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CRM: The Good, The Bad And The Ugly  
User currently offlineflyingturtle From Switzerland, joined Oct 2011, 2550 posts, RR: 14
Posted (2 years 8 months 4 weeks 1 day 6 hours ago) and read 4314 times:

Hello fellow a.nutters,


since reading all the AF447 debates, I wanted to open a new thread to collect and discuss examples of CRM in aviation incidents and accidents.

A rather philosophical question: Is there any difference between good and exemplary CRM?

Well, let's start...

Good:
- UA 232 in Sioux City. Tasks were shared with a DC-10 flight instructor who fortunately traveled on the same aircraft.
- QF 32 in Singapore. It was mainly the check airmen who discussed the ECAM messages and decided which ones to disregard, and thus relieving the others.

Bad:
- the Tenerife disaster. I don't count this as "ugly" because CRM didn't exist in the form it does today.

Ugly:
- AF447. None of both PF and PNF were assigned duties in case something would turn out bad. And as I understood, the CPT was reluctant in offering and discussing his perception of the situation. Nobody took care of reading the checklist, and much worse, nobody clearly told the other what he was thinking.


Kind regards,

David


Keeping calm is terrorism against those who want to live in fear.
7 replies: All unread, jump to last
 
User currently offlineNorthwest727 From United States of America, joined Jul 2005, 491 posts, RR: 0
Reply 1, posted (2 years 8 months 4 weeks 1 day 5 hours ago) and read 4281 times:

The list of bad and ugly can go on, as can the successful CRM outcomes (crew working together to land an airplane with a failed component successfully seldom makes news, unlike one where a crash happens).

Failed CRM examples include CO3407, EA401, UA173, etc.

[Edited 2012-03-27 07:11:07]

User currently offlineDashTrash From United States of America, joined Aug 2006, 1563 posts, RR: 2
Reply 2, posted (2 years 8 months 4 weeks 1 day 1 hour ago) and read 4143 times:

Quoting Northwest727 (Reply 1):
Failed CRM examples include CO3407

I'm not sure I completely agree, but admit it's hard to argue. Does that make sense? 3407 was a catastrophic loss of situation awareness. There were many factors that led to it, but I'm not sure poor CRM was much more than a small contributor.


User currently offlinestealthz From Australia, joined Feb 2005, 5743 posts, RR: 44
Reply 3, posted (2 years 8 months 4 weeks 12 hours ago) and read 3984 times:
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Quoting flyingturtle (Thread starter):
- QF 32 in Singapore. It was mainly the check airmen who discussed the ECAM messages and decided which ones to disregard, and thus relieving the others.

It was fortunate there were additional resources on board, took some load off the duty crew and provided additional input.
Would the outcome have been different without them? Who knows, probably not but the stress level of the crew might have been higher.
UA232, I believe the Senior officer that came forward assisted with controls, could the more junior officer that returned to the cabin(AFAIK, sadly did not survive)have performed that function... maybe, maybe not, guess we will never know.

Teneriefe, Pretty good example of bad CRM, CRM has existed as long crews have comprised more than one person. Perhaps there was no name for it, perhaps it was not studied or managed as carefully as it is today.

The HMS Bounty, the USS Caine(fictional) are examples of bad CRM



If your camera sends text messages, that could explain why your photos are rubbish!
User currently offlineCosmicCruiser From United States of America, joined Feb 2005, 2255 posts, RR: 15
Reply 4, posted (2 years 8 months 4 weeks 7 hours ago) and read 3906 times:

Quoting stealthz (Reply 3):
CRM has existed as long crews have comprised more than one person. Perhaps there was no name for it, perhaps it was not studied or managed as carefully as it is today.

I disagree because it wasn't taught as a required, functioning part of every flight. Of course there has always been certain individuals that are good at communication but certainly a small percentage. I had an old Delta pilot (now passed on) tell me that when he was a new F/O in the early 50s, the capt. would say "don't touch anything, don't say anything and if I want you I'll speak to you." Certainly not the best way to run a flight deck. CRM has certainly been an important improvement as to how we fly and manage complex modern jets.


User currently offlineHAWK21M From India, joined Jan 2001, 31712 posts, RR: 56
Reply 5, posted (2 years 8 months 4 weeks 4 hours ago) and read 3867 times:

Quoting stealthz (Reply 3):
Teneriefe, Pretty good example of bad CRM, CRM has existed as long crews have comprised more than one person. Perhaps there was no name for it, perhaps it was not studied or managed as carefully as it is today

Pressure & too vast seniority difference between the crew.



Think of the brighter side!
User currently offlinerfields5421 From United States of America, joined Jul 2007, 7607 posts, RR: 32
Reply 6, posted (2 years 8 months 4 weeks 3 hours ago) and read 3820 times:

Good - I was on a C-121J back in early 1973 from NAS Atsugi to NAS Guam. We took a lightning strike about three hours out and short circuited a panel.

We lost all the limited navigation instrumentation we had on the plane.

It was a clear day, we had good vision of the islands from 20K.

The squadron XO was on the plane - and he 'managed' the situation as a training exercise. How to use available squadron personnel on the plane to minimize the workload on the cockpit flight crew, to supplement the troubleshooting of the flight engineer and the navigator, as we completed the flight to Guam.

At a safety standown a couple months later, Capt Prosser (the XO) went over the event as an example of how flight crews are supposed to work together, how they are supposed to make use of all available resources.

Bad - In September we lost an A-3 Skywarrior on a flight from Guam to NAS Cubi Point. The crew of five was able to bail out over the only destroyer in the JMSDF with an embarked helicopter and recovered safely.

On that flight, which was to transfer a 'good backend (ELINT)' aircraft to Cubi to exchange for a 'bad backend' aircraft - was being used as a navigational training exercise with three navigators aboard - two transitioning from the C-121s.

About 1/2 way to the Philippines, the pilot did a slow circle to see if the 'student' nav would catch the action. The pilot noticed about 1/2 way through the 360 that the electronic compass was not tracking the turn. He stopped the turn when he thought he reached the original course (They left Guam at 10:30 local time and were due in Cubi at 12:30 local time - so the sun was almost directly overhead.)

The pilot refused to trust the wet compass because it did not agree with his perception of the course of the aircraft. The plane captain and one of the navigators were convinced the wet compass was working, demonstrating that a magnetic tool would cause the compass to deviate.

There were a lot of other issues related to navigation, including new HF-DF software installed that morning when made the USAF unable to locate the aircraft.

Long story, but they ended up bailing out almost 900 miles off course after flying north northwest for hours while the pilot was convinced they were heading west southwest, and would not listen to his crew.


User currently offlinepilotpip From United States of America, joined Sep 2003, 3152 posts, RR: 10
Reply 7, posted (2 years 8 months 3 weeks 4 days 14 hours ago) and read 3530 times:

The S5 overrun in CLE is a great example of horrible CRM. There was almost a complete role reversal between the captain and the FO, including the FO completely ignoring the captain's request for a go around. That alone should not have been a request. It should have been a command and after saying it twice the captain should have taken control.


DMI
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