Airbus old accident

[sheppey]

Airbus crash during circling at night six years ago. The accident report was probably mentioned in Pprune a few years back. Since then there would be hundreds of new pilots trained to fly the Airbus and who probably have never heard of this accident.

If nothing else, it is well worth they study this accident for all the factors involved.

A321, vicinity Islamabad Pakistan, 2010 - SKYbrary Aviation Safety (http://www.skybrary.aero/index.php/A321,_vicinity_Islamabad_Pakistan,_2010?utm_source=SKYbrary&utm_campaign=24c17b4adc-395_EGPWS_Warnings_29_02_2016&utm_medium=email&utm_term=0_e405169b04-24c17b4adc-276530305)

[fa2fi]

I think it's pertinent to all, not just Airbus flyers. They flew a perfectly good plane into a hill despite the plane screaming at them. The Skygod CP had zero CRM skills, bullied the FO, FO then lacked assertiveness particularly when it was evident something bad was about the happen. They also lost visual during a circling manoeuvre and no attempt to execute a missed approach was attempted. A lesson to us all.

[Uplinker]

That is all very well, but in my experience of CRM, assertiveness has never been mentioned. Assertiveness has never been tested. Assertivness has never been taught.

Training in this area is woeful. We watch a few videos and agree that something should have been done or said by the ill fated pilots, but that's it.

My experience of CRM over many years is that

a) Most of the flightdeck want to go home as soon as possible. The majority are simply not interested in CRM at all. They will skip breaks and rush through stuff just to get finished and get home before the rush hour. Some are heard saying "what a waste of time".

b) The general atmosphere towards those who are keen to get involved in the classroom is: don't - you wil make the day last longer and we want to get home, so don't say anything.

c) It is assumed that every first officer - including the 200 hour novice - will be able to confidently manage a situation such as the one in the link, stand up to the fiercest egomaniac, handle bullying and still be able to rise above this and offer advice and ultimately take control. Yet none of this ability has ever been checked or tested.

d) When it all goes wrong, what is usually implied is that the F/O should have done something - when that F/O has been given no training or tools with which to do it.

[oicur12.again]

uplinker,

I totally agree with your comments.

My cynicism about aviation grows every year and is reinforced when doing classes such as CRM.

My last CRM, run by a very famous carrier with a red animal logo on its tail, was merely a day of listening to accident CVR's. Nothing more.

As if hearing the UA DC10 crash CVR for the tenth time in our careers is going to help.

“…when that F/O has been given no training or tools with which to do it.”

Exactly, although I would replace the word “FO” with “crew” as I think all pilots are thrown into the deep end of line ops without appropriate training in many areas, not just CRM.

I get sick of people asking “how can that possibly happen” every time an airline crashes and my usual response is “how can it not happen”.

My airline, that I just joined (my 6th) is trying to improve on time performance and recently sent an email to pilots highlighting the importance of on time departures simply by saying we “must try harder”.

Really? How exactly. It’s the airline giving us poor tools, techniques, procedures and expectations that result in late departures.

Sorry for the rant but sometimes I am simply ashamed of this industry!

[B2N2]

c) It is assumed that every first officer - including the 200 hour novice - will be able to confidently manage a situation such as the one in the link, stand up to the fiercest egomaniac, handle bullying and still be able to rise above this and offer advice and ultimately take control. Yet none of this ability has ever been checked or tested.

That statement is perfect right there.....

[Machinbird]

Most of the flightdeck want to go home as soon as possible. The majority are simply not interested in CRM at all. They will skip breaks and rush through stuff just to get finished and get home before the rush hour. Some are heard saying "what a waste of time".I'm not surprised if they are trying to teach CRM and assertiveness in the classroom.
The place you need assertiveness is in the cockpit, not the classroom. The place to teach CRM and assertiveness is in the simulator. That way both sides of the cockpit have a better idea of what the training department believes to be an appropriate level and method of assertiveness.

All the classroom is good for is to brief and refresh the fundamentals.

FWIW, a F-111 crewman told me that their preferred method of getting the other guy's attention was to grab the other guy's oxygen mask hose and pull.
Now that is being assertive.:}

[Rwy in Sight]

I am an SLF, but due to a thesis a long time ago I had to read a few things about CRM. Over the years I developed a question I like to ask crew (or anyone involved with professional flying): can you teach CRM to someone not having the necessary qualities from his/her up bring?

In my country, for a long time most civilian FD crews were coming from an Air Force with no CRM classes, so pilots were train to listen to their superior without too much talking back. When I was flying on those flights I was concerned how much a former Air Force turned civilian Captain would listen to his crew when things turned bad - I had no doubt he would pass his CRM course with flying colors given his capability to obey orders.

So it seems your post has answer my question.

[Uplinker]

Most of the ex airforce guys I fly with are excellent. However, there are one or two bad apples who were so used to being in charge and not being questioned by their juniors that a dangerous lack of CRM prevails in their cockpits.

Like some Atlantic Barons and others who said 'gear up and shut up, and where's my coffee?', these pillocks think they are infallible sky gods and they will not accept criticism. Some of them were single fast jet pilots and did not operate with a crew before flying commercially. They don't think there is anything wrong with the way they conduct flights and think the CRM course is for everyone else junior to them.

As far as passing a CRM course, we have no exam. We just sign an attendance sheet.

[Rwy in Sight]

Uplinker,

thanks for the answer. I share your feelings about Air Force pilots. I am not sure what makes a good pilot CRM wise.

Regarding passing a CRM exam - by passing an exam I am referring to whether some one not CRM prone would do good CRM when the problems require it.

[oicur12.again]

Several airlines I have worked for have made CRM an assessment point in sim recurrent. One airline would make every second sim session a CRM only sim and use low light cameras to record your performance for de briefing.

It really highlighted your weak points in participating as a crew member and I recall how many unresolved discrepancies we ignored, despite thinking our performance was stellar under the heat of battle.

But most airlines don’t do that.

Most airlines sim training is simply box ticking to keep the regulator happy no matter how irrelevant or non-threatening to real world line operations the exercise may be.

We get really good at V1 cuts and single engine NPA’s but that’s NOT what is causing accidents in western airlines. There have been some very close calls here in the US resulting from ABYSIMAL decision-making and poor cockpit management.

AA 737 over run, Southwest 737 over run, Southwest 737 nose gear collapse, USAir RTO after liftoff, DL MD88 runway excursion, Southwest 737 landing at the wrong airport, Dreamline landing at the wrong airport.

Complacency, normalization of deviance and my favorite – RUSHING, are becoming so common in this game that it’s a wonder more metal does not get bent!!!

And pilots have become too spineless to stand up to the on time pressure being placed on them by the airlines they work for.

Just my opinion!

[AirRabbit]

What concerns me is the misstake that is sometimes made when well-meaning folks slide crewmembers through the myriad of ‘stick ‘n’ rudder’ tasks, expose them to the text book/classroom idea of C-R-M and pin stripes on their sleeves and send them out to make money for the airline. Typically, an understanding of what is affectionately known as “CRM” includes the following: 1) Opening or attention getter; 2) Statement of concern; 3) Statement of the problem as recognized; 4) Offering a solution; and 5) Obtaining an agreement.

It is certainly not my intent to minimize the importance of being able to communicate in the cockpit of airplanes (and, by that, I don’t mean ‘communicate’ as some understand it to mean “limited to verbal aspects”) however, I believe that the overridingly important skills and abilities that simply HAVE to be present in any airplane cockpit are those that are directly used to manipulate the controls to ensure that the airplane achieves and maintains the desired flight path and condition … and I define “condition” as the configuration, heading, altitude, airspeed, and direction of flight (both vertically and laterally) … where ‘configuration’ includes the position of reconfigurable aspects of the airplane (landing gear, flaps, speed brakes, throttle position, and all three aspects of trim). But, these ‘skills’ don’t stop there – they must include a knowledge of and an ability to recognize what the airplane ‘condition’ should be at any point, and if the necessity exists to modify that ‘condition,’ the ability to apply the proper adjustment of the available controls to achieve the desired condition. If one pilot has, and properly uses, these skills, the other pilot will easily recognize those skills and the associated competence – and probably do so very early in that particular pairing. It is THAT recognition (particularly when it is in BOTH directions) that will allow a regular and a meaningful reliance on one another to accomplish the tasks required to achieve a safe and efficient operation.

Again, it is not my intent to minimize the importance of proper, regular, and meaningful communications within the cockpit … but a recognition by one cockpit crewmember of the displayed competence of the other cockpit crewmember is critically important in any resolution of circumstances that portend a critical development that requires an immediate recognition – and possibly immediate action – by that cockpit crew.

So – all of the ‘classroom,’ textbook, and role-play efforts typically associated with CRM notwithstanding, and I continue to support their use, I remain of the opinion that far and away THE most critical aspect of what goes on in airline cockpits is the competent and professional recognition of any and all situations as they develop, and the display of equally competent and professional manipulation of the airplane controls to maintain the airplane condition or correct to the desired condition … and we absolutely must do all we can to provide the necessary exposure of these skill sets to each pilot to allow each one to develop and refine their own level of professionalism and competence. AND, as far as I know, the ONLY way to achieve this is through regular exposure of those pilots to the tasks defined in the regulations … and, importantly, we MUST regularly review those regulations to ensure that they say what they need to say to result in the competent professionals that are required at the controls of airplanes in the air today … and tomorrow.

[Uplinker]

A classic case of lack of CRM was the Kegworth crash.

No disrespect whatsoever intended to the flight deck, because CRM was in its infancy then, and there were other serious issues with instrument readouts; but on that day, both pilots identified the wrong engine and shut down the only good engine they had.

The cabin crew and some passengers were confused when the Captain told them which engine was faulty, because they could all see it was the other engine that was in trouble.

Had this information from the cabin crew been fed into the DODAR process, the correct engine would have been identified and the emergency would have had a successful outcome.

As I say, no disrepect or Monday morning quarterbacking intended, and in fact this crash is used to teach CRM today. The main point of CRM is to use all available sources of information and all team members to process an emergency.

[AirRabbit]

I also have no desire to disrespect commenters to this thread, nor to disrespect either of the pilots involved in the Kegworth accident, and I think it’s completely appropriate to include a review of the events prior to and during this particular accident sequence. However, from what I understand from reading the report of the Kegworth accident, it seems as though the critical decision to shut down the ‘thought-to-be’ malfunctioning engine was made after incorrectly identifying the problem based exclusively on what was believed to be an ‘understanding’ of the air conditioning/pressurization airflow, rather than identifying the malfunctioning engine on the basis of engine indications. Apparently, there was no attempt of determine the cause of the ‘sudden pounding noise’ nor an attempt to locate the source of the ‘severe vibrations;’ both of which were apparently accompanied by a higher-than-normal fuel flow to that engine.

While it is completely logical to review the “traditional CRM” issues that were absent, I think the facts of this specific accident equally point to a strikingly absent attempt to include a serious examination of the engine indications – ALL of the indications – prior to determining that shutting down what should have appeared to be an apparently normally operating engine was the course of action to follow. I understand that the ‘new’ engine vibration instruments were smaller and had a different ‘look,’ but there is no indication that either crew member attempted to identify the offending engine by a comparison of the remainder of ALL the prominently displayed engine instruments – with which, one would think, both crew members were substantially familiar – including the fuel flow indications, which, apparently, would have been seen to be different, due to the auto-throttle adjustment attempt to maintain normal RPM after separation of the fan blade.

Of course, my focus has regularly been (and will likely continue to be) the training that crew members receive initially and (hopefully) regularly thereafter. Such training should regularly be on ALL of the normal operating procedures AND the procedures to be followed when something goes awry. And such procedures should include, and be regularly reviewed, how the decision to shut down an engine on an airborne airplane is to be made, and what procedures should be followed for that decision to be carried out.

[Goldenrivett]

Of course, my focus has regularly been (and will likely continue to be) the training that crew members receive initially and (hopefully) regularly thereafter.
Please see Page 98.
https://assets.digital.cabinet-office.gov.uk/media/5422fefeed915d13710009ed/4-1990_G-OBME.pdf

"The commander himself might have had a better chance to observe these abnormal indications if he had not disengaged the autopilot..."

Apparently, the single engine training practice in the simulator of flying with the autopilot disengaged (especially on ILS approach) made the Captain instinctively disconnect the autopilot. Manual flying increased his work load considerably and left him with less brain capacity to diagnose his problems properly. The crew never reviewed their initial fault diagnosis.

[AirRabbit]

Hi Goldenrivett – Thanks for the comment and the reference. From reading the report you referenced, it sounds like the person writing that report believed essentially as I do … and it would appear that the training this crew received was awfully short on the “what-is-actually-wrong” and the “what-do-we-do-about-it” aspects of their training. And … I’m not sure that disconnecting the autopilot was necessarily the ‘wrong’ thing to do … as doing this would require the pilot flying the airplane to manually apply the flight controls … which very likely could have given the pilot at the controls a much more accurate understanding of what the airplane was doing … and, thereby, a better understanding of what engine was malfunctioning. Sometimes, the autopilot can input and/or hold aileron, rudder, and/or elevator positions that ‘mask’ the tendencies of the airplane, and make any such identification that much more difficult. Of course, if you aren’t trained on those aspects, if you aren’t given an opportunity to see (and ‘feel’) those things during your training (both initially and recurrently), you might be unable to recognize them, particularly when under the duress of a serious or a developing, and potentially serious, problem. Again, training is such an incredibly important aspect of aviation safety – and that includes the identification of problems or developing problems, as well as a much better understanding of the most logical, most advantageous, and the quickest way to resolve any such problem. Training simply cannot be “do the task; do it right; go to the bar.” There is SOOOO much more to training that when all those ‘other’ aspects of what is collectively called “training” are passed over (or ignored) there are some really valuable aspects of training that may be overlooked – and therefore not examined or brought into the “mix” when they could be a key element of achieving a satisfactory (and safe) outcome. I hope this doesn't sound like a ‘lecture’ … because that is NOT my intent ... but my fear is that “training” almost always takes a back seat to “qualification” and I'd very much like 'training' to be the driving process in aviation safety - as it should be!

[lomapaseo]

Ask yourselves, was there a lesson learned?

Did you learn it for yourself?

Are today's training and procedures adequate for others to not repeat this event?

Note: there will always be left some risk of a repeat by virtue of missing

"rule Based"
"Skill based"

but hopefully for this combination of causes the

"Knowledge Based" part has been addressed by today's pilots

[AirRabbit]

Part 1 of 4
Sometimes an interested observer can pick up on the fact that there is a rather routine misunderstanding by instructors and evaluators of what it takes to fly an airplane. Routinely, the understanding is that instructors teach the necessary skills and evaluators verify that an applicant can demonstrate a sufficient mastery of those skills. Job done? Well ... maybe ... maybe not. The piloting process is one that encompasses a series of appropriate behaviors to achieve the singular goal of completing a safe and efficient flight. As indicated in a post above, pilot behaviors fall into three basic categories or behavior “sets:” 1) skill-based behaviors; 2) rules-based behaviors; and 3) knowledge-based behaviors. Each of these behavior sets encompasses both strengths and weaknesses and developing an understanding of and an appreciation for these strengths and weaknesses in each of these behavior sets can assist in providing a strong basis for informed decision making when operating an airplane.

Skill-Based Behaviors
Because skill-based behaviors are the most immediately visible to a student, they are usually the first type of behaviors a pilot encounters, and, therefore, draws the significant portion of his/her attention at the beginning of training. Coordination of flight controls, use of pitch and power to maintain or adjust altitude, airspeed, rate of decent, or rate of climb, and maintaining the necessary and correct visual references during a specific maneuver or task are all examples of skill-based behaviors. In order to successfully fly an airplane a pilot must develop, master, and be able to demonstrate basic skills. Certainly, during the early stages of training and, not surprisingly, as each additional commitment to maintain existing proficiency or develop a new proficiency comes along, skill-based behaviors are, and must be, the significant focus for pilots. Developing at least basic proficiency in the necessary skills is both necessary and important in order to fly an airplane. However, and to show how behavior sets are related, and most seasoned and experienced flight instructors will confirm that imparting appropriate knowledge about the “hows” (helping to form knowledge-based skills) and the “whys” (also to form knowledge-based, but may include the formation of rules-based skills) to a student who is developing or honing a specific proficiency to accomplish a specific task, will, more often than not, allow that skill-based behavior to be achieved more easily.

As skill-based behaviors are developed and internalized, they are repeated; and as they are repeated the less conscious thought is required to perform the task. The tasks tend to become increasingly “automatic.” They tend to become “habit.” As our skills progress we find we can make airplane configuration changes (extend landing gear, increase flap settings, set the ground spoilers), change navigation radio frequencies, make power adjustments to affect airspeed changes, select differing instrument display alternatives, and maintain the desired flight path, all with enough left-over thought process capability to mentally review the route home and the stops necessary to acquire what our spouse had wanted to complete the dinner plans previously made.

The more we practice a particular skill, the more deeply habituated it becomes, making it increasingly difficult to change the particular perceptions and the pattern of movements learned to perform a given skill. This is why re-learning a skill improperly taught or incompletely learned initially is so very challenging. The more a pattern has become habituated, either by time or by some other motivating factor, if or when it becomes necessary to learn a “new process” for the accomplishment of a task or a portion of a task, it becomes a significant issue that drags the pilot back to the point of using up a greater portion of that once left-over thought process capability – and, at times, may demand more thought process than may be realized, and may be demanded to the detriment of the remainder of the previously habituated skill. In fact, one of the most often overlooked reasons for requiring some kind of recurring proficiency training or evaluation is to identify, and where necessary, correct, inappropriately developed habits.

[AirRabbit]

Part 2 of 4

Rules-Based Behaviors
Rules-based behaviors are behaviors for which a routine or a specific procedure has been developed, learned, and used by the pilot. Using a checklist or following a Standard Operating Procedure (SOP) are excellent examples of rules-based behaviors. A focus on such behaviors allows even moderately skilled pilots to operate an airplane both safely and efficiently in most situations and environments. Rules-based behaviors do not require that the behavior be memorized or internalized. Here, it is the “rule” or the “procedure” that is memorized. For example, what the pilot must know regarding a specific activity for dealing with a pre-flight inspection or a pre-takeoff procedure is that he or she must make use of a standardized checklist or an accepted and memorized procedure. The key focus of rules-based behaviors is the focus on standardized procedures: i.e., “if this gage reads this number or lower, you must turn this switch to ‘ON,’ and rotate that knob to this position.”

Rules-based behaviors provide a tried and true framework for the application of skills. They are typically based on long developed and tested knowledge and experience. The history of errors and successes resulting from years and years of experience form the basis for procedures designed to prevent future errors and guide future successes. Rules-based behaviors make up a generous portion of flight operations and pilot training for excellent reasons. This is particularly true when flying in a multi-crew environment. In such an environment, unless standardized procedures are established and followed, chaos would reign supreme. The standardization of functions that are necessary (all of which are highly structured and standardized) define the actions that are to be taken; by whom they are to be taken; the order in which they are accomplished; and even the communications between crew members. This assists greatly toward achieving an efficient and safe flight.

Knowledge-Based Behaviors
The potential weakness when operating under a rules-based behavior system occurs when there is an initial misdiagnosis of a problem or situation and the wrong procedure is applied. The successful implementation of rules-based behaviors requires sufficient skill-based behaviors and the required knowledge to know when particular procedures should be applied – bringing us to the third category of behaviors – knowledge-based behaviors. These behaviors apply in situations where a decision must be made regarding which specific rule must be applied or when no specific rule or procedure has been established. Said differently, this is where pilots depend on decision making, relying on their own, personal knowledge, tempered with what experience they have, to effectively address particular situations. Knowledge-based solutions often appear to be the highest form of problem solving. Unfortunately, such behavior is subject to a wide range of human errors. Getting “creative” in a difficult situation can lead, and often does lead, to making a situation worse rather than better.

At any given moment pilots only know what they can see, hear, feel, and most importantly, recognize. Any decisions made, must be made on those bases. The basic characteristics of human thought is to structure information and then make inferences from that structure. If the assessment made is accurate, and if appropriate knowledge and understanding of rules and procedures are applied, the probability is that the resulting skill application will result in a successful outcome. A significant issue that often has a determining influence on any such outcome is that the information structuring process tends to occur very early when assessing a situation. If that structuring seems to make sense, if all the parameters seem to fit with all the information available, humans, particularly pilots (as they are more often in a dynamic and potentially dangerous situation) are more than likely to believe the framework created is correct. Therefore, any subsequent information entering the equation – particularly if that subsequent information seems to contradict the framework that has been created – humans (and thereby pilots, primarily because of the urgency of their situation) tend to exclude or disregard that “new” information.

[AirRabbit]

Part 3 of 4
A sometimes difficult premise to understand is that a very skilled pilot is not necessarily a safe or efficient pilot. Piloting an airplane requires more than skills, regardless of how finely honed those skills may be. A skill is simply a learned and practiced level of proficiency at performing a given task. A new or unfamiliar environment can sufficiently distract a pilot from applying the correct, necessary skill for a particular situation. If the pilot is suffering from stress or fatigue, certainly the performance of that pilot is going to suffer, and it may suffer to the extent that the pilot’s skill simply cannot overcome the inaccuracies in, or the absence of, appropriate decisions that govern the skill applied under the circumstances. A habitual missed approach procedure calling for application of power, rotation to a defined pitch attitude, achieving a specified airspeed, and putting the airplane into a one-half standard rate left-hand turn at a specified altitude to reverse course, for example, may be the usual procedure when visual contact with the runway is lost when flying at the pilot’s home airport. However, when approaching an airport with a large hill or mountain immediately to the left of the arrival course, because of stress, fatigue, or confusion, applying that same learned procedure is not going to be a satisfactory decision, even if the pilot conducts the procedure in an excellent, error free manner. The hill or mountain is still on the left – and the pilot will fly, very precisely, at the proper configuration and airspeed, directly into that hill or mountain ... a well-performed but inappropriate procedure.

A decision must be made when and where to apply a particular skill. The fact that skill-based behaviors do tend to become habituated and automatic may lead us into precisely applying the wrong skill for current conditions. Have any of you ever driven to work in the morning and, after arriving, realized that you have no recollection of the drive? You were operating on “automatic;” you were applying habituated skills with little or no conscious thought. What would have happened had the lady in one of the numerous cars adjacent to you during that trip been too absorbed in talking on her cell phone and allowed her car to drift into your lane? You probably don’t know; and neither do I. The point is – something would have happened – and the potential for that “something” having been less than optimum is pretty sizeable. All of us are creatures of habit. Habits inhabit all of us.

All of us have heard about pilots landing a retractable gear airplane with the gear retracted. Of course, that is not a skill for which that pilot was trained – and one can presume that each of those pilots, at one time, had demonstrated their proficiency and skill at landing their airplanes – safely and correctly. So, what happened in these cases? In 2006, the pilots of a Canadair Regional Jet began what many would argue was the beginning of a skillful takeoff procedure from Lexington, Kentucky. Unfortunately, it was the wrong runway – a runway that was much too short for a safe takeoff. Why? In 2009, the passengers on board an Atlanta-bound B-767 narrowly averted tragedy when the pilot making the landing mistakenly landed on the parallel taxiway instead of the runway. What was the reason?

Developing a list of skill-based behavior errors is not the goal here. Pointing out the negative potentials of applying skill-based behaviors outside of an appropriate framework for judgments to guide those behaviors, however, IS the goal. Pilots who rely on skills alone, where those skills provide the sole basis for how the airplane is to be flown, taking little or no consideration of the fact of the framework in which such judgments and decisions are made must be recognized as setting the stage for less than optimum outcomes.

[AirRabbit]

Part 4 of 4
It is extremely difficult to remain neutral about information in a difficult, time-critical, problem-solving situation. Even negative information, which would indicate a flaw in the established structure and assumptions, tends to be disregarded or ignored once there is some recognition of success – even if that “success” really is only a temporary absence in the worsening of the perceived situation. The tendency is to expect a gain in momentum toward achieving the expected, positive results. Recall the MD-82 landing at Little Rock, AR, in 1999. When the approach was begun, the weather was beginning to deteriorate. The crew flew the airplane closer to the airport, closer to the ground – both being what the crew wanted. The approach and landing probably was within the capabilities of the airplane and the crew at the time the initial landing clearance was given. The information was received and processed. A plan was formulated and the crew began to exercise that plan. They were notified of a change in the winds and the crew made an adjustment in their plan – they chose to land on a different runway. Both pilots were skilled and knowledgeable – both were aware of the rules involved in this activity. However, as the approach continued, the weather worsened. Windshear had been reported. A thunderstorm moved over the airport. The runway was being rained on heavily. The visibility was reducing. The wind values were increasing and another, dramatic change in the wind direction occurred. Undoubtedly, the stress level in the cockpit rose. The flight crew failed to arm the automatic ground spoiler system. They failed to arm the automatic braking system. After touching down, the airplane began to skid and went off the departure end of the runway. The Captain and 10 passengers died. The First Officer, 3 of the cabin crew, and 41 passengers were seriously injured. One cabin crew member and 64 passengers suffered minor injuries.

Clearly stress and distraction only make bad things worse. Stress is not normally a performance enhancer. Conventional wisdom says that problems that might be easily solved given time and leisure when on the ground, become a breeding ground for disaster in an environment with increasing pressure, limited time, and a heightened stress level. Situations occur where pilots might easily become overloaded with multiple, necessary tasks; they may be led to make errors in what they do; and they may fail to do what should be done.

Relying on knowledge and skill alone puts pilots at an immediate disadvantage and even more so for those pilots who lack the advantage of extensive experience. Experience is the process of becoming a competent, safe, and efficient pilot as opposed to someone who flies an airplane while relying on only two of the three types of behavior sets. Each set of behaviors must be developed and applied appropriately and in the correct combination to allow us to successfully carry out the duties required of an airplane pilot. The focus and discipline of using rules-based behaviors provides the most solid framework to integrate and apply both skill-based and knowledge-based behaviors. Without skills, it is impossible to successfully fly an airplane; without knowledge it becomes extremely difficult to select the correct procedure to apply under various conditions, but without the foundation of rules-based behaviors we would be operating essentially “on our own,” without an interest or a respect of what is or should be expected of a pilot. It would essentially be like driving our automobiles around without an understanding of or an adherence to the meaning of traffic lights or other traffic regulating signs and indications. Driving would be chaotic at best, and very likely disastrous on a scale that is unimaginable if we didn’t have a set of traffic rules and a rules-based behavior expectation of drivers. It would press human imagination beyond its limits to try to visualize an aviation system in which there were no rules-based behaviors established and followed – even if enforcement is required when and where necessary.