Safety Management and CRM
In its final weather briefing before the approach, ATC reported winds consistent with the landing runway but stated the information was 20 minutes old. A later review of ASOS recordings indicated an actual tailwind of 8 knots was likely at the time of landing.
Flight 81’s HB 125-100A was not equipped with a thrust reverser system but instead had a “lift-dump” system installed. Airbrakes—wing panels that deployed both upward and downward—were interconnected with the wing flaps to provide aerodynamic braking. With flaps full (45 degrees) the dump feature extended the airbrakes to their limits. The aircraft was also equipped with an anti-skid braking system designed to provide maximum braking action during rollout.
The landing was within the TDZ at the correct landing speed. At 4.1 seconds after touchdown the airbrakes were deployed and the first officer (PNF) stated, “(we’re) dumped,” followed immediately by, “we’re not dumped” with the captain replying, “no we’re not.” In fact, the lift dump action was not taken until 8.9 seconds after touchdown.
After another 10 seconds of landing roll the airbrakes were stowed, flaps raised and power added in that sequence. An aborted landing, or go-around, was initiated. All too late, however, as the aircraft lifted off out of control, contacted an ILS antenna and crashed. Six passengers and crew of two perished and the aircraft was destroyed.
There were any number of crew performance issues leading up to this tragic accident. The extent of any preflight briefing is unknown, but there is no evidence of any approach briefing or for actions to be taken on landing. No enroute flight service weather checks were recorded even though there was severe weather activity near the destination airport. The surface wind information was 20 minutes old in this convective environment (“a couple of heavy cells were located within 5 miles of OWC”), yet winds were not checked when Flight 81 approached final. The approach and landing checklist performance was hasty and incomplete. There was no discussion of the landing conditions and certainly no preparation for a potential missed approach as required by company procedure. In fact, at the captain’s urging, the first officer spent time on final approach talking to the FBO about parking and fueling arrangements. After landing the lift dump action was uncertain and a delay in deployment resulted.3 Finally, the decision to advance power and go around was reached far too late.
Rather than fault the crew it is more productive to explore the related organizational issues and attempt to understand why poor CRM was allowed to prevail in this cockpit.
The company relied on the simulator training facility to provide its full range of standard operating procedure (SOPs). That is, the company’s pilots were trained to the SOPs contained in the training facility’s Technical Manual, yet these procedures were not incorporated into the company’s GOM. “When asked during post-accident interviews, company pilots could not cite or explain [simulator training facility’s] SOPs consistently.” And, directly related to this accident, there was no SOP or training conducted with respect to go-around after lift dump.
Company culture certainly played a role. For example, the attitude of captains to new hires was less than supportive. “Sit there,” “[don’t] touch anything,” “detrimental to flight,” and “babysitting” were contained in interview statements.
With respect to CRM, the accident report is particularly damning. The company provided in-house CRM and emergency procedures training twice a year. However, its GOM did not contain any CRM procedures. In addition its training manual only listed CRM as a subject but provided no curriculum or course content. The outside training facility did address CRM as a subject in its simulator training. However, the facility had no “formal curriculum or stated standards for CRM”—poor CRM would result from a lack of briefings and facility “instructors look for good communications between crewmembers.”
The company had a formal Safety Management System in place. Having a CRM and Human Factors training program and being able to demonstrate that aircraft crewmembers have received such training are fundamental SMS requirements. Despite the deficiencies from the report as noted above, the company obtained a “platinum” rating through an SMS auditing process. It appears as though the rare metals commodities market has suffered a steep decline.
CRM is an integral part of an SMS program. During a thorough SMS evaluation an auditor would check training records, conduct pilot interviews, review operating policies related to CRM and observe cockpit crew performance on an actual flight to reach an informed opinion of an operator’s CRM standards and proficiency. Perhaps this and similar recent accidents will raise awareness of the need for improved CRM training standards and implementation.
We have discussed CRM in past Cockpit Concepts and will look at the task management aspects of Flight 81 and other flights in a future issue. In the meantime, comments on the topic raised are welcome.
--Bob Jenney (email@example.com)
1Aircraft Accident Report NTSB/AAR-11/01 (Adopted March 15, 2011). Quotations contained herein are from this report.
2Skybrary (www.skybrary.aero) also has a summary report: H25B, vicinity Owatonna MN USA, 2008 (RE LOC HF). Many thanks to reader Seied for the tip.
3As an aside, the company operated four HB 125-100A aircraft, two with thrust reversers and two with lift dumps. Although not mentioned in the report, when fleet differences exist temporary confusion can result in delayed action without adequate flight preparation/briefing.
Aviation.Org Update: December 2014
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