM and the rear door CC thought the situation was about to become life threatening, and they evacuated.
In hindsight, this situation was not life threatening, and her decision to initiate an evacuation was an error. As was the fact that she did not (attempt to?) inform the pilots of her intention.
The company is to be applauded for the way they have dealt with this SCCM, for the way they have treated this as a learning experience and for the consequent clarification of when to initiate an evacuation provided to their CC.
This SCCM did the wrong thing for the right reasons.
There but for the grace.....
The beauty of this website is the opportunity to learn from this, for both cockpit and cabin crew.