Miscommunication btwn CC and Flight Deck....

[SkySista]

Hey all....

I'm currently writing a report for classes regarding CRM and how deficiencies can contribute to accidents. To narrow it down a bit, I have decided to focus on miscommunication between Cabin Crew and Flight Deck. (both ways)

Thus far I have two examples, one is the Airtours(?) 737 which shut down the wrong engine after CC didn't tell the Capt the sparks were from OTHER engine... the other is that ASA Brasilia where the CC didn't inform the Capt the whole engine was gone...

Just wondering if anyone else know of other examples (as well as situations where Flight Deck omitted/misinformed CC which resulted in injury/death...)

Also if you personally have had any experience with this, and are willing to provide date/time/type of incident (obviously if it is on public record only) please PM me. I ask this because w ehave to reference any experiences told to us so they know it 'really happened'.... lol.....

Mod, feel free to move to Safety/CRM if that's a more appropriate place...

Thanks for any help you can give!! :ok:

Sky

[sinala1]

Thus far I have two examples, one is the Airtours(?) 737 which shut down the wrong engine after CC didn't tell the Capt the sparks were from OTHER engine
Are you referring to the BMI Kegworth B737-400 incident? If not, I will try and get a detailed incident report for you - a *very* good incident to learn from, comes up in every CRM course I have done...

Another good incident to study is QF1 in BKK - a B744 overran the runway and ended up in a golf course. The actual runway overrun was not anything to do with the cabin crew (obviously!) however the ensuing half hour or so are quite interesting - the aircraft's E&E bay (the part of the a/c that has all the controlling devices for interphones etc) was submerged in mud and subsequently rendered useless - very difficult for the crew on the main deck to communicate with the flight deck re evacuation etc... the link to the official Australian Transport Safety Bureau report can be found here (http://www.atsb.gov.au/aviation/acci/ojh/index.cfm) and is well worth the read....

A further incident worth reading about is an Air New Zealand B762 taking off out of Brisbane that had an engine cowling separation and subsequent return to BNE. The flight crew contacted the Supervisor, who failed to pass the information on regarding brace commands to be shouted, cabin preparation etc (commands used on ANZ were at the time different depending on whether it was prepared/unprepared)... the result was half the crew shouting the prepared brace commands, other half shouting unprepared brace commands... you can find the link to the ATSB report here (http://www.atsb.gov.au/aviation/pdf/200205780.pdf)... its a long but very worthwhile read!

Hope these help - and I am sure I can track down some more for you if you want! A QF one springs to mind re a B767 crew who were standing for landing.....

Cheers!
:ok:

[jettesen]

another good one is the air canada dc-9 incident where the toilet caught fire, and there was mis communication between the cc and f/d and the fo/ and capt. plane was ablaze, and subsequently large loss of life. F/O told captain fire was out but wasn't.

[Hand Solo]

Might have a problem if you're trying to communicate with the Flight Deck. Why no try talking to the Flight Crew instead, you're much more likely to get a response.

[flapsforty]

Interesting topic SkySista :ok:

Seems a matter of semantics to me Hand Solo. For example in our mob, flight crew is everybody who works onboard the AC, with the pilots being cockpit crew and ourselves cabin crew.
Here on PPRuNe I've learnt that there are many different ways we refer to eachother, some nice, some not so nice, but in the context of this thread the term flight deck comes across as entirely neutral to me.

Jettesen, that incident is one I often refer to during the SEP bit of the briefing. Wouldn't mind refreshing my memory on it; anybody got a good link?

[flybywire]

Sky, the BMI 737-400 Kegworth accident is a VERY good example, and new crews always respond very well to it during initial training. The video reconstruction that has been produced is very well done too. It enlightens all the different rings of the chain that led to the disaster-from flight crew being converted on the new 737 too quickly to the confusion about right=Nr2 engine and right=correct engine, miscommunication between passengers and cabin crew and the already present tension between Flight and Cabin crew.
I have a very detailed report on that, I just need to find it!!!

Another always valid talking point is the Saudi Arabian Airlines L-1011 accident which happened on aug 19th 1980. They had a fire in the cargo hold, which spread into the cabin very quickly, soon after leaving Ryadh and landed back, but a series of communication mistakes resulted in the death, on the ground, of all the crew+passengers on board (Plane didn't stop immediately and crews didn't evacuate). :uhoh:
It is very interesting, I would look into it if I were you. Again I have some very detailed information about it at home but need to do some tidying up!!!

If you want a less tragic one, the Qantas 747 which floated over the runway-big problems with CRM in the cockpit- and then overrun the runway is a good one. Crews at the front opened the doors and those at the back of the jumbo didn't even notice the nose had collapsed!!! :uhoh:

Anyway, the internet is a very useful source, you'll find tons of information. :ok: I will try to find the documents anyway (hopefully before Christmas!!!) ;)

Ciao :)

FBW

PS: on the airtours 737-200, if I am not mistaken, the fire was on the ground. The plane never got off the ground.

[Fujiflyer]

flybywire, I think the welcome pa was started whilst the a/c was still decelerating down the runway and was stopped midway when the CC realised something was wrong.

[jettlager]

Fujiflyer,

you are correct.

[flybywire]

Fujiflyer you are probably right. In fact after that incident some airlines changed the procedure for the welcome pa-they now do it once the aircraft has safely turned onto the taxiway.
(post above edited)

[LOTflyer]

Very interesting. This reminds me the situation from 1998 when one of B767 engines got on fire on take off from BKK and when the supervisor entered the flight deck for the info on situation she heard " get to **** out of here" - from the cpt. Sad but truth. Fortunatelly it was really experienced lady so the cabin crew knew what to do.

Other situation, an example of bad or even NO preflight briefing. On a WAW-JFK flight there was a bomb threat, that was disclosed short before landing. The crew were asked to prepare the cabin for prepared emergency landing. When the supervisor started to read the emergency PAs nobody knew where to stand in the cabin/the position to take during PAX briefing. Total mess.

[GalleyHag]

You can gain valuable information from the Cabin Safety Inspector at CASA as well as the Asia Pacific Cabin Safety Working Group. If you need the contact info just PM me.

[SkySista]

Wow! I hadn't expected so many replies so soon!!

Thanks everyone for your information and sources - this will give me tons with which to work...

Re the 737 incident, I think I'm confusing two different events.. I think now one was a) involving Airtiurs and b) the other was Kegworth (if that is the one in which they ended up near the Motorway??) Anyway I shall look up both.

I can't believe QF1 didn't occur to me - it is a pet subject of one of our lecturers (whose main interest is human factors and so forth). I guess mainly I had been looking at that incident from a FD perspective...

This also ties in well with the whole subject of procedures and automation.... how much is too much before crew become over-reliant on SOPs or automation (e.g. crew following an SOP in emerg situation even if it doesn't make sense.... )

Top job, all!! Very much appreciated!!!! :ok:

Will let you know what I come up with...!

(Just gotta get up the nerve for the speech part.......) :\

[sinala1]

(Just gotta get up the nerve for the speech part.......)
I have a link that can help you with that too! www.jackdaniels.com (http://www.jackdaniels.com) :E

(Suggested served with ice and coke, or straight up if thats the way you like it!)

[SkySista]

Sinala, you're a darling, I'm sure that would do the trick... only problem I can see it might work too well! :}

Hope flying is going well with you... are you back in Oz?? It's hard to keep track of everyone these days!! :cool:

Edit: I forgot to add, in my report I want to contrast the bad CRM with the example of the UAL232 crew (Al Haynes & co in Sioux City, '89) I need to know if it's true that afterward, many airline crews were tested and none got even close to the airfield in the sim... I have heard this many times but did not know if it was just a myth.... :confused:

[Rollingthunder]

Flaps

Air Canada flt 797.

http://www.airborne.org/flying/forum3.htm#Air%20Canada%20Flight%20797

[sixmilehighclub]

I was cabin crew on a B737 a few years back, as me & my colleagues were all standing down the back counting the bar money we all felt a little turbulence, so I looked out the window to see if we were going through clouds in our descent, and saw grass passing the window.

Yep. We had landed.

I did also hear of a colleague who in late descent had piled into the flight deck with the other crew to check out the view of her house, to save time she hit the button to play the pre-landing PA prior to going in, thinking the cabin would be ready to secure when they came out. Unfortunately on leaving the flight deck the crew looked up and stopped dead in their tracks. The entire cabin were dressed in their lifejackets. She'd hit the ditching PRA code by mistake. Ummmm ACARS for 150 replacement lifejackets please Captain.......


:}

[SkySista]

Thunder,

thanks for that link, an interesting event. That comment about the 5 minute delay is SCARY indeed!!!

The comments made by other crew wrt having Swissair 11 in mind... goes to show that at least it brought the issue to attention... sad that people had to die to do it though... :(

As for getting from FL390 to landing in 22 minutes - yowza!!! Would not want to guess how that would affect one's stomach!! :yuk:

[A300Man-2005]

Sixmilehigh

What became of the Flight Deck Crew on the flight that had landed whilst you were still standing at the aft? Surely there must be a procedure for cabin secure prior to landing - I guess this is another perfect (albeit bizarre, but could have been serious) example of how important CRM is!

[jettlager]

SOPs were altered after the incident.

Up until then, no acknowledgement from the cabin was required by the flight deck prior to landing.

CSMs must now acknowledge via interphone call a "20 000ft prepare cabin PA" from flight deck.

Jettlager

P.S. The crew werent just standing down the back.
The CSM landed in a J/C [fwd cabin] passengers lap on landing.

[SkySista]

The CSM landed in a J/C [fwd cabin] passengers lap on landing.

Depending on the said crew, I bet the pax didn't complain.... :E

Seriously though, I wondered how the flight crew could 'forget' to get in touch with the CC prior t landing...

on another note.. is it acceptable for CC not to 'secure cabin' for landing because of turbulence?? Friends flew QF once and she said on landing some of the overheads flew open dumping bags etc out, apparently the CC had been told by the Capt. to sit down and so none of the 'before landing' stuff was done.... :confused:

[SkySista]

like in the above case, not really a big deal IMO.

sorry, do you mean the CC standing up for landing, or the cabin not secure??

I mean, I was just not sure if the cabin not being secure was a more common occurrence than I thought... :)

[jettlager]

Skysista,

SOPs improved again at qf with turbulence PA from flight deck.

CSM must acknowledge PA with flight deck.

If this occurs on approach/decent the CSM has an opportunity/obligation to advise the that the cabin isn't secure for landing and that we must be "released" to rectify prior to landing.

Cheers Jettlager

[SkySista]

thanks for clarifying...

Flaps, that same thought had crossed my mind... usually when I fly I can tell when we are coming in (if not viusally then change in engine pitch and so forth....) but i agree sometimes you can just get 'caught out'!

Jettlager, thanks. I am guessing in this case it must have been pretty severe, as according to my friend once the crew had been told to sit down they did not come through the cabin again. Also she said it got quite rough she was actually a bit scared, nothing looked too unusual but as I mentioned some bags came out of the overheads, luckily the crew had been good in not allowing anything too heavy up there in the first place!!! :}

Was also not a very full flight, maybe this had something to do with it? (e.g. crew had just before seen pax were mostly belted in/asleep etc) so knew cabin was as good as they could get under circumstances...

as you say if there is a good enough reason... Obviously in that case the crew decided it would be more dangerous to walk thru the cabin than to secure it.....

[sinala1]

Obviously in that case the crew decided it would be more dangerous to walk thru the cabin than to secure it.....
Precisely.... remember the first rule of your DRABC is to check for danger! No point in hurting yourself in an attempt to help others...

The incident most relevant here that I can really recall (other than BMI B734 Kegworth) is a QF B767 that landed with the crew standing... I will relate the story the best I can recall it, however if any QF crew are able to confirm/clarify it would be appreciated... (studied this in CRM a few years ago, but not seen it since!)

Upon boarding the a/c the CSM was advised by the flight crew that the seatbelt signs "ding" sound was inop, however the signs themselves were still working. This was important info, as the seatbelt signs were used at QF (as I am sure they are at most airlines) as a non-verbal method of communication with crew in regards to being seated for take-off/landing etc. The CSM however was unfortunately concentrating on an IFE problem and forgot to pass the information on to the crew. When time came for landing, the crew were still in the cabin collecting headsets on touchdown due to being unaware of how close landing was - because they had not heard the "double ding" and were not aware that it was inop... Anyone able to clarify details for me?

Forgive the rushed typing job - I am particularly jetlagged (just got in from Las Vegas after one of those flights) and am really not in the most coherent frames of mind! :zzz: :ouch:

[wiggy]

SkySista
I think the Airtours 737 accident you're thinking of is the abandoned takeoff accident at Manchester.

[A300Man-2005]

The "Airtours" incident at Manchester involving a 737 was actually "British Airtours", and not Airtours International (or MyTravel, as they are now known).

It was an incident in 1985 (I think), and a Boeing 737-200 operated by British Airways' charter division, British Airtours (designator KT - and who later bacme known as Caledonian Airways after BA's buy out of that brand) aborted take off from Ringway, due to a problem with one of the engines. The aircraft was bound for the Greek Island of Corfu, with 131 (?) passengers onboard.

The incident was considered landmark in many ways because it changed the way the world flies. Additional measures, such as modified seat fabric and construction and floor level lighting all arose as a result of the tragedy at Manchester.

Aitrours International never operated the Boeing 737 per say, unless wet leased for additional capacity.

[SkySista]

thanks again for the posts.

Re: "Airtours", I should have specified "British", it was just me 'abbreviating' and assuming everyone would know what I meant! I forget there's so many airlines in UK/Europe :E

(Always been only 2-4 here in Oz :} )

Already those links mentioned have brought up interesting issues re: smoke hoods, emerg descent, cabin interiors, seating etc. Even though for this report I probably won't go into toooo much detail on those, I will definitely print and file this info for future use!! :ok:

[SkySista]

Just wondering, does anyone know where I might find "artist's impression" images of Kegworth and /or the ASA Brasilia incident?? Trying to find a picture that would give some idea of what someone looking out of the window would have seen.

Want to use it as a slide in the intro of my presentation, to make it a bit more 'real' - trying to get the attention of (mostly) teenagers here. Nothing overly dramatised, just a reasonable "guess". Screen cap from that Air Crash episode would be good... or perhaps of the Air Canada lav fire... i.e., what it would have looked like inside the plane?