Learjet 25 after landing gear malfunction at MCC (McClellan, Sacramento CA). Proper aircraft configuration is not always so obvious.
Crew resource management (CRM), which evolved in the late 1970s, was originally referred to as cockpit resource management. To the unknowing, the “crew” in today’s CRM seems to reflect a scientific approach, albeit a good one, to human behavior and interaction. I still like the term “cockpit” in CRM as this implies all resources affecting decisions and actions in the cockpit.
Following an accident in Portland OR in 1978, NTSB recommended issuing an operations bulletin addressing “principles of flightdeck resource management.” Furthermore, a literature search on the evolution of CRM provides reference to work completed at a workshop entitled “Resource Management on the Flightdeck,” sponsored by NASA in 1979.
CRM is not simply a model for human behavior—it’s a culture, a way of thinking and a way of conducting business. It requires implementation from the upper levels of an organization and must be part of everyday operations and training.
Continued advances in technology and machinery will bring ever more automation into the cockpit, which will require application of new skills, CRM concepts and applications.
CRM cannot replace years of experience, but will certainly help ensure crewmembers obtain them. As FAA Advisory Circular AC120-51E states, “demonstrated mastery of CRM concepts cannot overcome a lack of proficiency. Similarly, high technical proficiency cannot guarantee safe operations in the absence of effective crew coordination.”
As the concept seems to follow trends in aircraft incidents, accidents and advances in technology, CRM will continue to evolve.
AC120-51E states that the mission of CRM is “to prevent aviation accidents by improving crew performance through better crew coordination”—a statement that seems to focus on human interaction and behavior. It is well documented that failure of—or breakdown in—application of CRM concepts and skills is a contributing factor in most aviation accidents.
As an instructor and check airman for a Part 135 operator in the early 1980s, I recall utilizing the CRM concept. The emphasis at the time was to “fly the airplane” using all available resources. At the time, 2 accidents of note were those of an Eastern Air Lines Lockheed L1011 in the Florida everglades (Dec 1972) and a United Airlines Douglas DC8 in Oregon (Dec 1978). In each of these accidents, a 3-pilot crew had become distracted to the point where no one individual was “flying the airplane.”
With the L1011, the pilots were engrossed with a failed landing gear annunciator and the aircraft descended into the everglades approximately 18 miles WNW of MIA (Intl, Miami FL). In fact, the bulbs were burnt out.
In the case of the DC8, it ran out of fuel and crashed approximately 6 miles SE of PDX (Intl, Portland OR) while its crew was preoccupied with a landing gear malfunction. In each of these accidents, no one individual had been assigned the task of actively monitoring the airplane, which resulted in tragedy. These accidents were influential in the development of CRM.
Today I’m again instructing under FAR Parts 135 and 91, still saying, “Fly the airplane.” We all can recall this statement from the beginning of our flying days. Today, I qualify it in 2 parts—“Get the airplane pointed in the right direction” and “Make it perform.”
Our pilot certificates are evidence that we have demonstrated proficiency in getting an airplane pointed in the right direction. Keeping the airplane pointed in the right direction, both vertically and laterally, includes the use of all available resources, including electronic guidance, visual aids and aural tones.
Getting out of the comfort zone
Making an airplane perform is easier said than done. The accidents referred to below are evidence of this—and while the emphasis may appear to be on larger airplanes, the principles apply to all aircraft classes and categories. Getting an airplane to perform entails being properly configured, on speed and with the thrust where it needs to be. This sounds simple, but is actually quite a complex task.
Flight track overlay of Doppler radar image just prior to Jun 1999 American Airlines MD82 runway overrun at LIT (Little Rock AR).
Review of NTSB accident reports shows 2 recurring themes. First, at least one crewmember was out of his/her comfort zone. Second, for various reasons, the airplane was not made to perform.
These 2 principles have roots going back to the early days of CRM. It is clear that performance targets were not met as the airplane was not made to perform, due to not being properly configured, not on the proper speed or not having the thrust where it should have been. NTSB accident reports contain findings, probable cause and contributing factors. And failures in the application of CRM concepts and skills were typically listed as causal or contributing factors.
We all have our comfort zone, which varies according to level of proficiency, overall career experience, basic aeronautical knowledge, experience with a particular aircraft, weather, a particular airport—the list goes on.
Actually, even the aircraft has a comfort zone, and a pilot knows his/her airplane is getting out of its comfort zone when it starts shaking or vibrating, visual warnings come on or stick shakers activate—or chimes or warnings sound, “Whoop, whoop, pull up, sink rate, sink rate.”
On a snowy day in Jan 1982, an Air Florida Boeing 737 crashed shortly after takeoff from DCA (National, Washington DC). As noted in the NTSB accident report, the first officer said to the captain, “That’s not right” 4 times during the takeoff roll. He was referring to the engine instruments, which appeared to be erroneous. Engine pressure ratio (EPR) indications appeared to be normal, reflecting a setting of 2.04, but the engines were in fact only producing an EPR of 1.70.
The “anomaly” the first officer was referring to was the engine rpm. N1 and N2 were not in the normal range for a takeoff thrust setting, and the throttles were not as far forward as they should have been. The report further states that “the aircraft’s stall warning stick shaker activated almost immediately after liftoff and continued until impact.” The accident report indicated that the aircraft was capable of flying out of this situation and could have done so.
Recognizing the symptoms
In Sep 1989, a USAir Boeing 737 departed the end of Runway 31 at LGA (La Guardia, New York NY) during a high-speed rejected takeoff (RTO) on a wet runway. The RTO was initiated due to difficulty experienced with directional control, which was due to the improper position of the rudder trim to full deflection. With a computed V1 speed of 125 knots, RTO was initiated at 130 kts, and the aircraft exited the end of the runway at a speed of approximately 34 kts.
Failure to deploy ground spoilers caused the MD82 overrun at LIT.
NTSB’s report stated that “braking during the RTO was less than the maximum braking achievable on the wet runway—the airplane could have been stopped on the runway” and described “the captain’s failure to detect the improperly trimmed rudder before the takeoff was attempted” as causal.
Contrary to both manufacturer and air carrier recommendations, the autobrake system was not “armed to RTO” for takeoff, which would have applied maximum braking pressure to the antiskid system during a high-speed RTO and resulted in minimum stopping distance.
Directional control difficulties were evident early during the takeoff roll. This should have, and probably did, bring the crewmembers out of their comfort zone. The report stated that the captain “had several indications of a problem during the takeoff roll before the airplane reached 100 kts.” The term “properly configured” applies to flight controls, trim settings, spoilers, high-lift devices, landing gear, brake pedals, reversers or any component which has an effect on the aircraft’s motion or direction and requires pilot input or positioning.
Properly configured, on speed
In Dec 1995, an American Airlines Boeing 757 crashed in mountainous terrain near Buga, Colombia, while executing a controlled flight into terrain (CFIT) escape maneuver. There was evidence that the crew’s situational awareness was deteriorating as they were hurried—statements to this effect were recorded on the cockpit voice recorder (CVR). Although the crew executed the applicable CFIT escape maneuver within 2 seconds of receiving a “Terrain, terrain, whoop, whoop” warning from the onboard ground proximity warning system (GPWS), the aircraft crashed some 250 ft below the top of the ridge line.
In an effort to expedite their descent, the 757 crew had deployed spoilers—these were fully deployed at moment of impact. An accident report prepared at the University of Bielefeld, in Germany, noted that “the flightcrew failed to discontinue the approach despite their confusion regarding elements of the approach and numerous cues indicating the inadvisability of continuing the approach” to CLO (Cali, Colombia).
Southwest Airlines Boeing 737 departed the end of the runway at MDW (Midway, Chicago IL) after failure to deploy thrust reversers in a timely manner.
In Jun 1999, an American Airlines Douglas DC9-82 (MD82) overran the end of the runway at LIT (Little Rock AR). The crew was uncomfortable with the approach and landing conditions, as shown by the CVR tapes, which included the captain’s statement, “This is a can of worms.” The first officer also called out, “Go around” at around 400 ft on the approach. At about 70 ft above field elevation, the GPWS gave a sink rate alert.
Tire marks indicated that the aircraft touched down 5228 ft from the departure end of the runway and around 1 ft to the right of runway centerline. The MD82 departed the end of the runway at a speed of around 97 kts. It’s hard to imagine how you can put 5000 ft of runway behind you and still be going at 97 kts—the NTSB report stated that “dynamic or reverted rubber hydroplaning did not occur during the accident airplane’s landing rollout.” It also said that “the lack of spoiler deployment was the single most important factor in the flightcrew’s inability to stop the accident airplane within the available runway length.” The auto-spoiler deployment was not armed, nor were the spoilers deployed manually upon landing.
In Mar 2000, a Southwest Airlines Boeing 737 ran off the runway at BUR (Burbank CA) and hit a blast fence at approximately 32 kts. Following is an excerpt from the NTSB accident report. “From 1810:24 until 1810:59, the [GPWS] alerts were being continuously broadcast in the cockpit, first as ‘Sink rate’ and then, at 1810:44, switching to ‘Whoop, whoop, pull up.’ At 1810:29, the captain stated, ‘Flaps 30—just put it down.’ At 1810:33, the captain stated, ‘Put it to [flaps] 40. It won’t go—I know that. It’s all right. Final descent checklist.”
The accident report included the observation that “the captain also stated in a post-accident interview that he visually perceived that the airplane was ‘fast’ as it crossed the approach end of Rwy 8.” The 737 touched down at 182 kts IAS with an average groundspeed in the flare of approximately 195 kts. It touched down approximately 2150 ft from the arrival end of the runway, which is 6032 ft long, at an estimated weight of 113,425 lbs and a maximum certified landing weight of 114,000 lbs.
Pointed in wrong direction
In Mar 2001, a Gulfstream III conducting an approach to ASE (Aspen CO) hit the ground some 2400 ft from the runway threshold. The crew was aware that an aircraft ahead of them on the approach—a Challenger 600—had executed a missed approach. In fact, the copilot said, “That’s not good.” The CVR also recorded the captain’s statement, “I can almost see up the canyon from here, but I don’t know the terrain well enough or I’d take the visual.”
A GIII made impact with terrain short of the runway at ASE (Aspen CO) after failing to brief the approach or a missed approach.
At one point in the approach, the captain deployed the spoilers with the landing gear extended and flaps in full landing position, contrary to the limitations of the aircraft flight manual (AFM). NTSB’s report gave the probable cause of this accident as “the flightcrew’s operation of the airplane below the minimum descent altitude without an appropriate visual reference for the runway.” The captain did not brief the approach or a possible missed approach.
In Oct 2004, a Pinnacle Airlines Bombardier CRJ crashed approximately 2.5 miles from JEF (Jefferson City MO), following a dual engine flameout. CVR recordings indicated very clearly that the captain and first officer were playing around.
NTSB’s report stated that “FDR data also showed that the airplane climbed from 37,000 to 41,000 ft at an airspeed that decreased from 203 kts/Mach 0.63 at the start of the climb to 163 kts/Mach 0.57 as the airplane leveled off.” It also stated that “the improper airspeed during the climb demonstrated that the pilots did not understand how airspeed affects airplane performance and did not realize the importance of conducting the climb according to the published climb capability charts.”
Their ascent began after the stall warning system activated for the third time while at or near 41,000 ft. The report said, “the captain did not take the necessary steps to ensure that the first officer achieved the 300-kt or greater airspeed required for the windmill engine restart procedure.” NTSB’s list of new recommendations resulting from this accident included “[working] with pilot associations to develop a specific program of education for air carrier pilots that addresses professional standards and their role in ensuring safety of flight.” This recommendation is valid not only for air carrier pilots, but for all professional pilots.
Failure to comply with AFM
In Feb 2005, a Challenger 600S ran off the departure end of the runway while executing a high-speed RTO at TEB (Teterboro NJ). The crew had not performed a weight-and-balance computation as required to comply with regulations. NTSB cited as probable cause “the pilot’s failure to ensure the airplane was loaded within weight-and-balance limits and their attempt to take off with a center of gravity well forward of the forward takeoff limit, which prevented the airplane from rotating at the intended rotation speed.”
LEX airport diagram shows Rwy 26 (3500 ft)—the accident runway—and intended departure Rwy 22 (7000 ft).
NTSB also noted that the captain “recalled a table in one of the airplane’s manuals that specified trim settings but that he thought the trim could be adjusted to various settings depending on the pilots’ preference.” With 2 pilots pulling aft on the control column, the nose wheel never lifted from the runway. RTO was initiated at around 160 kts, approximately 5 seconds after reaching the rotation speed of about 135 kts. The aircraft departed the end of the runway at approximately 110 kts.
Aircraft configurations as presented in the AFM are based on extensive engineering and flight test data. This information should be the best available to make the airplane perform—not a matter of personal preference.
In Aug 2006, a Comair CRJ crashed on takeoff from LEX (Lexington KY). The accident occurred about 1 hour before sunrise in VMC. The available Metar at the time reported no clouds below 9000 ft and visibility of 8 miles. The aircraft had been cleared to depart from Rwy 22 (which is 7003 ft long), but inadvertently departed from Rwy 26 (3501 ft), ran off the end of the runway and hit a fence and trees.
NTSB’s report noted Bombardier’s calculation that the aircraft would need 3744 ft to start rotation. The agency gave the cause of the accident as the “crewmembers’ failure to use available cues and aids to identify the airplane’s location on the airport surface during taxi and their failure to cross-check and verify that the airplane was on the correct runway before takeoff.”
Again, it’s a matter of “Fly the airplane. Get it pointed in the right direction and make it perform.” Your comfort zone is just that—yours—and, as a professional pilot, it’s up to you to stay within it. Continue to learn, train and gain experience, and advance your CRM skills. These efforts will help ensure you stay within your comfort zone.
As CRM has developed, we have studied and practiced the concept of breaks in the “error chain” and the prevention of aircraft accidents. Typically, the error chain requires a succession of errors to result in an accident. Failure to apply any one of the fundamentals of making the aircraft perform may result in tragedy—but if pilots apply them consistently, they will be way ahead in the practice of CRM and accident prevention.
Harold Conway flew for 24 years in the airline industry for Part 121 and 135 carriers. He holds an ATP with ratings in the Gulfstream V, Boeing 737, Airbus A320 and numerous turboprops. He currently instructs in the GV and G550.
