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Effective crew management as antidote to pilot errors
The airline industry has had years of experience in addressing airlines’ Crew Resource Management (CRM), which carriers appear not to be adhering to, thereby causing unavoidable accidents in the country. WOLE SHADARE reports
Associated Airlines prepared for crash
On October 3, 2013, an Embraer 120ER with registration 5N-BJY, a chartered flight, departed Lagos to Akure on an Instrument Flight Rules (IFR). The Captain was the Pilot Flying (PF) and the First Officer was the Pilot Monitoring (PM).
The aircraft departed with No. 1 Engine torque indicator stuck at 76 per cent. A crew-derived non-standard procedure was used to set the No. 1 Engine take-off power, as the torque indicator is the primary gauge for setting power. After take-off power was set, a take-off flap configuration aural warning came on, indicating that the flap position did not agree with the selection. This was followed by auto-feather aural warning. The No. 2 propeller RPM was low.
The PM was concerned that in addition to the warnings the aircraft was slow and advised the PF to abort the take-off. The aircraft got airborne, climbed to 118ft AGL, stalled and crashed into the Joint Users Hydrant Installation (JUHI), close to the airport, with the landing gears in the DOWN position. There was post impact fire, 16 fatalities and four serious injuries. The Accident Investigation Bureau (AIB) released the following as a probable cause.
“The decision of the crew to continue the take-off despite the abnormal No. 2 Propeller rpm indication. Low altitude stall as a result of low thrust at start of roll for take-off from No. 2 Engine caused by an undetermined malfunction of the propeller control unit.”
Unprofessional conduct
There was also poor Crew Resource Management (CRM) as Captain of the ill-fated aircraft, his First Officer and entire crew worked at cross purposes before and during take-off. The aircraft came down at 118 meters after take-off, killing all on-board with the exception of four people who sustained major injuries.
In short, take-off should have been aborted when the crew noticed defects with the airplane but it decided to continue with the flight. The flight crew in summary acted unprofessionally, exhibited poor company culture, coupled with inadequate regulatory oversight; a serious indictment on the Nigerian Civil Aviation Authority (NCAA). The Dana plane crash, like that of Associated and many other plane crashes that have happened in Nigeria and around the globe were caused by this.
Dana’s similar path
For the Dana crash that happened in 2012, which has been adjudged the deadliest accident in the country, occurred because the pilot of the ill-fated crash, an American, Capt. Peter Waxton, and the crew failed to apply appropriate omission of the use of the checklist coupled with the crew’s inability to appreciate the severity of the power-related problem,and their subsequent failure to land at the nearest suitable airfield, therefore killing 153 souls on-board and another 10 on the ground.
The Lagos-bound aircraft from Abuja with registration number 5N-RAM left the Nnamdi Azikiwe International Airport (NAIA), Abuja, on a sunny afternoon but crashed into a two-storey building at Ishaga, on the outskirts of Lagos, barely five minutes to the Murtala Muhammed Airport (MMA), Lagos.
These and many other crashes are classic examples of lack of coordination, gross indiscipline and high level of unprofessionalism and obvious absence of good CRM.
Case for CRM
The goal of CRM is to reduce accidents due to pilot error. It encourages first officers and other crew members to respectfully question the captain.
It creates a more harmonious and safer cockpit. Instead of having the captain make decisions unchallenged, CRM training allows for the first officer to have input on a situation. It also encourages flight crews to work as a team rather than separate units with one decisive leader.
The accident that resulted in the largest-ever number of fatalities occurred in 1977, when two Boeing 747s collided on the runway on the island of Tenerife.
Along with other major accidents during the 1970s, this formed the beginning of a new era for flight safety.
Pilots’ skill under scrutiny
Flight safety no longer seems to be primarily a matter of a pilot’s skills in handling their planes or even of technical reliability; pilots’ skills relating to interaction with other people were found to be at least as important.
While no one can assess how many lives have been saved or crashes averted as a result of CRM training, the impact has been significant.
Although policies put in place to reduce pilot errors are not universal across the world, there are varying guidelines about how long a pilot can captain a flight, how many co-pilots should be present and how many hours a pilot can fly before taking mandatory breaks.There are also varying guidelines about how many hours of training pilots must complete, below what altitude they should not hand over control of a plane and when they should abort landings.
Mitigating errors
The vast majority of aircraft accidents result from pilot error. This has become obvious through series of investigations. However, maybe aviation professionals haven’t done a good job of educating aircraft owners of that fact. Many companies spare no expense maintaining their aircraft to top mechanical standard, and then continually gripe about the cost and inconvenience of initial and recurrent training for their pilots.
Expert’s view
Commissioner, AIB, Akin Olateru, an aircraft engineer, explained that most accidents were as a result of human or pilot errors.
His words: “Human beings all over the world are the most complex machine on earth. Anything that got to do with human is bound to fail someday. This is why there is nowhere in the world that is not accident prone. “
There is no airline today that you can say does not have serious incident. There is no perfect system anywhere, but all we can do as a nation, responsible people and responsible agency is to ensure we step up the game in human factor. “Human factor has been identified as the cause of accidents all over the world. We are holding a seminar to ensure that the operators, service providers invest in that training called human factor. On our own as government agency, we are bringing in US NTSB in May to come and give lecture on how we can deal with this human factor. “They are going to look at all our past accidents.
They will be here for one week. We are going to invite all the stakeholders; the airlines, service providers. Everybody will be there to see how we can deal with air traffic issue. How we deal with issues airworthiness, how we can deal with flight operations issues, how we deal with airports, aerodrome issues among others. Those are the things they are going to be teaching us in five days in May. “It is not a one approach thing. NCAA are doing their bit, airlines are doing their bit. Before you know it, we are going to have a system that is going to add value.”
Conclusion
Aviation industry risk-management processes have not kept pace with a rapidly changing environment. While the US Federal Aviation Administration (FAA) claims that this is the “Golden Age of Safety,” and other aviation researchers assure of the chance of dying in an airline accident becoming infinitesimal, 70 per cent of commercial pilots believe a major airline accident will happen soon.
