SQ006 Revisited
Guest
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I think the SIA speed brake ideal came about because of two separate reasons.
The first was because the 747 Classic wasn't permitted to have the speedbrake used with flaps extended due to the static loading through the flap gap on the trailing edge flaps, and also because of the associated buffeting on the tailplane by the inboard panels. I believe the 744 doesn't have this limitation.
The second reason was because it was "unprofessional". Maybe somebody should have given Mr Boeing SIA management's views during the design stages. Obviously Boeing have got it wrong again :] By frowning on the use of speed brake it also gave great point scoring opportunities during the Loss of Face game.
I am also of the opinion that if the act of flying becomes so resticted by rules then it reduces the ability to think outside the box when a life threatening situation occurs. The optimum is a happy medium that disallows the cowboys and promotes situational thinking. A point to ponder, though, is that a heavy weighting of rules also allows low experienced pilots to function as operating crew ..... and that is fine until something goes wrong.
The first was because the 747 Classic wasn't permitted to have the speedbrake used with flaps extended due to the static loading through the flap gap on the trailing edge flaps, and also because of the associated buffeting on the tailplane by the inboard panels. I believe the 744 doesn't have this limitation.
The second reason was because it was "unprofessional". Maybe somebody should have given Mr Boeing SIA management's views during the design stages. Obviously Boeing have got it wrong again :] By frowning on the use of speed brake it also gave great point scoring opportunities during the Loss of Face game.
I am also of the opinion that if the act of flying becomes so resticted by rules then it reduces the ability to think outside the box when a life threatening situation occurs. The optimum is a happy medium that disallows the cowboys and promotes situational thinking. A point to ponder, though, is that a heavy weighting of rules also allows low experienced pilots to function as operating crew ..... and that is fine until something goes wrong.
Guest
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Hold your horses Rockhound, I don’t “continue to propagate the belief” etc etc. I merely wrote that “the accidents mentioned appeared to have the following in common”.
Maybe I should have said “along with other common features of the individual company cultures involved in the following accidents, that of stifling the expression(s) of doubt by the FO/FE is noteworthy”.
I guess you might like to consider that KLM took urgent steps to investigate and then radically change its culture post Tenerife – see Farside. Air NZ caused a national uproar with its operational methods plus company attitudes and was the subject of a judicial inquiry post Erebus, following which it took good care to dramatically alter its culture. Air Florida went out of business before it too could examine itself and conclude that a culture change was overdue. If your interested, I’ll confirm that SIA is now looking very carefully at its own culture (though it won’t admit it) and change is in the air, led by Lt Gen Bey.
You seem very confident that cultural influences leading to silence at critical times by FO’s and FE’s have no bearing on the Taipei crash. If only this was true. If I can throw my 2 cents in. When I left the air force for airline flying, I was pretty clueless for the first few years about the job itself and then how to handle “difficult” captains or “difficult” common perceptions. I can remember three or four occasions in these early (bad old) days when I allowed myself to be convinced that the captain was right and I was the half-wit who didn’t know what he was doing. I was brought up with a couple of real jolts when I realised I was right and it was the captain who was the half-wit and we had just got away by the skin of our teeth, from disaster (in the days before CHIRPS). Please be advised that it can happen and that a company culture has a MAJOR influence on how captains behave but more so on how subordinate crew-members behave in these critical situations. I know this as I’ve been in companies with both “good” and “bad” cultures!
Maybe the CVR can’t give the true picture as it isn’t configured to read the mind of the FO/FE. I guess when technology gets that far we’ll have a clearer idea of events leading up to crashes.
You seem to be to be a pretty erudite kind of guy on the basis of your postings that I’ve read and you are real forthright in expressing your certainties. Do you have a particular professional capacity that allows your ease of expression? I notice that you are not a pilot. I guess we’d all be interested to know where you’re coming from.
Rgds Tosh26
Maybe I should have said “along with other common features of the individual company cultures involved in the following accidents, that of stifling the expression(s) of doubt by the FO/FE is noteworthy”.
I guess you might like to consider that KLM took urgent steps to investigate and then radically change its culture post Tenerife – see Farside. Air NZ caused a national uproar with its operational methods plus company attitudes and was the subject of a judicial inquiry post Erebus, following which it took good care to dramatically alter its culture. Air Florida went out of business before it too could examine itself and conclude that a culture change was overdue. If your interested, I’ll confirm that SIA is now looking very carefully at its own culture (though it won’t admit it) and change is in the air, led by Lt Gen Bey.
You seem very confident that cultural influences leading to silence at critical times by FO’s and FE’s have no bearing on the Taipei crash. If only this was true. If I can throw my 2 cents in. When I left the air force for airline flying, I was pretty clueless for the first few years about the job itself and then how to handle “difficult” captains or “difficult” common perceptions. I can remember three or four occasions in these early (bad old) days when I allowed myself to be convinced that the captain was right and I was the half-wit who didn’t know what he was doing. I was brought up with a couple of real jolts when I realised I was right and it was the captain who was the half-wit and we had just got away by the skin of our teeth, from disaster (in the days before CHIRPS). Please be advised that it can happen and that a company culture has a MAJOR influence on how captains behave but more so on how subordinate crew-members behave in these critical situations. I know this as I’ve been in companies with both “good” and “bad” cultures!
Maybe the CVR can’t give the true picture as it isn’t configured to read the mind of the FO/FE. I guess when technology gets that far we’ll have a clearer idea of events leading up to crashes.
You seem to be to be a pretty erudite kind of guy on the basis of your postings that I’ve read and you are real forthright in expressing your certainties. Do you have a particular professional capacity that allows your ease of expression? I notice that you are not a pilot. I guess we’d all be interested to know where you’re coming from.
Rgds Tosh26
Guest
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As of 6 months ago SIA was not code sharing with UA. Star Alliance and milage share, yes, code share, no.
If SIA does indeed code share with a US airline, then yes there is liability. It needs to be brought to the attention of the proper unions in detail.
If SIA does indeed code share with a US airline, then yes there is liability. It needs to be brought to the attention of the proper unions in detail.
Guest
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Midnight Rambler:
Yes, I do use speed brake when I need to get down fast but not under the circumstances that boofhead described. No, I don't use the speedbrake to slow down a 744 for flaps extension. I use the speedbrake for high speed descent because it kills the lift on wing and keeps the airspeed below the red line. Go talk to the QFI at the flying club if you have forgotten how to slow down a plane for flaps extension.
Sincerely,
Smith
Yes, I do use speed brake when I need to get down fast but not under the circumstances that boofhead described. No, I don't use the speedbrake to slow down a 744 for flaps extension. I use the speedbrake for high speed descent because it kills the lift on wing and keeps the airspeed below the red line. Go talk to the QFI at the flying club if you have forgotten how to slow down a plane for flaps extension.
Sincerely,
Smith
Guest
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Annoymous forum is it? Whatever that is, I won't argue. My little example is not made up, it is true.
This thread is meant to be related to SQ6, not How to Fly. I would suggest you post your comments on Tech Log, under the heading "How Boeing Asked ME to Re-Write the B744 Normal Procedures". I would be glad to debate you there.
This thread is meant to be related to SQ6, not How to Fly. I would suggest you post your comments on Tech Log, under the heading "How Boeing Asked ME to Re-Write the B744 Normal Procedures". I would be glad to debate you there.
Guest
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Look, smith, your method may be correct but it is not the only correct method. High and fast and wanting to get down is a place I would want to use the speedbrake. It is there for a purpose and I would choose to use it then. My CHOICE.
As boofhead says, your attitude, which is reminiscent of the philosophy of some real old dinosaurs I've flown with ( "Thou shalt only use speedbrake when all else fails and at the cost of your professional demeanour") smacks of superiority and has no place in a modern cockpit.
I was beginning to think this speedbrake thing was an irrelevant side-issue, but you seem to have made an illustrative point.
Also, inasmuch as you may think I am hiding behind my alias to express my fantasies, I have flown the 747 for 11 years and the 744 for 8 of those. I must have had it wrong all that time.
As boofhead says, your attitude, which is reminiscent of the philosophy of some real old dinosaurs I've flown with ( "Thou shalt only use speedbrake when all else fails and at the cost of your professional demeanour") smacks of superiority and has no place in a modern cockpit.
I was beginning to think this speedbrake thing was an irrelevant side-issue, but you seem to have made an illustrative point.
Also, inasmuch as you may think I am hiding behind my alias to express my fantasies, I have flown the 747 for 11 years and the 744 for 8 of those. I must have had it wrong all that time.
Guest
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Tosh,
Thank you for your kind words but please believe me when I say that I hold very few certainties. Indeed, I find it difficult enough to gather simple facts (if there are such things). And I certainly don't feel confident that cockpit culture played little part in the SQ006 accident. I joined this particular discussion because Insider 107 alleged that at Tenerife the KLM captain took off despite the protests of his F/O and then proceeded to draw an analogy with the SQ006 crew in respect of the PVD indication. I still believe that Capt Foong fully appreciated F/O Cyrano's warning that the PVD was anomalous but that the concerns of both of them were overridden by the visual cues that indicated to them both that they were on the correct runway. Nothing that Insider, Gladiator, Titan, etc. have subsequently posted has caused me to change my belief. As to the role of other factors relating to SIA corporate/cockpit culture, practices, policy, etc. in this accident, e.g. pressure to take off in the face of an approaching typhoon, insufficient crew rest, and the like, I've formed some opinions but these are based on even thinner qualifications and subject to change without notice. After all, I'm just a pax who loves to fly and takes a keen interest in aviation - and considers it a privilige to be able to participate in discussions among airmen on PPRuNe.
Rockhound
Thank you for your kind words but please believe me when I say that I hold very few certainties. Indeed, I find it difficult enough to gather simple facts (if there are such things). And I certainly don't feel confident that cockpit culture played little part in the SQ006 accident. I joined this particular discussion because Insider 107 alleged that at Tenerife the KLM captain took off despite the protests of his F/O and then proceeded to draw an analogy with the SQ006 crew in respect of the PVD indication. I still believe that Capt Foong fully appreciated F/O Cyrano's warning that the PVD was anomalous but that the concerns of both of them were overridden by the visual cues that indicated to them both that they were on the correct runway. Nothing that Insider, Gladiator, Titan, etc. have subsequently posted has caused me to change my belief. As to the role of other factors relating to SIA corporate/cockpit culture, practices, policy, etc. in this accident, e.g. pressure to take off in the face of an approaching typhoon, insufficient crew rest, and the like, I've formed some opinions but these are based on even thinner qualifications and subject to change without notice. After all, I'm just a pax who loves to fly and takes a keen interest in aviation - and considers it a privilige to be able to participate in discussions among airmen on PPRuNe.
Rockhound
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The PVD was on because the ILS frequency had been set into the FMS NavRad page. Was the ILS inserted because the SID required it to be tracked outbound, as in runway 06 at TPE? The ILS deviation indications would automatically be shown on the PFD once the ILS was tuned, and the ND would have shown the aircraft right of the runway. The localiser would have shown a left deviation as we know, but wouldn't this raise questions since it was possibly required for SID tracking. The B744 standby AI should also have had the ILS selected as a backup, but was it? There are 3 indications indicating that you are not aligned with the localiser, and 1 that you are not aligned with the runway, all of them right infront of you. Why the PVD was solely noted is disturbing, and why did no-one check the other 3 indications when the PVD showed a discrepancy?
[This message has been edited by EasyGo-Lucky? (edited 14 March 2001).]
[This message has been edited by EasyGo-Lucky? (edited 14 March 2001).]
Guest
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All are valid points. Rockhound either does not understand the point regarding the PVD, or he or she understands it but is trying to divert attention. I think it is the latter.
It is very simple. Not withstanding the LOC tracking required for the SID (that would have also acted as a backup since SIA's SOP requires LNAV), why would one insert the ILS frequency if the intent was not to utilize it, at least as a backup. OK so the PVD was not required (TPE not certified), however the visibility is very very low, are you not going to use a resource, a good resource, available to you?
Hello, CRM, Resource Management!
The Captain's statement, "never mind, I can see the runway", was a clear 'Flying 101' mistake, not even misjudgement.
What is the first thing you do in low visibility? Trust your instruments. The decision to go was a misjudgement, thereafter he clearly made mistakes by,
a) Brushed aside a resource that he intended to use (having entered the 05L ILS frequency).
b) Brushed aside the F/O's input.
c) Ignored the PVD.
d) Ignored the ND (runway not ligned up).
I see nothing else but negligance. Now I am not picking on the Captain, however, bad judgement and serious mistakes indicate either,
a) A weak Captain.
b) Other factors such as pressure, company culture, fatigue, etc.
What Rockhound does not appreciate is that we are/were the insiders, whistleblowers, etc. If we do not/did not tell you, then who would? You would have never known the other elements.
When I attended the CRM courses at SIA, how come there were no local Captains attending the course? Too good? Too perfect? Master ability? If attend, lose face? What was it? Cost too much?
I never got a straight answer for the above question. Any locals care to clear this question?
It is very simple. Not withstanding the LOC tracking required for the SID (that would have also acted as a backup since SIA's SOP requires LNAV), why would one insert the ILS frequency if the intent was not to utilize it, at least as a backup. OK so the PVD was not required (TPE not certified), however the visibility is very very low, are you not going to use a resource, a good resource, available to you?
Hello, CRM, Resource Management!
The Captain's statement, "never mind, I can see the runway", was a clear 'Flying 101' mistake, not even misjudgement.
What is the first thing you do in low visibility? Trust your instruments. The decision to go was a misjudgement, thereafter he clearly made mistakes by,
a) Brushed aside a resource that he intended to use (having entered the 05L ILS frequency).
b) Brushed aside the F/O's input.
c) Ignored the PVD.
d) Ignored the ND (runway not ligned up).
I see nothing else but negligance. Now I am not picking on the Captain, however, bad judgement and serious mistakes indicate either,
a) A weak Captain.
b) Other factors such as pressure, company culture, fatigue, etc.
What Rockhound does not appreciate is that we are/were the insiders, whistleblowers, etc. If we do not/did not tell you, then who would? You would have never known the other elements.
When I attended the CRM courses at SIA, how come there were no local Captains attending the course? Too good? Too perfect? Master ability? If attend, lose face? What was it? Cost too much?
I never got a straight answer for the above question. Any locals care to clear this question?
Guest
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Have I understood Gladiator right? Was it a fact that CRM courses were run at SIA, but that attendance was up to individuals?
If that is correct then the creation of CRM awareness amongst SOME flight crew, but not others, almost certainly created a situation which is worse than if no CRM courses were held at all.
If that is correct then the creation of CRM awareness amongst SOME flight crew, but not others, almost certainly created a situation which is worse than if no CRM courses were held at all.
Guest
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CRM or ARM courses as they are known at SIA were not voluntary. The courses were of no benefit whatsoever though, just an excuse for a few days in Manila/Bangkok at the Companys expense. The only ones who did benefit were those who designed or ran the course. There are individuals who require urgent CRM training but with the current crew shortage I'm sure the Company could not justify the loss of productivity.
Guest
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I really didn't want to throw another two cents in, as I've already said my piece more than once, but I cannot let Gladiator's last posting go by unchallenged.
Gladiator, I believe I do fully understand the efficacy of the PVD - thanks in large measure, by the way, to your explanation of it earlier on this thread. And why would I want to "divert attention" from it???!
However, what I most strongly protest is your assertion that Capt Foong "brushed aside" F/O Cyrano's observation (warning, if you like) concerning the PVD. From the CVR transcript (times are UCT):
1516:07 CM2: And the PVD hasn't lined up
1516:10 CM1: Yeah we gotta line up first
1516:12 CM3: We need 45 degrees
1516:23 CM1: Not on yet er PVD huh never mind we can see the runway, not so bad.
So 16 seconds had elapsed after Cyrano drew attention to the PVD indication (and 12 seconds after the relief pilot's comment on the PVD) when Foong acknowledged the PVD discrepancy and voiced his decision to ignore it. This hardly constitutes "brushing aside" an objection and he certainly didn't cut Cyrano off in mid-sentence, as the Taipei Times article had it.
For what it's worth (not much, I know), I don't take issue with the rest of Gladiator's posting.
Rockhound
PS to Glad: I am a he (if it were otherwise, I suppose I would have called myself Rockbitch).
Gladiator, I believe I do fully understand the efficacy of the PVD - thanks in large measure, by the way, to your explanation of it earlier on this thread. And why would I want to "divert attention" from it???!
However, what I most strongly protest is your assertion that Capt Foong "brushed aside" F/O Cyrano's observation (warning, if you like) concerning the PVD. From the CVR transcript (times are UCT):
1516:07 CM2: And the PVD hasn't lined up
1516:10 CM1: Yeah we gotta line up first
1516:12 CM3: We need 45 degrees
1516:23 CM1: Not on yet er PVD huh never mind we can see the runway, not so bad.
So 16 seconds had elapsed after Cyrano drew attention to the PVD indication (and 12 seconds after the relief pilot's comment on the PVD) when Foong acknowledged the PVD discrepancy and voiced his decision to ignore it. This hardly constitutes "brushing aside" an objection and he certainly didn't cut Cyrano off in mid-sentence, as the Taipei Times article had it.
For what it's worth (not much, I know), I don't take issue with the rest of Gladiator's posting.
Rockhound
PS to Glad: I am a he (if it were otherwise, I suppose I would have called myself Rockbitch).
Guest
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There have been some great posts recently and I’d like to comment on some of them
Boofhead
Re: your post of 8 March. Yes, “the real error was taking off on the wrong runway. The captain made the mistake and the crew did not call him on it”. Please see my reference to “why” being the key question in the debated (mine was in fact “why” did the crew line up on the wrong runway and subsequently attempt a take off? - the implication being why did no one say anything). You imply that the crew was just negligent in ensuring use of correct runway - “there is no way a reasonable pilot would make this mistake if he took the time to study them [the taxi charts]”. However, I do not believe that we are discussing a negligent crew.
If I may say so, I think your statement to the effect “the weather reports were within company limits and almost all pilots would have decided to go” reveals the narrowest of assessment criteria in the formulation of your judgements (please read my initial post at the beginning of this thread - you’ve no need to agree with it) and without going into details of your writers actions/inactions over the years, a sweeping presumption of the judgement of your professional peers. We are not second guessing the crew on the decision to go in the prevailing weather conditions, merely saying that any causal anxiety/stress produced by its severity was a factor leading up to the accident and that if there had not been cultural/SQ cultural pressure on the crew to proceed in such conditions, then this anxiety stress factor would not have been present (because they wouldn’t have gone). Final word on your post of 8 March is - yes, I think we will see the truth, if only because the survivors/relatives have filed suit in a California court and there is no way SQ can duck that.
Re your post of 9 March. "The accident would not have occurred if the original mistakes had not been made and it would not have happened if the CRM had been better". Yes, of course the FO's would not have just sat there knowing their lives were in jeapody. Your proposition that pilots are spoon fed and rule bound throughout their careers and hence do not think, was perhaps relevant at this critical time and that they were concentrating on the rules and regulations to the exclusion of good old fashioned airmanship. This is contained in my original posting, when I postulated "mindset 2". Once lined up, as no one else said anything, each individual assumed the others were happy and so said nothing about any residual doubt that may have been in their minds - a combination of human psychology and SQ culture that CRM is designed to break and which, yes could happen in other airlines but did happen in SQ through, amongst other things, lack of effective CRM culture/training and which, hence makes SQ firmly responsible for the acccident.
Skydrifter
As usual I like your posts (not just because we seem to be generally in agreement). “In thousands of words we’ve all been saying essentially the same thing. Now is the time to put the obvious lessons into action. Most importantly is to share the cases where CRM has worked”.
Rongotai
I believe you are right on the nail. May I quote you here rather than refer readers to a preceding post? It will make it so much easier to relate to the contents of this post.
1. Yes, it is true that there is a universal human predisposition to misinterpret sensory signals about what the 'real' situation is, and especially to distort visual signals into 'seeing' what one expects to see or hopes to see. Thus it is possible for any pilot to choose the wrong runway, descend into terrain, etc. etc.
2. It is also generally not disputed that the PROBABILITY of such misinterpretation is increased when there is poor visibility, loss of horizon, sector whiteout conditions, and so on. Few would dispute this because (a) it is common sense; and (b) the empirical evidence for it being true is overwhelming.
3. It is slightly less generally accepted that extreme physical conditions - such as those prevailing at Taipei on the night of SQ006 - place psychological stress on flight crew, and psychological stress itself increases the probability of making an error in interpreting the environment. This proposition is still common sense, and still supported overwhelmingly by empirical evidence. It seems that it is slightly less generally accepted because here some people begin to mount the argument that pilots are professionals who should be able to deal with stress without it impairing their performance or judgement. My response to that is 'nice idea, but totally disconnected from the real world.'
4. Once it is demonstrated and accepted that stress impairs judgement, and impaired judgement increases the probability of a critical event occurring, then it is reasonable to ask what factors cause stress in pilots and how they can be ameliorated.
5. It is not at all generally accepted that cultural factors - national or organisational, and management practices, can have the effect of increasing or decreasing stress on flight crew who work within them. Yet the empirical evidence that this is so is still overwhelming. So why is it that so many people want to discount these factors in considering accident causation? Semi rhetorical question! The answer seems to be a deeply ingrained belief that technical training and technical competence can overcome the stress effects of cultural factors. To which I reply 'Nonsense. That can never be so.'
6. If my points to date are accepted, then it is entirely legitimate to question whether or not the organisational culture of SQ has the effect of increasing stress on its flight crew. If the answer is 'yes' then it follows that the airline is negligent if it fails to address cultural factors which serve to increase the probability of its flight crew experiencing avoidable stress and thus that be more prone to making errors.
Precisely put and shows that there was no one absolute accident cause but a series of events or circumstances which, when combined, led up to the accident.
Rockhound
Thanks for your postings of 8/9 March both of which I found very well thought out and which caused me to think at length for answers. I am sorry that you remain of the view that the accident cannot be "ascribed to SIA corporate/cockpit culture, Singaporean or Asian attitudes, the failings of overworked and underpaid crews etc." (your post of 28 Feb 2001). Perhaps I might again try to convince you that myself and others might be on the right track in respect of the cause(s) of the SQ006 disaster?
I think the point that I may have been trying to get over was to the effect that whilst “Captain Foong acknowledged the PVD was discrepant and FO Cyrano was satisfied that they were lined up on 05L, hence did not pursue the matter” was not to say that the FO was happy with the situation (or could express such happiness on the CVR) in that, it is entirely possible (even probable) that he would have been thinking along the lines of “OK why is it discrepant - usually its pretty reliable and why does the ND not show us on 05L? Oh, OK, maybe it’s a map shift - the captain seems happy enough and we are lined up on the correct runway after all”. Further, I think that he was distracted by events leading up to that point and perhaps did not (a) wish to lose face by questioning and being shown to be wrong (b) wish to counter the SQ chain of command by questioning the captain’s competence in safely conducting the flight (at this stage by getting the aircraft to the correct runway). In this latter respect, if he did so question, he would not expect to be berated by an overbearing captain but would instead fear further lose of face and the possibility of a PQ report back to fleet, that could definitely affect career prospects.
Gaunty’s posting of 9 March, quoting Captain Dan Maurino, Head of Human Factors, ICAO and Rongotai’s post, also of 10 March, expanding Captain Maurino’s views perhaps provides a further, relevant, CRM dimension to the disaster.
On the question of weather conditions prior to departure - simply put Captain Foong was inevitably the recipient of one of either two pressures that were going to cause severe stress to him. Firstly “do I delay and subsequently field the inevitable ‘phone call from the fleet management which will cause me great stress later on” or alternatively “do I go despite the weather being atrocious and me being worried about it and it causing me great stress right now but I’ll have it behind me once I’ve taken off and climbing”. It’s one or the other I’m afraid. The third alternative, which I’ve suggested previously, is that SQ’s training is deficient in that sufficient attention has not been focused on operation in extreme weather conditions.
Gaunty
Both very nice postings of 9 March. Perhaps as a side issue, although I think it may be germane if consideration is given to a thesis of multi-cause of the SQ006 accident, is the hubris (we have both written on this subject before) of the taxiing crew prior to turning onto 05R, as revealed by the CVR and posted by Titan on 28 Feb. They all seemed to be having a very good laugh at the expense of the Aussies and strongly implying that the Aussie logic in respect of next right/second right was in error. It is of the most tragic irony that the crew applied their own logic as to which was next right before turning off the taxiway (ie second right) but the Aussie logic for their next right turn (onto the wrong runway 05R), when, using their stated logic, they should have taken the second right onto the correct runway, 05L. Could it be that some form of stress provided the distraction and hence the fatal error or do the words “whom the gods would destroy they first blind with hubris”, apply?
Titan
Exactly put when you make "a couple of points". Rockhound please re-read. All readers may be interested to note that a highly respected and experienced aviation medicine practitioner could not communicate the fatigue situation to his personal friend, the now invisible SQ Director of Flight Training. Demonstration of SQ management receptiveness/open-mindedness?
Finally, some time ago, I completed a particular manufacturer’s course that contained, amongst the technical/flight sim training, a section devoted to “human factors/crew resource management”. I recall going through the usual classroom exercises that I know we are all familiar with and which are designed to demonstrate how our minds work in various situations. Following this, a non-aviation behavioural psychologist made a powerful presentation to the effect that events leading to an accident can be considered as links in a chain, which, if unbroken either by design or by good fortune, must inevitably lead to the accident which such a chain of circumstances predicates. The telling points brought out were that: (a) if at any stage a link of the chain was broken, then the accident would not happen (b) the individual links in the chain could be made up of innocuous, seemingly irrelevant and hence easily overlooked items/events (c) it was possible for airline managements, in an “overview” position, to be able to identify such links and so eradicate them before any event and it was similarly possible for flight crews to identify such links “on the day” and so “break the chain” of events on a particular flight, which otherwise would lead up to an accident.
These processes, however, required a strong commitment to the principles of CRM by management (who were going to spend the money) plus trust and openness between management and flight crews and the same relationship features between the crewmembers themselves.
Without repeating ad nauseum the collective invective against SQ management, I would offer my own view that the present SQ flt ops management (M de V and cronies) has not (a) any real concept of what it’s about and (b) are not interested anyway, as to implement a full CRM programme would cost money. Plus the flight crews have absolutely ZERO trust in the present management, nor between themselves, as, during the 19 year de Vaz tenure, a system of secret reporting on other crew memebers by selected (usually FO) spies has spread like a blight.
World class airline? Pull away the glossy cover and you'll see the rat's nest of bungling, ineptitude, amateurism, conyism, hypocrisy and vindictive spite which has made the organisation what it is today.
Boofhead
Re: your post of 8 March. Yes, “the real error was taking off on the wrong runway. The captain made the mistake and the crew did not call him on it”. Please see my reference to “why” being the key question in the debated (mine was in fact “why” did the crew line up on the wrong runway and subsequently attempt a take off? - the implication being why did no one say anything). You imply that the crew was just negligent in ensuring use of correct runway - “there is no way a reasonable pilot would make this mistake if he took the time to study them [the taxi charts]”. However, I do not believe that we are discussing a negligent crew.
If I may say so, I think your statement to the effect “the weather reports were within company limits and almost all pilots would have decided to go” reveals the narrowest of assessment criteria in the formulation of your judgements (please read my initial post at the beginning of this thread - you’ve no need to agree with it) and without going into details of your writers actions/inactions over the years, a sweeping presumption of the judgement of your professional peers. We are not second guessing the crew on the decision to go in the prevailing weather conditions, merely saying that any causal anxiety/stress produced by its severity was a factor leading up to the accident and that if there had not been cultural/SQ cultural pressure on the crew to proceed in such conditions, then this anxiety stress factor would not have been present (because they wouldn’t have gone). Final word on your post of 8 March is - yes, I think we will see the truth, if only because the survivors/relatives have filed suit in a California court and there is no way SQ can duck that.
Re your post of 9 March. "The accident would not have occurred if the original mistakes had not been made and it would not have happened if the CRM had been better". Yes, of course the FO's would not have just sat there knowing their lives were in jeapody. Your proposition that pilots are spoon fed and rule bound throughout their careers and hence do not think, was perhaps relevant at this critical time and that they were concentrating on the rules and regulations to the exclusion of good old fashioned airmanship. This is contained in my original posting, when I postulated "mindset 2". Once lined up, as no one else said anything, each individual assumed the others were happy and so said nothing about any residual doubt that may have been in their minds - a combination of human psychology and SQ culture that CRM is designed to break and which, yes could happen in other airlines but did happen in SQ through, amongst other things, lack of effective CRM culture/training and which, hence makes SQ firmly responsible for the acccident.
Skydrifter
As usual I like your posts (not just because we seem to be generally in agreement). “In thousands of words we’ve all been saying essentially the same thing. Now is the time to put the obvious lessons into action. Most importantly is to share the cases where CRM has worked”.
Rongotai
I believe you are right on the nail. May I quote you here rather than refer readers to a preceding post? It will make it so much easier to relate to the contents of this post.
1. Yes, it is true that there is a universal human predisposition to misinterpret sensory signals about what the 'real' situation is, and especially to distort visual signals into 'seeing' what one expects to see or hopes to see. Thus it is possible for any pilot to choose the wrong runway, descend into terrain, etc. etc.
2. It is also generally not disputed that the PROBABILITY of such misinterpretation is increased when there is poor visibility, loss of horizon, sector whiteout conditions, and so on. Few would dispute this because (a) it is common sense; and (b) the empirical evidence for it being true is overwhelming.
3. It is slightly less generally accepted that extreme physical conditions - such as those prevailing at Taipei on the night of SQ006 - place psychological stress on flight crew, and psychological stress itself increases the probability of making an error in interpreting the environment. This proposition is still common sense, and still supported overwhelmingly by empirical evidence. It seems that it is slightly less generally accepted because here some people begin to mount the argument that pilots are professionals who should be able to deal with stress without it impairing their performance or judgement. My response to that is 'nice idea, but totally disconnected from the real world.'
4. Once it is demonstrated and accepted that stress impairs judgement, and impaired judgement increases the probability of a critical event occurring, then it is reasonable to ask what factors cause stress in pilots and how they can be ameliorated.
5. It is not at all generally accepted that cultural factors - national or organisational, and management practices, can have the effect of increasing or decreasing stress on flight crew who work within them. Yet the empirical evidence that this is so is still overwhelming. So why is it that so many people want to discount these factors in considering accident causation? Semi rhetorical question! The answer seems to be a deeply ingrained belief that technical training and technical competence can overcome the stress effects of cultural factors. To which I reply 'Nonsense. That can never be so.'
6. If my points to date are accepted, then it is entirely legitimate to question whether or not the organisational culture of SQ has the effect of increasing stress on its flight crew. If the answer is 'yes' then it follows that the airline is negligent if it fails to address cultural factors which serve to increase the probability of its flight crew experiencing avoidable stress and thus that be more prone to making errors.
Precisely put and shows that there was no one absolute accident cause but a series of events or circumstances which, when combined, led up to the accident.
Rockhound
Thanks for your postings of 8/9 March both of which I found very well thought out and which caused me to think at length for answers. I am sorry that you remain of the view that the accident cannot be "ascribed to SIA corporate/cockpit culture, Singaporean or Asian attitudes, the failings of overworked and underpaid crews etc." (your post of 28 Feb 2001). Perhaps I might again try to convince you that myself and others might be on the right track in respect of the cause(s) of the SQ006 disaster?
I think the point that I may have been trying to get over was to the effect that whilst “Captain Foong acknowledged the PVD was discrepant and FO Cyrano was satisfied that they were lined up on 05L, hence did not pursue the matter” was not to say that the FO was happy with the situation (or could express such happiness on the CVR) in that, it is entirely possible (even probable) that he would have been thinking along the lines of “OK why is it discrepant - usually its pretty reliable and why does the ND not show us on 05L? Oh, OK, maybe it’s a map shift - the captain seems happy enough and we are lined up on the correct runway after all”. Further, I think that he was distracted by events leading up to that point and perhaps did not (a) wish to lose face by questioning and being shown to be wrong (b) wish to counter the SQ chain of command by questioning the captain’s competence in safely conducting the flight (at this stage by getting the aircraft to the correct runway). In this latter respect, if he did so question, he would not expect to be berated by an overbearing captain but would instead fear further lose of face and the possibility of a PQ report back to fleet, that could definitely affect career prospects.
Gaunty’s posting of 9 March, quoting Captain Dan Maurino, Head of Human Factors, ICAO and Rongotai’s post, also of 10 March, expanding Captain Maurino’s views perhaps provides a further, relevant, CRM dimension to the disaster.
On the question of weather conditions prior to departure - simply put Captain Foong was inevitably the recipient of one of either two pressures that were going to cause severe stress to him. Firstly “do I delay and subsequently field the inevitable ‘phone call from the fleet management which will cause me great stress later on” or alternatively “do I go despite the weather being atrocious and me being worried about it and it causing me great stress right now but I’ll have it behind me once I’ve taken off and climbing”. It’s one or the other I’m afraid. The third alternative, which I’ve suggested previously, is that SQ’s training is deficient in that sufficient attention has not been focused on operation in extreme weather conditions.
Gaunty
Both very nice postings of 9 March. Perhaps as a side issue, although I think it may be germane if consideration is given to a thesis of multi-cause of the SQ006 accident, is the hubris (we have both written on this subject before) of the taxiing crew prior to turning onto 05R, as revealed by the CVR and posted by Titan on 28 Feb. They all seemed to be having a very good laugh at the expense of the Aussies and strongly implying that the Aussie logic in respect of next right/second right was in error. It is of the most tragic irony that the crew applied their own logic as to which was next right before turning off the taxiway (ie second right) but the Aussie logic for their next right turn (onto the wrong runway 05R), when, using their stated logic, they should have taken the second right onto the correct runway, 05L. Could it be that some form of stress provided the distraction and hence the fatal error or do the words “whom the gods would destroy they first blind with hubris”, apply?
Titan
Exactly put when you make "a couple of points". Rockhound please re-read. All readers may be interested to note that a highly respected and experienced aviation medicine practitioner could not communicate the fatigue situation to his personal friend, the now invisible SQ Director of Flight Training. Demonstration of SQ management receptiveness/open-mindedness?
Finally, some time ago, I completed a particular manufacturer’s course that contained, amongst the technical/flight sim training, a section devoted to “human factors/crew resource management”. I recall going through the usual classroom exercises that I know we are all familiar with and which are designed to demonstrate how our minds work in various situations. Following this, a non-aviation behavioural psychologist made a powerful presentation to the effect that events leading to an accident can be considered as links in a chain, which, if unbroken either by design or by good fortune, must inevitably lead to the accident which such a chain of circumstances predicates. The telling points brought out were that: (a) if at any stage a link of the chain was broken, then the accident would not happen (b) the individual links in the chain could be made up of innocuous, seemingly irrelevant and hence easily overlooked items/events (c) it was possible for airline managements, in an “overview” position, to be able to identify such links and so eradicate them before any event and it was similarly possible for flight crews to identify such links “on the day” and so “break the chain” of events on a particular flight, which otherwise would lead up to an accident.
These processes, however, required a strong commitment to the principles of CRM by management (who were going to spend the money) plus trust and openness between management and flight crews and the same relationship features between the crewmembers themselves.
Without repeating ad nauseum the collective invective against SQ management, I would offer my own view that the present SQ flt ops management (M de V and cronies) has not (a) any real concept of what it’s about and (b) are not interested anyway, as to implement a full CRM programme would cost money. Plus the flight crews have absolutely ZERO trust in the present management, nor between themselves, as, during the 19 year de Vaz tenure, a system of secret reporting on other crew memebers by selected (usually FO) spies has spread like a blight.
World class airline? Pull away the glossy cover and you'll see the rat's nest of bungling, ineptitude, amateurism, conyism, hypocrisy and vindictive spite which has made the organisation what it is today.
Guest
Posts: n/a
Yes, come to think of it, the ARM courses I've been on did not feature any local captains, only FO's.
I've also asked around today, since reading gladiator's last post and no ex-pat I've spoken with can recall ever being on a course with a local captain!
Coincidence? Maybe they are all perfect as gladiator says.
I've also asked around today, since reading gladiator's last post and no ex-pat I've spoken with can recall ever being on a course with a local captain!
Coincidence? Maybe they are all perfect as gladiator says.
Guest
Posts: n/a
It is interesting to note that Singapore Airlines is conducting a safety survey with Dr. Helmreich an accomplished and well known guru in the field of CRM/Risk Management. This should be the first sign of a positive change in safety awareness in the company. However why would one select a team responsible for formulating the survey ,which only excists of local captains and totally excludes expat crews from over a dozen different countries and airlines, to include BA, Swissair, Quantas, and other flag carriers. A perfect example of zero CRM, not using resources ready available in the company. Or could this be another example of the xenophobic attitudes here in general. Remember:” You have to ask the right questions to get the right answers”.
Guest
Posts: n/a
I have heard this story about tuning a ILS as a backup for lat guidance before.
If required to fly the SID it's OK.
But some airlines use it during the ground roll.
Imagine, with a RVR of 125 m they look outside at the lights, below 125m they start to look inside at the LOC deviations.
I call these guy's dangerous and I hope it is not SOP at SIA.
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Smooth Trimmer
If required to fly the SID it's OK.
But some airlines use it during the ground roll.
Imagine, with a RVR of 125 m they look outside at the lights, below 125m they start to look inside at the LOC deviations.
I call these guy's dangerous and I hope it is not SOP at SIA.
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Smooth Trimmer