Aviation Investigation Report Out Boeing 737-210C Controlled flight into terrain
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2 communication rule
First Air had a 2-communication rule. Here is what the TSB said in their analysis (section 2.9 of report):
The company’s two-communication rule in the FOM Footnote 163 authorized the FO to assume control of the aircraft and fly it to a safe situation in the event that the pilot flying (PF) became obviously or subtly incapacitated. The captain of FAB6560 was verbally responsive to the FO’s comments and suggestions, and was making control inputs. Therefore, the captain was not obviously incapacitated. However, his persistence in following his course of action despite the FO’s verbal advisories indicates that he was experiencing subtle incapacitation, which was likely due to the stress associated with the deteriorating approach parameters and associated workload.
It is likely that the FO did not recognize the captain’s behaviour as that of subtle incapacitation. If the FO considered the two-communication rule, it is likely that he concluded that the captain was not incapacitated and the rule did not apply.
The FO’s non-application of the two-communication rule highlights a deficiency in the rule, in that the rule relies on the judgment of the PNF to determine whether subtle incapacitation exists. Recognition of subtle incapacitation may take considerable time, and it may not occur at all. Outside of the two-communication rule, there was no guidance provided to address a situation in which the PF is responsive but is not changing an unsafe course of action. This situation presented a unique problem for the FO of FAB6560; that is, how far should he allow the aircraft to deviate before taking over control from the captain?
There is a history of incidents and accidents in which the FO was the PNF and warned of a deteriorating situation, but did not take control when the captain continued an unsafe course of action (section 1.17.8.5). In all of these occurrences, the company had some form of two-communication rule, but the defence failed because the FO did not intervene and take control of the aircraft. Some likely reasons for this failure are difficulty in identifying subtle incapacitation, ambiguity in the wording of the procedure, or inhibitions on the part of FOs to take the drastic measure of taking control from a captain.
At the time of the First Air accident, there was no training or guidance within the company on how an FO would escalate a concern to the point that a go-around or change of control could be commanded. In the absence of policies and procedures, such as PACE (probing, alerting, challenging, and emergency warning), enabling the FO to escalate his concern as well as providing the authority to take control of the aircraft from the captain, the FO was limited to an advisory role. The FO was clearly aware of the increasing risk. The approach had continued beyond 2 points at which a go-around was required: first, when there is full localizer deflection, and second, in an unstable approach below 1000 feet. At both of these points, the FO attempted to communicate the need to go around to the captain. While not as definitively and clearly expressed as they could have been, these attempts are indicators that the FO was continuing his efforts to change the captain’s course of action.
The FO had previously flown as captain on another aircraft type with the company. However, he was new to the B737, and although obviously uncomfortable with the navigational situation, deferred to the captain.
There was no policy specifically authorizing an FO to escalate his role from advisory to taking control, and this FO likely felt inhibited from doing so. The FO made many attempts to communicate his concerns and suggest a go-around, but did not take control of the aircraft from the captain.
This accident and the other 3 occurrences cited (section 1.17.8.5) are indicators that failure of FOs to take control in deteriorating situations will occasionally result in catastrophic consequences in the global fleet of transport aircraft. Without policies and procedures clearly authorizing escalation of intervention to the point of taking aircraft control, some FOs may feel inhibited from doing so.
It is likely that the FO did not recognize the captain’s behaviour as that of subtle incapacitation. If the FO considered the two-communication rule, it is likely that he concluded that the captain was not incapacitated and the rule did not apply.
The FO’s non-application of the two-communication rule highlights a deficiency in the rule, in that the rule relies on the judgment of the PNF to determine whether subtle incapacitation exists. Recognition of subtle incapacitation may take considerable time, and it may not occur at all. Outside of the two-communication rule, there was no guidance provided to address a situation in which the PF is responsive but is not changing an unsafe course of action. This situation presented a unique problem for the FO of FAB6560; that is, how far should he allow the aircraft to deviate before taking over control from the captain?
There is a history of incidents and accidents in which the FO was the PNF and warned of a deteriorating situation, but did not take control when the captain continued an unsafe course of action (section 1.17.8.5). In all of these occurrences, the company had some form of two-communication rule, but the defence failed because the FO did not intervene and take control of the aircraft. Some likely reasons for this failure are difficulty in identifying subtle incapacitation, ambiguity in the wording of the procedure, or inhibitions on the part of FOs to take the drastic measure of taking control from a captain.
At the time of the First Air accident, there was no training or guidance within the company on how an FO would escalate a concern to the point that a go-around or change of control could be commanded. In the absence of policies and procedures, such as PACE (probing, alerting, challenging, and emergency warning), enabling the FO to escalate his concern as well as providing the authority to take control of the aircraft from the captain, the FO was limited to an advisory role. The FO was clearly aware of the increasing risk. The approach had continued beyond 2 points at which a go-around was required: first, when there is full localizer deflection, and second, in an unstable approach below 1000 feet. At both of these points, the FO attempted to communicate the need to go around to the captain. While not as definitively and clearly expressed as they could have been, these attempts are indicators that the FO was continuing his efforts to change the captain’s course of action.
The FO had previously flown as captain on another aircraft type with the company. However, he was new to the B737, and although obviously uncomfortable with the navigational situation, deferred to the captain.
There was no policy specifically authorizing an FO to escalate his role from advisory to taking control, and this FO likely felt inhibited from doing so. The FO made many attempts to communicate his concerns and suggest a go-around, but did not take control of the aircraft from the captain.
This accident and the other 3 occurrences cited (section 1.17.8.5) are indicators that failure of FOs to take control in deteriorating situations will occasionally result in catastrophic consequences in the global fleet of transport aircraft. Without policies and procedures clearly authorizing escalation of intervention to the point of taking aircraft control, some FOs may feel inhibited from doing so.
A First Officer might not have ‘the right’, but s/he has many rights as a supportive crew member. Also, consider how these pilots are to become Captains, or indeed how current Captains made the transition.
cockney s, all of the ‘knowing’ is based on hindsight - outcome bias. All that we might know is what was said and to some extent what was done, and even based on that the events are a creation of our minds. Factual knowledge might have been taught, or refreshed during an approach briefing, but there is no guarantee that this knowledge will be call on in situations requiring many thoughtful activities.
The report discusses these aspects, but without knowing exactly what the crew saw and understood – as related by them, there cannot be any clear conclusion – other than perhaps that they 'did not know' and that both crew members did not act as expected. Thus the post-accident questions should consider why appropriate action was not taken – what were the contributing factors, or even why we should have such an expectation that the crew will always manage.
Most modern aircraft have compass comparators, did this aircraft have such a system, would it work in gyro mode. If not, then crew procedures should be strengthen when setting and cross-checking the gyro mode.
Aircraft with comparators pose similar problems as crew cross-checks; a disparity can be identified, but without a third reference then the erroneous system cannot be identified. Humans tend to give technology greater credence than verbal warnings, thus with an attention getting system alert a GA might have been flown and the problem resolved at a safe altitude, but not crosschecking the st-by compass during an ILS.
cockney s, all of the ‘knowing’ is based on hindsight - outcome bias. All that we might know is what was said and to some extent what was done, and even based on that the events are a creation of our minds. Factual knowledge might have been taught, or refreshed during an approach briefing, but there is no guarantee that this knowledge will be call on in situations requiring many thoughtful activities.
The report discusses these aspects, but without knowing exactly what the crew saw and understood – as related by them, there cannot be any clear conclusion – other than perhaps that they 'did not know' and that both crew members did not act as expected. Thus the post-accident questions should consider why appropriate action was not taken – what were the contributing factors, or even why we should have such an expectation that the crew will always manage.
Most modern aircraft have compass comparators, did this aircraft have such a system, would it work in gyro mode. If not, then crew procedures should be strengthen when setting and cross-checking the gyro mode.
Aircraft with comparators pose similar problems as crew cross-checks; a disparity can be identified, but without a third reference then the erroneous system cannot be identified. Humans tend to give technology greater credence than verbal warnings, thus with an attention getting system alert a GA might have been flown and the problem resolved at a safe altitude, but not crosschecking the st-by compass during an ILS.
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He KNEW the instruments were overwhelmingly telling him they were off-course
heKNEWthere was high ground ahead
heKNEW they were in breach of SOP's
he KNEW his own life and the lives of the Pax and crew were at risk
he KNEW the Captain was following a wrongful course of conduct.
heKNEWthere was high ground ahead
heKNEW they were in breach of SOP's
he KNEW his own life and the lives of the Pax and crew were at risk
he KNEW the Captain was following a wrongful course of conduct.
An accident that is in a few ways a bit similar to this is the Korean Cargo 8590 where the Capt buried a 747 into a field just outside London. The unfortunate FO didn't dare speak his mind, but the FE did, to no avail. This was blamed on the Korean culture, but it seems Westerners are not so outstanding at CRM as some would like to claim.
Really really sad.
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Under those circumstances, I would suggest thatself-preservation and duty to obey safety=rules should transcendall deference to another, wilfully violating crewmember.
It is likely that the FO did not recognize the captain’s behaviour as that of subtle incapacitation.
The underlying point is that while rules, procedures, CRM and the whole lot are important and have saved lives they are not a panacea. They can't substitute for what the poster above called the instinct for self-preservation. By definition that is not something that can be trained for.
Without policies and procedures clearly authorizing escalation of intervention to the point of taking aircraft control, some FOs may feel inhibited from doing so.
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Go Around Initiation
First, I'm not a pilot, but someone who has undertaken research of aviation CRM in order to compare it with another system (law, as it happens).
It struck me that the safest course of action would be for either PF or PNF to be able independently to initiate a go around. Is that the case - could the FO have declared go around instead of asking, or is it still the PF's discretion?
I presume the only situation where a go around would be inhibited by the circumstances would be critical low fuel (which, I'm guessing would be briefed and obvious). In any other situation, I'd have expected any doubts about continuing the approach to mean an executed go around, with a discussion as to those doubts afterwards - is that generally SOP?
It struck me that the safest course of action would be for either PF or PNF to be able independently to initiate a go around. Is that the case - could the FO have declared go around instead of asking, or is it still the PF's discretion?
I presume the only situation where a go around would be inhibited by the circumstances would be critical low fuel (which, I'm guessing would be briefed and obvious). In any other situation, I'd have expected any doubts about continuing the approach to mean an executed go around, with a discussion as to those doubts afterwards - is that generally SOP?
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First, I'm not a pilot, but someone who has undertaken research of aviation CRM in order to compare it with another system (law, as it happens).
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@ mountainbear
If the FO misjudged the situation all are still alive and the only cost is a bit of fuel and a red face. It provides an oportunity to decide after if the action was wise or not.
A training oportunity that is lost if the aircraft has allready spread itself over the ground.
If the FO misjudged the situation all are still alive and the only cost is a bit of fuel and a red face. It provides an oportunity to decide after if the action was wise or not.
A training oportunity that is lost if the aircraft has allready spread itself over the ground.
DOVE
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“They’d all be walking, talking and alive if they went around”...
Words, words, words.
We can make it as long as we like it, but.
We're not talking about philosophy nor of rhetoric, but of aviation.
Also if the solution of the two flight crew members in commercial aviation is not perfect, it is certainly effective for the management of a situation in which one of the pilots fails.
It follows that it is essential for the two to coordinate and integrate themselves, namely they have to know moment by moment what the other is doing and is about to do, and is sure that everyone knows.
This is achieved through the slavish observance of Standard Operations and Calls.
Undoubtedly a single pilot decides, executes and controls at his libido all flight operations, such as the extension of flaps, landing gear etc. (but for sure he has no passengers on his plane).
In the cockpit of an airplane with two members that would be very very wrong.
If I remember correctly the Pilot Flying was ordering the execution of a manoeuvre (such as the extension of the gear), Pilot Not Flying (now Pilot Monitoring), after checking that there were each and every conditions (for example speed limit) for the execution, complied, repeating the order. Upon reaching the new configuration, the PM always gave verbal confirmation.
During the approach, there were calls to be made in case of exceeding the normal parameters:
- Configuration
- Speed (if the speed was more than +10 / -5)
- Attitude (if it was +/- 5°)
- Vertical speed (if the variometer was more than -1000 ft / min)
- Localizer (if Loc was more than half dot from the center)
- Glide (the same as above)
If at the third one of those calls (in this case "Localizer! Localizer! Localizer") there was no response from the PF, the other had to intervene: "Emergency Authority. I have control! Go Around!"
An unnecessary GO AROUND is better than a CFIT
And believe me: in the end everybody will be thankful to you.
We can make it as long as we like it, but.
We're not talking about philosophy nor of rhetoric, but of aviation.
Also if the solution of the two flight crew members in commercial aviation is not perfect, it is certainly effective for the management of a situation in which one of the pilots fails.
It follows that it is essential for the two to coordinate and integrate themselves, namely they have to know moment by moment what the other is doing and is about to do, and is sure that everyone knows.
This is achieved through the slavish observance of Standard Operations and Calls.
Undoubtedly a single pilot decides, executes and controls at his libido all flight operations, such as the extension of flaps, landing gear etc. (but for sure he has no passengers on his plane).
In the cockpit of an airplane with two members that would be very very wrong.
If I remember correctly the Pilot Flying was ordering the execution of a manoeuvre (such as the extension of the gear), Pilot Not Flying (now Pilot Monitoring), after checking that there were each and every conditions (for example speed limit) for the execution, complied, repeating the order. Upon reaching the new configuration, the PM always gave verbal confirmation.
During the approach, there were calls to be made in case of exceeding the normal parameters:
- Configuration
- Speed (if the speed was more than +10 / -5)
- Attitude (if it was +/- 5°)
- Vertical speed (if the variometer was more than -1000 ft / min)
- Localizer (if Loc was more than half dot from the center)
- Glide (the same as above)
If at the third one of those calls (in this case "Localizer! Localizer! Localizer") there was no response from the PF, the other had to intervene: "Emergency Authority. I have control! Go Around!"
An unnecessary GO AROUND is better than a CFIT
And believe me: in the end everybody will be thankful to you.
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Aviation Investigation Report Out Boeing 737-210C Controlled flight into terrain
Perhaps there should be a rule, that if the FO calls for a go around, regardless of the Captains view, a go around MUST be performed, without question.
That can be SOP for anyone.
That can be SOP for anyone.
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Prazum:
With good CRM, the captain and the F/O would have been more in sync.
Having said that, in general, the F/O needs to be an experienced pro, not a 200 hour "shot gun" ride along.
Perhaps there should be a rule, that if the FO calls for a go around, regardless of the Captains view, a go around MUST be performed, without question.
That can be SOP for anyone
That can be SOP for anyone
Having said that, in general, the F/O needs to be an experienced pro, not a 200 hour "shot gun" ride along.
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missed approach
Despite a few unstable approaches in thousands of airliner approaches, my F/O has never suggested a go-around. Pre-emptive action by the captain almost invariably makes such calls unnecessary, and I have never seen the situation deliberately set up in a sim. In fact, simulator time constraints usually mean such go-around calls by PNF will disrupt the program and these calls are usually avoided. Both pilots and the sim instructor/checker are aware of this deviation, but it is bad practice for the crew.
Sometimes sim PNF is discretely briefed to avoid out of configuration or go-around calls to force PF initiation of corrective measures. I can see a rare need for this, but an unwanted result can be contribution to risk of aircraft CFIT.
In fact, many airlines are unknowingly training F/Os to not make go-around calls. If it is difficult for a Canadian F/O to call and then force the issue, how much more difficult must it be for a Korean crew?
Sometimes sim PNF is discretely briefed to avoid out of configuration or go-around calls to force PF initiation of corrective measures. I can see a rare need for this, but an unwanted result can be contribution to risk of aircraft CFIT.
In fact, many airlines are unknowingly training F/Os to not make go-around calls. If it is difficult for a Canadian F/O to call and then force the issue, how much more difficult must it be for a Korean crew?
Last edited by autoflight; 9th May 2014 at 01:12.
