Flight Safety DIGEST OCTOBER 2005
Analysis of CREW CONVERSATIONS Provides Insights for Accident Investigation Flight Safety Digest Flight Safety Foundation For Everyone Concerned With the Safety of Flight Vol. 24 No. 10 October 2005 www.fl ightsafety.org
OFFICERS AND STAFF Chairman, Board of Governors Amb. Edward W. Stimpson President and CEO Stuart Matthews In This Issue Executive Vice President Robert H. Vandel General Counsel and Secretary Kenneth P. Quinn, Esq. Treasurer David J. Barger Analysis of Crew Conversations ADMINISTRATIVE Provides Insights for Accident Manager, Support Services Linda Crowley Horger Investigation 1 New methods of examining recorded voice communications FINANCIAL can help investigators evaluate interactions between fl ight Accountant Millicent Wheeler crewmembers and determine the quality of the work environment on the fl ight deck. MEMBERSHIP Director, Membership and Development Ann Hill On-board Fatalities Lowest Membership Services STATS Coordinator Ahlam Wahdan Since 1984 for Large Commercial Jets Membership Services Coordinator Namratha Apparao Boeing data assembled according to a new taxonomy created by an international team indicate that controlled fl ight into PUBLICATIONS terrain and loss of control in fl ight were, by a considerable margin, the leading causes of on-board fatalities in accidents Senior Editor Mark Lacagnina 18 from 1987 through 2004. Senior Editor Wayne Rosenkrans Senior Editor Linda Werfelman Associate Editor Rick Darby Ethics Is a Safety Issue Web and Print Y Production Coordinator Karen K. Ehrlich ‘Data smoothing,’ ‘pencil whipping,’ ‘normalization of Production Designer Ann L. Mullikin deviance’ — they’re all tempting shortcuts against which Production Specialist Susan D. Reed LIBRAR aviation personnel must take a principled stand in a safety Librarian, Jerry Lederer culture. Aviation Safety Library Patricia Setze 24 TECHNICAL Director of Technical Programs James M. Burin Flight Crews Cleared for Technical Programs Specialist Joanne Anderson Near-simultaneous Takeoffs From Managing Director of Intersecting Runways Air Transport Safety Services Louis A. Sorrentino III Q-Star Program Administrator Robert Feeler A preliminary report from the U.S. National Transportation BRIEFS Manager, Data Systems Safety Board quotes the fi rst offi cer as saying that the captain and Analysis Robert Dodd, Ph.D. delayed rotation of their Boeing 737 as an Airbus A330 passed 28 Manager of Aviation overhead with ‘very little separation.’ Safety Audits Darol V. Holsman
Founder Jerome Lederer 1902–2004
Flight Safety Foundation is an international membership organization dedicated to the continuous improvement of aviation safety. Nonprofi t and independent, the Foundation was launched offi cially in 1947 in response to the aviation industry’s need for a neutral clearinghouse to disseminate objective safety information, and for a credible and knowl- edgeable body that would identify threats to safety, analyze the problems and recommend practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive infl uence on aviation safety. Today, the Foundation provides leadership to more than 900 member organizations in more than 150 countries. Cover illustration: © Copyright 2005 Getty Images Inc. N EW ARTICLE TITLE? Copyright © 2005 Rubberball Analysis of Crew Conversations Provides Insights for Accident Investigation
New methods of examining recorded voice communications can help investigators evaluate interactions between flight crewmembers and determine the quality of the work environment on the flight deck.
— MAURICE NEVILE, PH.D., AND MICHAEL B. WALKER, PH.D.
ockpit voice recorders (CVRs) are in- Following the investigation of a controlled-fl ight- stalled in aircraft to provide informa- into-terrain (CFIT) accident involving an Israel tion to investigators after an accident. Aircraft Industries Westwind 1124 jet aircraft, CThey provide records of fl ight crew which struck terrain near Alice Springs, Northern activities and conversations, as well as a variety Territory, Australia, on April 27, 1995, the Bureau of other auditory information. Information from of Air Safety Investigation (BASI, which became CVRs has proved useful in determining the events part of the newly formed multi-modal Australian leading up to aircraft accidents for many years. Transport Safety Bureau [ATSB] in 1999) evalu- However, there has been little discussion in the ated available methods to analyze recorded voice safety investigation fi eld about appropriate ways communications. to analyze recorded voice communications, par- ticularly in terms of analyzing the quality of the [CFIT, as defi ned by the Flight Safety Foundation interaction between crewmembers. CFIT Task Force, occurs when an airworthy
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aircraft under the control of the fl ight crew is It is acknowledged that a perfect understanding fl own unintentionally into terrain, obstacles or of cockpit activity is diffi cult to achieve without water, usually with no prior awareness by the the opportunity to interview the fl ight crew as a crew.] part of an investigation. However, the methodol- ogy described in this paper is intended to expand As a result of the BASI research, the ATSB con- the level of understanding that can be obtained tracted independent specialists in an emerging from a cockpit voice recording as a part of an fi eld known as “conversation analysis” to analyze investigation. the CVR from the Westwind accident. The proj- ect was conducted by Maurice Nevile, Ph.D., and A.J. Liddicoat, Ph.D., both then of the Australian Executive Summary National University. The independent consultants’ report provided conclusions regarding the crew ecorded voice data, such as from CVRs or interaction that were consistent with the original Rair traffi c control (ATC) tapes, can be an BASI investigation report. More important, the important source of information for accident project showed that the conversation analysis investigation, as well as for human factors re- method provided a very useful approach to search. During accident investigations, the extent identify, describe, demonstrate and explain dif- of analysis of these recordings depends on the fi culties in conversation between two or more nature and severity of the accident. However, individuals. most of the analysis has been based on subjective interpretation rather than the use of systematic This paper discusses the nature of conversa- methods, particularly when dealing with the tion analysis and its potential for use in safety analysis of crew interactions. investigation, as well as its potential for dem- onstrating the importance of appropriate crew This paper presents a methodology, called communication practices. To help explain the conversation analysis, which involves the de- usefulness of the method, information from tailed examination of interaction as it develops the original consultancy project’s examination moment-to-moment between the participants, in of the Westwind CVR is included. This paper context. Conversation analysis uses highly detailed is not an investigation of the circumstances of and revealing transcriptions of recorded voice (or the accident. video) data that can allow deeper analyses of how people interact. It is important to note that a cockpit voice re- cording provides limited information about ac- tivity in a cockpit and cannot provide a complete The paper uses conversation analysis as a tech- understanding of all activities nique to examine CVR data from the Westwind and interactions among fl ight accident. crew. It does, however, provide a good understanding of what The conversation analysis methodology provided happened and why. The analysis a structured means for analyzing the crew’s in- can be enhanced by comparing teraction. The error that contributed directly to average sound recordings from the accident — an incorrectly set descent alti- normal multi-crew communi- tude — can be seen as not the responsibility of cation and activity on a fl ight one pilot but, at least in part, as the outcome of with a recording from a particu- the way the two pilots communicated with one lar fl ight that is being studied. another. The analysis considered the following This comparison can provide aspects in particular: more detailed insights into crew activities and interactions on a • The significance of overlapping talk (when particular operation despite both pilots spoke at the same time); the lack of visual information — for example, from a cockpit • The copilot’s silence after talk from the pilot- video recording. in-command (PIC);
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• Instances when the PIC corrected (repaired) identifying the reasons for such the copilot’s talk or conduct; and, errors rather than the errors themselves (Maurino et al., • A range of aspects for how the two pilots 1995; Reason, 1990, 1997). communicated to perform routine tasks. These reasons may include In summary, the conversation analysis methodol- a range of factors associated ogy showed how specifi c processes of interaction with the task and environmen- between crewmembers helped to create a work- tal conditions, as well as the ing environment conducive to making, and not broader organizational context detecting, an error. By not interacting to work in which the crews operated. together as a team, pilots can create a context However, to identify these un- for error. derlying reasons, the nature of the crew actions needs to be When analyzing recorded voice data, and especially examined in detail. In addition, for understanding instances of human error, often the context in which the actions occurred also a great deal rests on investigators’ interpretations needs to be considered (Dekker, 2001a, 2001b, or analysts’ interpretations of what a pilot said, 2002; Reason, 1997). or what was meant by what was said, or how talk was understood, or how the mood in the cockpit This paper discusses a technique that can be or the pilots’ working relationship could best be used to analyze recorded voice communications described. Conversation analysis can be a tool for in context and shows how this technique can be making such interpretations. used to demonstrate how and why communica- tion between two or more pilots was not effec- tive. The technique, called conversation analysis, Introduction involves the detailed examination of interac- tion as it develops between the participants. We t is now widely accepted that human error is a use this technique to examine the CVR from an Icontributing factor in most aircraft accidents accident flight. We show how specific processes (Wiegmann and Shappell, 2003). For many of of interaction between crewmembers can help these accidents that involved larger aircraft and to create a working environment conducive crews with two or more pilots, some of the errors to the pilots making, and not detecting, an related to problems in communication or task co- error. ordination between the pilots (Salas et al., 2001). The research paper is the outcome of collabo- Consequently, there has been a considerable ration between an academic researcher with a amount of research that has examined the na- background in applied linguistics and micro- ture of crew communication and coordination sociology who has conducted a major study of (Helmreich, Merritt and Wilhelm, 1999; Wiener, routine communication in the airline cockpit Kanki and Helmreich, 1993). There also has been (see Nevile, 2004a), and a senior transport safety a considerable amount of effort expended in train- investigator with an academic background in or- ing airline pilots in crew resource management ganizational and cognitive psychology and with techniques (Salas et al., 2001) and a considerable substantial experience investigating human factors amount of effort expended in developing and in aircraft accidents. applying techniques to evaluate crew perfor- mance in these areas, using behavioral markers and techniques such as the line operations safety Current Methods audit (Flin et al., 2003; Helmreich, Klinect and Wilhelm, 1999). ranscriptions of CVR recordings and ATC Tvoice recordings typically list only the speak- It is also widely accepted that, even though er, the time at which the utterance began and the human error may have been a factor in a par- words spoken. Detailed information about how ticular accident, investigations should focus on the words are spoken usually is excluded. This
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is probably because investigators have limited in similar situations. Also, it does not use all the tools to analyze this data in a structured manner. available information about how things are said However, it also may be due in part to sensitivities or communicated, and this information can be associated with releasing CVR information. important in establishing the context for the crew communications. A technique that focuses on this Two main types of techniques have been used for additional information is conversation analysis. more structured analysis of recorded voice com- munications. The fi rst type, commonly termed “speech analysis” (or “voice analysis”) looks at Conversation Analysis a pattern of voice information and related be- havior to identify possible factors affecting an onversation analysis is a micro-analytical individual’s performance. This generally involves Capproach to the study of naturally occur- measurement of variables such as fundamental ring interaction. As a discipline, its origins are in frequency (pitch), speech rate (number of syl- sociology and are usually traced to a paper written lables per second), intensity (or loudness), speech in the mid-1970s by Sacks, Schegloff and Jefferson errors, response time and aspects of the speech (1974) on the organization of turn-taking in con- quality. The data are then compared with care- versation. The early development of conversation fully selected samples, generally from the same analysis is especially associated with the ideas of person under normal conditions. Speech analysis Harvey Sacks (Sacks, 1992; Silverman, 1998) has been successfully employed to examine the and the infl uence of ethnomethodology (e.g., infl uence of factors such as stress and workload Garfi nkel, 1967; ethnomethodology is a branch (Brenner, Doherty and Shipp, 1994; Ruiz, Legros of sociology dealing with nonspecialists’ under- and Guell, 1990), alcohol (Brenner and Cash, standing of social structure and organization). 1991) and hypoxia (ATSB, 2001). However, it Conversation analysis shows in detail how natu- focuses on the factors affecting a specifi c indi- rally occurring interaction is sequentially ordered vidual, rather than the pattern of communication and collaboratively produced and understood by between individuals. participants, moment-to-moment, in what has been described as the “intrinsic orderliness of The second type of technique has involved the interactional phenomena” (Psathas, 1995). coding of speech acts (Helmreich, 1994; Predmore, 1991; Transportation Safety Board of Canada, Conversation analysis looks at how interaction 2003). This process typically involves coding each is something people jointly accomplish “locally” utterance in terms of its function or thought unit (i.e., there and then). Recent introductions to (e.g., command, advocacy, observation, inquiry). conversation analysis are provided by Hutchby It also involves coding action decision sequences and Wooffi tt (1998) and ten Have (1999). of utterances in terms of their task focus (e.g., fl ight control, damage assessment, problem solv- Conversation analysis increasingly is being drawn ing, emergency preparation). The coded data are upon in studies of interaction for work in institu- then examined in terms of how tional settings and professional settings, such as they are distributed between the in medicine and counseling, education, law and crew and how they change over policing, business, human-computer interaction, time during the fl ight. Where and control centers (e.g., Drew and Heritage, 1992; possible, comparisons are made Button, 1993; Heath and Luff, 2000; McHoul and with available data from other Rapley, 2001; Richards and Seedhouse, 2004). crews. Most relevant, one of the authors of this paper has used conversation analysis for a video-based Although speech act coding study of routine communication, or “talk-in- can offer useful insights into interaction,” in the airline cockpit (Nevile, 2001, communication dynamics, its 2002, 2004a, 2004b, 2005b, in press). effectiveness can be limited by a lack of available data on In this paper, four features of conversation analy- how other crews from similar sis are central to the presentation and analysis of backgrounds communicated recorded voice data:
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• Conversation analysis is concerned with unfolding mindset” of the naturally occurring data, not data specifi- people involved “in parallel cally generated for research purposes. It uses and tight connection with how recordings, and the transcriptions made of the world was evolving around them, of naturally occurring interactions. these people at the time” Analysts may make use of observation, in- (Dekker, 2001a). With conver- terviews or other ethnographic techniques, sation analysis, the analyst can but their emphasis is on how the participants use highly detailed transcrip- develop and demonstrate their actions and tions of spoken data (or even understandings in real time; visual data) as indications of how the pilots themselves • Conversation analysis uses highly detailed create particular patterns of and revealing transcriptions of recorded communication and interpret voice (or video) data that can allow deeper and understand what they are doing and what analyses of how people interact. The process is going on, in context. The technique, therefore, of transcribing is an important part of the offers a means for describing, in terms that are discovery process and involves repeatedly defensible because they are grounded in the listening to the recording. Transcribing is voice data, how members of a flight crew are undertaken with an open mind about what working together. might be there, a process called unmotivated looking; The Accident • Conversation analysis is data-driven and re- lies for its claims on the evidence available e will focus on data from the Westwind ac- in the data itself, on what the participants cident and use this accident as an example themselves say and do, and just how and W of what can be done, and what can be found, when they do so as the interaction develops. using methods and principles of conversation Claims about participants’ understandings analysis. This paper is not an attempt to outline and actions must be based on, and demon- and understand all the complex factors that strated in, analyses of the transcription data. contributed to the accident. Instead, we focus Conversation analysis looks at what happens on the way in which the pilots interacted with and at what happens next and asks “Why one another. that now?” Analysts avoid preconceptions of participants or settings, and ascribing to participants’ mental, motivational or emo- The Westwind was being operated on a night car- tional states, but seek evidence for these go fl ight (BASI, 1996; see “‘Cockpit Relationship’ in the details of how interaction develops; Cited in Westwind Accident Report,” page 6). and, The two-pilot crew was conducting a practice nonprecision approach in clear, moonless condi- • Conversation analysis examines what tions. The approach involved a stepped descent people say and do in context, seeing how in three stages using three navigation aids. The these actions occur in sequence relative flight proceeded normally until the aircraft to one another, rather than isolating ac- crossed the fi nal approach fi x, at which point tions from their contexts of occurrence. the pilot-in-command (PIC) asked the copilot Conversation analysis shows how actions to set the “minima” in the altitude alert selector. are both shaped by context and also shape The copilot responded by calling out and setting context by influencing participants’ subse- 2,300 feet, and this action was acknowledged by quent actions and understandings of what the PIC. However, the relevant minimum height is happening. that applied to the accident aircraft at that stage in the approach was 3,100 feet. Soon after leveling Using conversation analysis meets recent off at 2,250 feet, the aircraft struck the top of a calls to analyze human error in context (e.g., mountain and was destroyed. Dekker, 2001a, 2001b), to “reconstruct the Continued on page 7
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‘Cockpit Relationship’ Cited in Westwind Accident Report
ommunication between the pilot- revealed that those difficulties continued • “When asked for the ‘minima’ by in-command (PIC) and the copilot during the accident flight. the [PIC], the copilot called, and the Cwas among the factors contributing [PIC] accepted, an incorrect minimum to the April 27, 1995, accident nine “The [CVR] indicated that these difficulties altitude for the aircraft category and kilometers (five nautical miles) northwest affected the copilot’s willingness to for the segment of the approach; of the airport in Alice Springs, Northern communicate with the [PIC],” the report Territory, Australia, in which the Israel said. “There were also indications that his • “The technique employed by the [PIC] Aircraft Industries Westwind 1124 was task performance was affected and that he in flying the approach involved a high destroyed and all three people in the was reluctant to query the instructions or cockpit workload; [and,] airplane (two pilots and one passenger) the performance of the [PIC]. For example, were killed, the Australian Bureau of Air there were no questions from the copilot • “The crew did not use the radio ■ Safety Investigation (BASI) said in the final concerning the approach briefing, even altimeter during the approach.” report on the accident.1 though a number of significant items were — FSF Editorial Staff omitted. Also, he did not comment on Night visual meteorological conditions the performance of the [PIC] during the Notes prevailed when the accident occurred at approach, despite the fact that tracking 1957 local time as the crew conducted and descent rate limits were exceeded.” 1. Bureau of Air Safety Investigation (BASI; a practice locator/nondirectional beacon 1996). Investigation Report 9501246, (NDB) approach2 to the airport to complete Several elements of crew behavior — Israel Aircraft Industries Westwind the second leg of a four-leg scheduled “communication between the crew, the 1124 VH-AJS, Alice Springs, NT, 27 cargo flight from Darwin to Sydney. The approach briefing, the approach method April 1995. Department of Transport report said that the skies were clear and the [premature] descent to 2,300 and Regional Development, Canberra, and moonless and that visibility was 40 feet” — were identified in the report as Australia. (BASI became part of the newly formed multi-modal Australian kilometers (25 statute miles). contributing to the accident. Transport Safety Bureau in 1999.)
The approach involved a stepped descent The CVR showed a “low standard” of 2. The Alice Springs locator/nondirectional in three stages. The PIC was flying the crew resource management (CRM) by beacon (NDB) approach that was in use airplane; the report said that he had both pilots, the report said. when the accident occurred required the briefed the copilot that “the ‘not below’ pilot to “fly overhead the Alice Springs altitude after the final approach fix for the “The [PIC] was critical of the copilot and NDB not below 5,000 feet,” the report approach (2,780 feet) would be used as did not adequately inform the copilot of said. “The aircraft was then to track approximately 11 [nautical] miles [20 ‘the minimum’ for their purposes. his intentions,” the report said. “The copilot kilometers] northwest to the Simpson’s did not use an appropriate, assertive style Gap locator at a minimum altitude of in communicating with the [PIC]. Had the “The flight proceeded normally until the 4,300 feet. After passing overhead this aircraft passed overhead the final approach pilots communicated more effectively, the position, the aircraft had to complete fix, when the [PIC] asked the copilot to set accident may have been avoided.” a procedure turn through 180 degrees the ‘minima’ in the altitude-alert selector. to again track overhead Simpson’s The copilot responded by calling and setting The report said that the significant factors Gap onto the final segment of the ‘2,300 feet.’ This altitude was the Category in the accident sequence included the approach. This segment involved the A/B aircraft minimum descent altitude, as following: aircraft tracking overhead the Temple Bar locator to the Alice Springs NDB depicted on the Jeppesen chart for the while descending from 4,300 feet. The approach. The minimum descent altitude • “There were difficulties in the cockpit minimum altitude permitted between for the Westwind, which is a Category C relationship between the [PIC] and the copilot; Simpson’s Gap and Temple Bar was aircraft, was 3,100 feet. The 2,300 feet 3,450 feet, and between Temple Bar called by the copilot was acknowledged by • “The level of [CRM] demonstrated by and the Alice Springs NDB, 2,870 feet. the PIC, and the aircraft then descended to After passing the Alice Springs NDB, both crewmembers during the flight that altitude. Shortly after leveling at about the procedure required the aircraft to was low; 2,250 feet, the aircraft struck the top of the continue straight ahead to the minimum descent altitude. For aircraft Categories Ilparpa Range.” • “The Alice Springs locator/NDB A and B, the minimum descent altitude [nondirectional beacon] approach was 2,300 feet (using actual QNH) and The report said that investigators had found was unique; for Category C aircraft, it was 3,100 feet. “evidence of difficulties in the relationship The Westwind is a Category C aircraft. between the two pilots before the flight, • “The briefing for the approach On a normal profile, the Category C at least from the copilot’s perspective,” conducted by the [PIC] was not minima would be reached between and that the cockpit voice recorder (CVR) adequate; Temple Bar and the Alice Springs NDB.”
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The PIC was a former airline pilot with 10,108 by using notation developed in conversation hours total fl ight experience, including 2,591 fl ight analysis is that the transcriptions can show much hours in Westwinds. The copilot had 3,747 hours more about what actually happened, and why. total fl ight experience, most of it in helicopters. Conversation analysis shows how transcribing He had 80 fl ight hours in the Westwind. The PIC voice data involves much more than record- was the handling pilot for the fl ight. ing what people say — it involves showing just how they say it. Typically, conversation analysis The accident investigation identified a number transcriptions of audio data can indicate at least of factors that contributed to this accident, in- the following: cluding that the technique employed by the PIC in flying the approach involved a high cockpit • How talk is sequentially ordered as turns, or workload. A number of the contributing fac- how and when participants exchange roles as tors involved problems in the communication speaker and listener (recipient); between the crew. The report concluded that there were difficulties in the cockpit relation- • Exact measures of silence in and between ship between the PIC and the copilot, and that utterances (timed to the tenth of a second); the level of crew resource management demon- strated by both pilots during the flight was low. • Periods when two or more people are talking Most of the information for these conclusions at once (overlapping talk), and the exact points came from the 30 minutes of recorded voice in talk when such periods begin and end; communication on the aircraft’s CVR. Although • Features of the manner of talk, such as length- the investigation team considered that there was ening of sounds, pitch contours and marked ample evidence to support the conclusions, it rises and falls in pitch, talk that is faster or experienced difficulty in clearly substantiating slower, or louder or quieter than surround- the conclusions in a precise manner. Based on ing talk, talk that is incomplete (e.g., cut off), this experience, a variety of techniques were ex- and aspects of voice quality (e.g., breathiness, plored for assisting in the analysis of recorded creaky voice); voice communications. One of these techniques was conversation analysis. • Tokens such as “oh,” “um” and “ah”; and,
A transcript of the CVR for the accident flight • Laughter (in individual pulses), and exactly was included in the BASI report on the acci- when laughter begins and ends. dent. This paper contains no substantially new information on what was said but contains new To highlight some of the features of conversation information in terms of how things were said. analysis transcription, we show for comparison This additional information has been released two transcriptions of the same segment of talk by the ATSB for the purposes of enhancing from the focus CVR. The fi rst (Example 1) is a aviation safety. basic transcription, in the form it appeared in the investigation report (BASI, 1996). It shows mainly What Happened, and Why who is speaking to whom, the words spoken and the time of speaking. (PIC is pilot-in-command, CP is copilot.) rior to reviewing segments of conversation Pfrom the focus accident, we need to outline the nature of conversation analysis transcription. Example 1 Conversation analysis has developed particular Time From To Text notation for representing systematically many 1934.05 PIC CP we’ll go down to forty-three hundred to there and if you details of talk (or non-talk activities) that stud- can wind in thirty-four fi fty and when we when we get over ies have shown to be signifi cant to participants there wind in twenty-seven eighty that’ll be the minimum themselves (i.e., for how participants interpret we’ll see how it looks for a giggle and you can put the what is going on, as evidenced in what they steps in now too if you wouldn’t mind but you only need to put the steps in below the lowest safe (non-pertinent do next; see “Transcription Notation,” page 8). transmissions) One advantage of transcribing recorded data
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 7 C ONVERSATION ANALYSIS
Transcription Notation
he transcription notation used °five° talk which is noticeably quieter ( ) talk which could not be in this article is adapted from a than surrounding talk transcribed T system originally developed by Gail Jefferson. Recent variations and five, flat or slightly rising pitch, (five) doubt about the talk explanations of the system can be found talk which can be heard as transcribed in Hutchby and Wooffitt (1998),1 ten Have incomplete (1999)2 or Lerner (2004).3 (now/yeah) doubt about the talk transcribed, with possible five. terminal falling pitch contour PIC pilot-in-command alternatives indicated ■ five? terminal rising pitch contour CP copilot — Maurice Nevile, Ph.D., and Michael B. Walker, Ph.D. rnav area navigation fi::ve rising pitch within word
(.) a pause less than two-tenths fi::ve falling pitch within word Notes of a second you:. rise fall pitch 1. Hutchby, I.; Wooffitt, R. (1998). (0.3), (1.4) pauses represented in seconds Conversation Analysis: Principles, and tenths of seconds you:. fall rise pitch Practices and Applications. Cambridge, England: Polity Press. bravo one talk in italics is spoken over the ↑five marked rise in pitch radio 2. ten Have, P. (1999). Doing Conversation = talk which is latched to other Analysis: A Practical Guide. London, >five< talk which is noticeably faster talk (i.e., follows immediately) England: Sage. than surrounding talk
In Example 2, we present the same segment of talk transcribed using nota- To highlight the key differences, we can see that tions developed in conversation analysis. the conversation analysis transcription does the following:
Example 2 • Represents the PIC’s talk as a number of separate turns, rather than as one long turn (18.0) PIC we’ll go down to fortythree hundred to there, (0.5) and if you c’n wind in — the breaks in talk, shown on separate lines thirtyfour fi fty, as periods of silence between turns, represent (0.6) points where the copilot could have heard the PIC and when we- (0.9) when we get over there wind in twentyseven eighty. PIC’s talk as complete in some way, and so the (0.3) copilot could have taken a turn to talk (e.g., PIC °that’ll be the minimum°. even if just to say “yeah” or “okay”); (1.8) PIC see how it looks. • Shows and times all silences, and their lengths (2.5) in seconds, both within and between the PIC’s PIC just for a ↑giggle, turns — for example, (1.8); (6.4) PIC ah::: you c’n put the steps in there too if you wouldn’t mind. • Shows details of the manner of talk, including (1.5) marked rises in pitch (↑) and intonation that PIC >but you only need< to put the steps in
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surrounding talk is louder (“wind”) or qui- or impossible with the limited eter (“°minimum°”) or faster (“>but you only data available in recorded voice need<”) or slower (“
Context for Error Unless we specify a source, we will be grounding our comments on well-established principles and ur suggestion in this paper is that the fi nal fi ndings of conversation analysis, as emerging in Ocrew errors that contributed to the accident research over the past three decades and discussed emerged from an immediate work environment in general texts, such as Hutchby and Wooffi tt that was conducive to errors occurring and not (1998) and ten Have (1999). We will also refer to being identifi ed. The ways in which the pilots research on routine cockpit communication using communicated with one another created a context conversation analysis, focusing on airline crews, for error. We will discuss, with some segments of conducted by one of the authors (Nevile, 2004a). representative CVR data, the following features The CVR data here are from a cargo fl ight, not a of interaction: passenger fl ight, but we will assume that there are common shared mission goals (safe landing) and • There were many instances of overlapping activities (fl ight tasks), and so preferred practices talk (i.e., both pilots speaking at the same for clear and effective communication for fl ying time); multi-engine commercial aircraft.
• There were many instances when the PIC Note that many or most data examples exhibit more said something and the copilot said nothing than one of the features we focus on in this paper. in reply (was silent), even though some form However, to avoid repetition of data, in most cases, of a response would have been a relevant and we have placed examples under just one of the projectable (expected) next action; main headings.
• The PIC often corrected (or repaired) the copilot’s talk or conduct when there was no Overlapping Talk sign of any problem, from the copilot’s point of view, in the copilot’s talk or conduct itself; n both ordinary conversation and talk in work and, Iand institutional settings, it is common for there to be points when more than one person • Many aspects of how the two pilots com- talks at a time. Such instances of overlapping talk municated to perform routine tasks suggest often occur at points where one person is heard to that the pilots were not working together in be possibly coming to the end of their turn at talk. harmony as a crew. The overlapping talk occurs as someone other than the speaker begins to talk and often emerges Individually, each of these features may mean little, as the next speaker and produces the next turn at but together they can have a cumulative effect. talk. Overlapping talk at the end of turns is usu- It is not our intention, and it is not necessary, to ally not treated by participants as interruption, conduct a quantitative analysis of particular but as part of the normal fl ow of talk to exchange features of the talk data. This is usually diffi cult turns and switch speaker/listener roles.
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However, Nevile (2004a, 2005a) has found it to More signifi cantly, however, there were also numer- be unusual for fl ight crews to overlap their talk. ous instances in the data where the PIC began to talk That is, pilots usually do not begin talking when even though the copilot had not fi nished his turn at another pilot is still talking. This was seen to be the talk, where there was potentially still talk of substance case even when pilots were talking and exchang- to be uttered and heard (see Example 5, Example 6 and ing turns very quickly — for example, during the Example 7). In lay terms, the PIC could be heard as performance of a checklist. interrupting the copilot. This occurred even at times when the copilot was presenting important informa- Pilots seem oriented to allow one another’s talk tion for the pilots’ joint conduct and understanding to emerge in the clear. Overlapping talk does of the progress of the fl ight. occasionally occur, but relatively rarely in task- oriented talk. Example 5 (1.1) In the CVR data for the accident fl ight, there CP >Alice on< number one, were more than 20 instances of overlapping (1.0) talk. On its own, this is a noticeable feature of PIC ye::p. the accident fl ight. The great majority of these (0.4) instances of overlapping talk occurred when the PIC Alice on number one, PIC began to talk when the copilot was already (0.5) CP? (yep). talking. That is, the PIC was the participant (2.6) responsible for initiating the overlapping talk. CP Simpson’s gap? (.) o:n [(0.2) number two,] Many of these instances were at points in the PIC [Simpson’s gap’s] on copilot’s talk where the PIC could expect that number two::, the copilot’s turn was coming to a close. That is, (0.7) the PIC was predicting or projecting the end of the copilot’s turn and beginning his own turn at talk in response (see Example 3 and Example Example 6 4). As we have said, this kind of overlap is com- (0.4) mon in everyday conversation but is uncommon CP thrust rever[sers check(ed).] in cockpit communication. Overlapped talk is PIC [(it’s on) light’s] out. (1.0) shown by [square brackets].
Example 3 Example 7
(10.1) (1.5) PIC now the minute we go over Spring Hi:ll, (0.6) CP below the: (.) lowest safe so, (0.5) twentynine or whatever it’s called Simp- err= (here) [(on the) ( )] CP =Simpsons [ga:p PIC [(twentynine)] PIC [Simpson is it? fi ve and eight (two) ( ) (0.2) (3.5) PIC yea:h. (1.4) These instances of overlapping talk suggest, at the very least, that these two pilots are not coordinat- Example 4 ing the timing of their communicative contribu- tions in the smooth manner found to be typical of (2.2) CP gear’s down (.) three greens co[nfi rm? commercial fl ight crews. However, where one pilot PIC [c:o:::nfi ::rm. initiated such points of overlapping talk far more (4.3) than the other pilot, that pilot could be heard to be CP okay hydraulic pressure’s checked in two:::, dominating the other pilot’s communication, and anti[skid, so also their contributions to the work of operat- [((tone, 1 second)) PIC one to run. ing the aircraft. Overlapping talk is also possibly (0.4) a problem because it can increase the chances of something being misheard, or not heard at all. The
10 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 C ONVERSATION ANALYSIS pilots may be speaking simultaneously, but they may not both be listening. Example 9 (9.8) Silence PIC okay you can take the rnav out tha:nks::: PIC just put Alice up, (high pitch tone, 1 second)) great deal of research in conversation analysis (18.8) Ahas shown how people speak in sequences of turns at talk and orient to (or are sensitive to) the sequential nature of conversational exchange. This Example 10 means that, overwhelmingly, when one person in an interaction produces a turn at talk (the fi rst (8.4) of a pair of utterances – or “fi rst pair part”), the PIC okay we’re assuming we’ve got the ah::: (0.9) the ident on a- (.) all the time okay? (.) if you other person produces talk that is appropriate as just identify ‘em and then (1.9) turn them off, a response to that fi rst turn (“second pair part”). (21.1) Moreover, particular types of turns at talk are associated with particular types of response and indeed can be thought of as expecting (or “prefer- Some examples of the copilot’s silence occurred ring”) particular types of response (e.g., question after the PIC corrected the copilot’s performance and answer, telling and acknowledging). of some action or failure to do something (see Example 11). Also, a pattern of the PIC talking Conversation analysis studies have consistently with no spoken response from the copilot was seen found that silences between the turns of a sequence, to occur, even when the PIC appeared explicitly to from as little as 0.3 or 0.4 of a second, are noticeable pursue a response from the copilot, as in Example to participants and are interpreted by participants 12, page 12, (especially in the PIC’s comment, “’n as meaning certain things, and can prompt action of fact, it’s a fair way out, isn’t it?”). This example some kind. For example, the silence possibly signals occurred after a problematic exchange of turns a problem with the fi rst turn, such as it was not where the PIC corrected an error by the copilot heard, or was not understood, or was unexpected, and the copilot attempted to defend his conduct. or will be disagreed with or declined. The lengths The copilot appeared to choose to be silent and and meanings of silences in work settings can vary fi nally only spoke when he had to complete a pre- signifi cantly from ordinary conversation, but in scribed sequence of reciprocal turns for setting the work settings, people also talk in sequences, and speed bugs (“set on the right.”). the cockpit is no exception (Nevile, 2004a, 2005b). When one pilot talks, the other usually responds, Example 11 and in a way that can be heard as appropriate. (8.6) In the CVR data from the accident fl ight, there were PIC okay if you can put the rnav (0.3) up thanks::. many instances where the PIC said something, the (1.4) PIC whoo::::h. fi rst pair part of a sequence (e.g., a telling/informing, (0.6) an instruction, or a question), but the copilot did PIC do that fi r:::st. not produce any appropriate and expectable spo- (1.6) ken response (e.g., an acceptance/acknowledgment, PIC bring em both out, or compliance, or an answer). An excellent example of (0.4) this was presented above in Example 2; additional ex- PIC o:kay. (4.3) amples are in Example 8, Example 9 and Example 10. ((alert sound - beep)) (0.8) Example 8 PIC righto. (46.6) (1.2) PIC ah::: have you got the ILS preed up there just PIC so you can put the inbound course up there::. in ca:se::? (22.8) (34.8) PIC thank you::. PIC thanks. (5.5) (35.3)
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next action. In these instances, silence is not simply Example 12 a case of no one speaking, but a case of the copilot (0.5) not speaking. In terms of verbal communicative PIC yeah I dunno how we’re gonna get rid of exchange between fellow pilots, for whatever rea- tha::t. son one party — the copilot — regularly withheld (1.5) talk and opted out. PIC I guess: all you can do if it doesn’ go away::, (1.0) is:: ah:: (1.0) put my information on your si:::de. (2.7) Correction (Repair) PIC it’s no good the way it i:s:. (5.8) onversation analysts have identifi ed a general PIC ‘n fact it’s a fair way out isn’t it? Cconversational practice, repair, which may be (33.8) of particular relevance to understanding error in PIC >there you go.< aviation and how it is managed. Repair refers to (1.9) PIC ’s got rid of it for a whi::le anyway. those points in spoken interaction where par- (1.6) ticipants deal with communicative problems of PIC okay we’re gonna do this: (.) for a bit of a some sort. Conversation analysts have found that giggle, in everyday conversation, people typically do not (1.3) correct each other. There is a marked tendency for PIC u:::m (.) elevation’s eighteen hundred feet, (1.5) we got enough fuel to ho:ld for one self-repair (Schegloff, Jefferson and Sacks, 1977); point four hours if need be, (1.5) a::nd ah:: that is, for the person who produced the “problem we gotta vee ref of one twenty set on the talk/conduct” (the repairable) to repair that talk left, or conduct, and to be granted the opportunity to (0.2) do so by the other person. CP set on the right. (4.8) Conversation analysts have shown that par- ticipants distinguish between the initiation of the In some of these cases, it is possible that the repair (i.e., showing that there is a problem) and copilot could indeed have been responding, but actually doing the repair (i.e., fi xing the problem). with a nontalk activity (e.g., a nod or an activity So, even where the other might initiate the repair, at an instrument panel). The cockpit is a work- there is still the tendency for self-repair. This place where the response to talk is often nontalk preference for self-repair is seen in data for fl ight activity; however, such activity almost always is crews (Nevile, 2004a). Conversation analysts have accompanied by talk (Nevile, 2002, 2004a, 2004b, shown that, when another person both initiates 2005b). A possible exception to this is during a and performs a repair (called other-initiated other- formal briefi ng, when pilots can speak in longer repair), that repair is typically delayed, hedged or (extended) turns, but even in briefi ngs, there usu- qualifi ed in some way. The person doing the repair ally is evidence of the pilots acknowledging one softens the blow. another’s contributions and orienting to a need to communicate verbally as they work together In the CVR data for the accident fl ight, there were (Nevile, 2004b). Other than during briefi ngs, it many instances of other-initiated other-repair. The is extremely unusual to have a string of turns at pilot who produced the problem talk or conduct talk where one pilot talks and the other pilot says did not initiate repair and did not repair that talk nothing in reply. or conduct. Overwhelmingly, the pattern of these instances involved the PIC both initiating and Conversation analysis discusses silence in terms of performing the correction/repair of the copilot’s “conditional relevance.” The copilot’s silence can talk or conduct (see Example 13, page 13, and be seen as an absence of speech in a context where Example 14, page 13, and also Example 11). The the PIC’s talk made it relevant for the copilot to PIC repaired the copilot’s talk/conduct when there say something. The copilot was entitled to say was no sign of any trouble, in the copilot’s talk/ something and, indeed, could be expected to say conduct itself, from the copilot’s point of view. The something. In conversation analysis terms, speech fi rst the copilot knew that there was something to from the copilot would have been a “projectable” be corrected in his talk or conduct was when the
12 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 C ONVERSATION ANALYSIS
PIC corrected it. More than this, the PIC did not that the copilot actually said the problem number, delay, hedge, or qualify his repairs of the copilot. “seven,” twice, the fi rst time in the turn that he cut The PIC gave the copilot no or little opportunity off. Therefore, it is possible that the PIC heard to correct the problem for himself. the problem “seven” twice and let it go the fi rst time, giving the copilot the chance to get it right. Example 13 However, that fi rst talk by the copilot was not completed (“seven mile f-f-”), and it was when (0.4) he completed his turn and presented the number CP and it’s a seven mile f-f- he had actually settled on (“=seven mile fi nal.=”) (0.5) ? ( )= that the PIC immediately corrected him. CP =seven mile fi nal.= PIC =no:: el↑even. Not only did the PIC do the repair himself imme- CP eleven. diately, with no delay, no hedging and no qualifi - (6.9) cation, the repair began with an explicit marker of negation. This had its prominence increased be- cause it was said with increased volume and was also lengthened (“no::”). The PIC continued his turn by Example 14 simply saying the repaired number “eleven,” and in (6.2) the following turn, the copilot accepted this repair CP the only trouble we might get is, (0.5) if they without question, indeed without delay. The PIC’s lea::ve. saying of “eleven” was a claim that this number (1.3) CP if they leave before us (0.3) they might was the correct one, and this claim was immediate- depart out on, (0.4) one two. ly accepted by the copilot. So, a possible problem (0.7) of crew understanding about the length of the fi nal PIC well they ca::n’t, (0.2) we got their freight. leg was resolved by one individual telling another, (1.6) effectively, that he was wrong, and the other indi- CP °(that’s right)° (9.3) vidual accepting this without question.
Performing Tasks Example 13 is a clear example of other-initiated other-repair and warrants further explanation. inally, we consider how the two pilots generally The copilot, as part of his preparation for the ap- Fperformed routine fl ight tasks for this period of proach, informed the PIC that it will be a “=seven the fl ight. Our general fi nding is that it was typically mile fi nal.=”. The copilot had two goes at saying the PIC who talked to initiate tasks, and he did so this, abruptly stopping his fi rst attempt with “seven in ways that can make prominent his authoritative mile f-f-.” status as PIC for the fl ight, and the other pilot’s ju- nior status. That is, the PIC’s wording can be heard The PIC corrected the copilot’s “seven” by saying to present tasks as being performed for him, as the ↑ “=no:: el even.” PIC, by the copilot, rather than as being performed collaboratively for both pilots as a crew, and by both The “=” symbols indicate that the PIC’s turn is pilots as a crew, albeit that it is often appropriately “latched” to the end of the copilot’s turn (i.e., the the case that the copilot is doing the required task PIC produced his talk with no delay whatsoever activity. Such wording could be heard as creating after the end of the copilot’s turn). Recalling that a sense that the copilot was serving the PIC, rather in interaction there is a tendency (or “preference” than that the two pilots were working together as in conversation analysis terms) for self-repair, the team members with different but equally neces- copilot was given no opportunity, after completing sary and valuable contributions to fl ight tasks. his problem turn, himself to repair the incorrect The nature of the copilot’s participation in task number. That is, the PIC did not say something performance could deepen this sense of how the like “Seven?” or “Are you sure it’s seven?” or “Is pilots were working. that right?” or even just wait a second or so to give the copilot a chance to rethink and possibly To demonstrate these points, we describe a num- identify and say the correct number himself. Note ber of specifi c aspects of the pilots’ communication
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 13 C ONVERSATION ANALYSIS
and interaction as they performed routine tasks. We The PIC also very frequently used the first stress, however, that many segments actually exhibit person singular personal pronoun “I,” which more than one of the aspects described below. presented him as central to the task and as the recipient for performance of the task, and the The collection of segments makes it easier to un- second person pronoun “you,” which presented derstand how, over time, the effect of particular the copilot as the one doing the task. That is, the aspects of communication can accumulate and PIC’s usual wording can convey the sense that create a context in which the pilots seem not to “you are doing the task for me.” Such use of “I” be working together but instead more according and “you” by a PIC and handling pilot is not in to their individual statuses and roles. itself exceptional as a means for making salient First, the PIC typically initiated tasks with com- relevant individual cockpit identities (Nevile, mands to the copilot. 2001, 2004a). However, their use almost to the exclusion of more inclusive plural forms (e.g., In grammatical terms, he used imperative struc- we/our/us) can mark this CVR data as unusual tures that communicate “Do X,” as shown in for cockpit talk. Coupled with his use of “I” and Example 15, Example 16 and Example 17. “you” pronoun forms, the PIC regularly used verbs such as “want” and “have” (e.g., “I want X” Example 15 and “Can I have X?”), making further salient his (10.1) individual roles on this fl ight as the PIC and han- PIC now the minute we go over Spring Hi:ll, (0.6) dling pilot, and the other pilot’s individual role or whatever it’s called as copilot doing actions for him (see Example 18 Simp- err= and Example 19, page 15). CP =Simpsons [ga:p PIC [Simpson is it? (0.2) Example 18 PIC yea:h. (1.4) (9.3) ↑ PIC ah:::m (.) set the next altitude u:p, (0.5) and PIC okay. the nex:t:, (0.5) NDB. (2.5) (1.3) PIC on number one, (0.5) I want ah::: (1.3) Alice NDB? (3.2) Example 16 CP °(alright)° (4.7) (2.9) PIC keep going. PIC number two I want that one, (4.8) (3.5) PIC keep going. (.) checks th[anks. PIC so we want tha::t, (0.9) and tha::t, (2.5) and CP [okay vee ref (0.2) that one [( ) one three set. (.) fuel [((static sound)) balance, EAO Melbourne control good evening echo PIC it’s within limits:::. alpha oscar posit[ion quebec (1.4) PIC [that to EAO [two three bravo one zero zero two, (0.5) maintaining fl ight level three Example 17 PIC [number one, (0.5) that to number two, (0.4) (1.4) and that is (0.2) pree::d HT? hotel tango ( ) good night (and thanks). EAO [ f i::ve zero] PIC he said to call Adelaide no:w didn’t he? PIC [up, (0.7) on number two.] CP yeh. (0.5) (0.3) EAO (correct) two three charlie [ (0.2) ] one zero two PIC well you can go off, (0.5) go (on/off) tha:t. seven. (4.5) ? (s- ) (respond). CP [okay::.] (9.5) (1.3)
14 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 C ONVERSATION ANALYSIS
Example 19 Example 20
(0.7) (0.8) PIC can I have? (0.7) an rnav (0.3) fo:::r, (0.2)
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 15 C ONVERSATION ANALYSIS
occurring on its own, or occurring only pilot, but at least in part as the outcome how talk was understood, or how the on occasion, could contribute to quite a of the way the two pilots communicated mood in the cockpit or the pilots’ work- different sense of working relationship. with one another. ing relationship could best be described. However, our suggestion is that these as- Conversation analysis can be a tool for pects, taken together and occurring over We considered the following aspects in making such interpretations. A particular a substantial period on the CVR for this particular: the signifi cance of overlap- value of conversation analysis as a quali- fl ight, point to a tendency for tasks to be ping talk (when both pilots spoke at the tative method is that it can be applied to performed in a way that can emphasize same time); the copilot’s silence after talk even very small amounts of data, even the pilots’ different individual statuses and from the PIC; instances when the PIC a single exchange of turns. By drawing roles, rather than a harmonious collabora- corrected (repaired) the copilot’s talk or on transcription and analytic methods tive team working relationship. (The dif- conduct; and lastly, a range of aspects for arising from conversation analysis, it is ference in status between pilots is often how the two pilots communicated to per- possible to eschew attempts to “get into referred to as the trans-cockpit authority form routine tasks. It is signifi cant to note people’s heads” and conjecture what gradient. Gradients that are too fl at or too that in pointing to evidence that the pi- they are thinking and feeling. Actually steep are generally considered to contrib- lots’ communication was problematic for analyzing language in use in aviation, or ute to less effective crew coordination and their work as a team, it was not necessary any other work setting, can involve much communication [Hawkins, 1987].) to rely on analyzing instances of overt more than classifying and counting this confl ict or communication breakdown. or that type of utterance or action. It can Conclusion Communicative problems can build up, involve seeing how language emerges in and be evidenced, over time. interaction in context, and serves to cre- ur aim has been to describe the ate context. ■ Ocontext for a human error, or to We hope to have demonstrated the consider how an error can be understood value of looking closely at recorded [FSF editorial note: To ensure wider as emerging from the immediate working voice data as a means for interpreting distribution in the interest of aviation environment as created by the pilots, in human performance and for interpret- safety, this report has been reprinted the ways in which they communicated ing human error in aviation in the light from the Australian Transport Safety and interacted with each other. We used of the world evolving around the pilots Bureau (ATSB) publication A Context a specifi c approach to naturally occurring at the time (Dekker, 2001a), and indeed for Error: Using Conversation Analysis communication and interaction, conver- as the pilots themselves create it. The to Represent and Analyse Recorded Voice sation analysis, to transcribe and analyze approach we have used can allow sys- Data, Aviation Research Report B2005/ CVR data of one aviation accident, in- tematic and data-based assertions about 0108, June 2005. Some editorial changes volving a commercially operated jet air- human action. How one represents data were made by FSF staff for clarity and for craft. We did not focus on the moment of affects greatly what one is able to see in style. Maurice Nevile, Ph.D., is affi liated error itself, but instead on the context in it and subsequently able to say about with the Division of Business, Law and which it occurred, or what we have called it. Conversation analysis is a micro- Information Sciences at the University an interactional context for error. We used approach to the transcription and analy- of Canberra (Australia), and Michael B. segments from the CVR data, transcribed sis of naturally occurring interaction, and Walker, Ph.D., is with the ATSB.] in rich detail using notation from conver- richly detailed transcriptions using nota- sation analysis, to suggest that aspects of tion of conversation analysis can make References the pilots’ interaction show the pilots to maximally visible how pilots themselves Australian Transport Safety Bureau (2001). be acting according to, emphasizing, their develop and understand their respective Investigation Report 200003771, Pilot and individual statuses and roles as PIC and contributions to interaction and to the Passenger Incapacitation, Beech Super King copilot, rather than a sense of working work required to operate their aircraft. Air 200 VH-SKC, Wernadinga Station, Qld, 4 collaboratively as a team. This paper has shown what kind of anal- September 2000. Department of Transport and yses and fi ndings conversation analysis Regional Services, Canberra, Australia. We suggest that such aspects of interaction transcriptions can make possible. Brenner, M.; Cash, J.R. (1991). “Speech Analysis contribute to a working relationship that as an Index of Alcohol Intoxication — The can be conducive to an error occurring When analyzing recorded voice data, and Exxon Valdez Accident.” Aviation, Space, and and not being identifi ed: They can allow especially for understanding instances of Environmental Medicine, 62, 893–898. for a collaborative construction of error. The human error, often a great deal rests on Brenner, M.; Doherty, E.T.; Shipp, T. (1994). error that contributed directly to the ac- investigators’ interpretations or analysts’ “Speech Measures Indicating Workload cident, an incorrectly set descent altitude, interpretations of what a pilot said, or Demand.” Aviation, Space, and Environmental can be seen as not the responsibility of one what was meant by what was said, or Medicine, 65, 21–26.
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Nevile, M. (2005a). “Conversation Analysis at New York, U.S.: Oxford University Press. Work: Overlapping Talk in the Airline Cockpit. Heath, C.; Luff, P. (2000). Technology in Action. Paper presented at the International Roundtable ten Have, P. (1999). Doing Conversation Analysis: Cambridge, England: Cambridge University on Discourse Analysis, City University of Hong A Practical Guide. London, England: Sage. Press. Kong, Hong Kong, 21–23 April. Transportation Safety Board of Canada (2003). Helmreich, R.L. (1994). “Anatomy of a System Nevile, M. (2005b). “You Always Have to Land: Supporting Technical Information: Techniques, Accident: The Crash of Avianca Flight 052.” Accomplishing the Sequential Organization of Tests, and Research (SR111). Appendix to International Journal of Aviation Psychology, 4, Tasks to Land an Airliner.” In Norris, S.; Jones, the Aviation Investigation Report, In-fl ight 265–284. R. (Eds.), Discourse in Action: Introducing Fire Leading to Collision with Water, Swissair Mediated Discourse Analysis (pp. 32–44). Transport Limited, McDonnell Douglas MD-11 Helmreich, R.L.; Klinect, J.R.; Wilhelm, London, England: Routledge. HBIWF, Peggy’s Cove, Nova Scotia 5 nm SW, J.A. (1999). “Models of Threat, Error and 2 September 1998, Report Number A98H003. CRM in Flight Operations.” In Jensen, R.S. Nevile, M. (in press). “Making Sequentiality Ottawa, Canada: Transportation Safety Board. (Ed.), Proceedings of the Tenth International Salient: and-prefacing in the Talk of Airline Symposium on Aviation Psychology (pp. Pilots.” Discourse Studies, 7(6). Wiegmann, D.A.; Shappell, S.A. (2003). A 677–682). Columbus, Ohio, U.S.: Ohio State Human Error Approach to Aviation Accident University. Predmore, S.C. (1991). “Microcoding of Analysis: The Human Factors Analysis and Communications in Accident Investigation: Classifi cation Scheme. Aldershot, England: Helmreich, R.L.; Merritt, A.C.; Wilhelm, J.A. Crew Coordination in United 811 and United Ashgate. (1999). “The Evolution of Crew Resource 232.” In Jensen, R.S. (Ed.), Proceedings of the Management Training in Commercial Sixth International Symposium of Aviation Wiener, E.L.; Kanki, B.G.; Helmreich, R.L. Aviation.” The International Journal of Aviation Psychology, 350–355. Columbus, Ohio, U.S.: (1993). Cockpit Resource Management. San Psychology, 9:19–32. Ohio State University. Diego, California, U.S.: Academic Press.
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 17 AVIATION STATISTICS
On-board Fatalities Lowest Since 1984 for Large Commercial Jets
Boeing data assembled according to a new taxonomy created by an international team indicate that controlled flight into terrain and loss of control in flight were, by a considerable margin, the leading causes of on-board fatalities in accidents from 1987 through 2004.
— FSF EDITORIAL STAFF
estern-built, large commercial jet of airplanes in the category increased to 19,077 in airplanes1 were involved in 32 ac- 2004 from 17,991 in 2003. cidents worldwide in 2004, the same W number as in 2003. The accidents Data for accident rates by the number of years fol- included 14 hull-loss accidents2 (Table 1, page 19), lowing introduction of each generation4 of large compared with 12 the previous year. The 180 on- commercial jet showed that accident rates were board fatalities represented a 63 percent reduction highest among fi rst-generation jets in the fi rst fi ve from the 483 on-board fatalities in 2003 and was the years and again after being in service for more than lowest number since 1984 (Figure 1, page 20). about 30 years (Figure 2, page 20). By comparison, the current generation showed its highest accident The data were published in the 2005 edition of the rate in the fi rst two years of service and the lowest annual statistical summary by Boeing Commercial accident rate of all generations in nearly all of the Airplanes.3 following 23 years.
Half of the 2004 accidents (16) occurred in the According to the Boeing data, the 10-year hull-loss landing phase of fl ight. Nine accidents (28 per- and/or fatal-accident rate for scheduled passenger cent) occurred during takeoff, four (13 percent) operations was 0.88 per million departures and 2.55 during taxi, two (6 percent) in climb or initial per million departures for all other operations (un- climb, and one in cruise. scheduled passenger and charter, cargo, ferry, test, training and demonstration). Flight hours and departures both increased for Western-built, large commercial airplanes in 2004. Figure 3 (page 21) shows hull-loss rates and/or Flight hours totaled 37.1 million and departures fatal accident rates by airplane type. The current totaled 17.5 million, compared with 33.9 million generation of large commercial jets (11 types with and 16.9 million, respectively, in 2003. The number Continued on page 21
18 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 S TATISTICS
Table 1 Worldwide Commercial Jet Airplane Accidents, 2004*
Hull Date Airline Airplane Type Accident Location Loss Fatalities Phase Description 01-Jan-04 Japan Air System MD-81 Tokunoshima, Japan 0 Landing Main landing gear collapsed 03-Jan-04 Flash Airlines B-737-300 Sharm El-Sheikh, X 148 Climb Airplane struck terrain after Egypt takeoff 05-Jan-04 Austrian Airlines F70 Munich, Germany X 0 Landing Emergency landing in fi eld 15-Jan-04 Iran Air B-747-SP Beijing, China 0 Landing Nose landing gear collapsed 19-Jan-04 Air Malta A320-210 Malta 0 Taxi Collision with light pole 20-Feb-04 Austral — Cielos del MD-81 Buenos Aires, 0 Takeoff Main landing gear wheels Sur Argentina departed 25-Feb-04 First Air B-737-200C Edmonton, Canada 0 Landing Offside landing 01-Mar-04 Pakistan International A300-B4 Jeddah, Saudi Arabia X 0 Takeoff Nose landing gear tire failure Airlines 02-Apr-04 Air Memphis B-707-300 Cairo, Egypt X 0 Takeoff Right main landing gear collapsed 09-Apr-04 Emirates A340-313X Johannesburg, South 0 Takeoff Takeoff overrun, go-around Africa 20-Apr-04 Alitalia MD-82 Trieste, Italy 0 Taxi Collision with dump truck 27-Apr-04 Aerosvit B-737-500 Moscow, Russia 0 Takeoff Runway excursion, nose landing gear collapsed 28-Apr-04 Centurion Air Cargo DC-10-30F Bogota, Colombia X 0 Landing Landing overrun 29-Apr-04 Turkish Airlines B-737-800 Gaziantep, Turkey 0 Landing Runway excursion 13-Jun-04 Turkish Airlines A321-210 Istanbul, Turkey 0 Landing Hard landing, tail strike 17-Jun-04 EgyptAir A300-B4-200F Khartoum, Sudan 0 Landing Hard landing, runway overrun San Pedro Sula, 06-Jul-04 Iberia Airlines A319-110 0 Landing Veered off runway Honduras 21-Jul-04 Aero California DC-9-14 Mexico City, Mexico X 0 Takeoff Settled after takeoff 25-Jul-04 Inter Airlines F100 Istanbul, Turkey 0 Landing Main landing gear collapsed 03-Aug-04 Volare Airlines A320-210 Valencia, Spain 0 Initial Severe hail damage Climb 09-Aug-04 Swiss BAe RJ100 Frankfurt, Germany 0 Cruise Dual engine damage 11-Aug-04 Air Guinee B-737-200 Free Town, Sierra X 0 Takeoff Rejected takeoff, runway overrun Leone 28-Aug-04 Transair Cargo SA Caravelle Gisenya, Rwanda X 0 Landing Landing overrun, post-accident fi re 08-Oct-04 Biman Bangladesh F28 Sylhet, Bangladesh X 0 Landing Landing overrun Airlines 14-Oct-04 MK Airlines B-747-200 Halifax, Canada X 7 Takeoff Struck terrain after takeoff 23-Oct-04 BETA B-707-300 Manaus, Brazil X 0 Taxi Right main landing gear collapsed 07-Nov-04 Air Atlanta Icelandic B-747-200F Sharjah, United Arab X 0 Takeoff Rejected takeoff, runway overrun Emirates Kota Kinabalu, 07-Nov-04 AirAsia B-737-300 0 Landing Runway excursion Malaysia 28-Nov-04 KLM-Royal Dutch B-737-400 Barcelona, Spain X 0 Landing Runway excursion Airlines 30-Nov-04 Lion Air MD-82 Solo City, Indonesia X 25 Landing Struck terrain during landing 09-Dec-04 ASTAR B-727-200 Atlanta, Georgia, U.S. 0 Taxi Main landing gear collapsed after landing 29-Dec-04 Chanchangi Airlines B-727-200 Lagos, Nigeria 0 Landing Nose gear–up landing 32 Total 14 180
A = Airbus B = Boeing BAe = British Aerospace DC = Douglas F = Fokker MD = McDonnell Douglas SA = Sud Aviation *The data apply to commercial jet airplanes worldwide that are heavier than 60,000 pounds/27,000 kilograms maximum gross weight. Commercial airplanes operated in military service and airplanes manufactured in the Soviet Union or the Commonwealth of Independent States are excluded.
Source: Boeing Commercial Airplanes
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 19 S TATISTICS
Figure 1 Accident Rates and Fatalities by Year, Worldwide Commercial Jet Fleet, 1956 Through 2004 50 1,400
1,200 40 Hull-loss and/or fatal accidents On-board Fatalities 1,000
All accidents 30 Fatalities 800
600 20
400
10 200 Accident Rate (Accidents per Million Departures) 0 0 1959 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Year Source: Boeing Commercial Airplanes
Figure 2 Accident Rates by Years Following Introduction, Hull-loss and/or Fatal Accidents, Worldwide Commercial Jet Fleet, 1959 Through 2004 60
First Generation 50 Second Generation Early Wide-body Current Generation 40
30
20
10 Accident Rate (Accidents per Million Departures)
0 024 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 Years Since Introduction Note: Generations are defi ned as follows: First — Boeing 707 and 720; Convair 880 and 990; Dassault Mercure; de Havilland Comet 4; Douglas DC-8; and Sud Aviation Caravelle. Second — Boeing 727; British Aircraft Corp. BAC 1-11; Douglas DC-9; Boeing 737-100/-200; Fokker F28; Hawker Siddeley Trident; and Vickers VC-10. Early wide-body — Airbus A300; Boeing 747-100/-200/-300/SP; Lockheed L-1011; and McDonnell Douglas DC-10. Current — Airbus A310, A300-600, A330, A340; BAe 146, RJ70/85/100; Boeing 757, 767, 737-300/-400/-500/-600/-700/-800/-900, 717, 747-400, 777; Canadair Regional Jets CRJ-700/-900; Fokker F70, F100; and McDonnell Douglas MD-80/-90, MD-11.
Source: Boeing Commercial Airplanes
20 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 S TATISTICS
Figure 3 Accident Rates by Airplane Type, Hull-loss and/or Fatal Accidents, Worldwide Commercial Jet Fleet, 1959 Through 2004
**Not flying 85 Boeing 707/720 126 7.38 14.46 Douglas DC-8 73 6.08 Boeing 727 82 1.10 Boeing 737-100/-200 72 1.31 Douglas DC-9 81 1.36 British Aircraft Corp. BAC 1-11 23 2.71 Fokker F28 35 5.80 Boeing 747-100/-200/-300/SP 26 2.12 McDonnell Douglas DC-10 23 2.71 Airbus A300 10 1.68 Lockheed L-1011 4 0.77 McDonnell Douglas MD-80/-90 13 0.39 Boeing 767 4 0.34 Boeing 757 5 0.34 British Aerospace BAe 146, RJ70/85/100 7 0.91 Airbus A310 6 1.60 Airbus A300-600 4 1.06 Boeing 737-300/-400/-500 18 0.36 Airbus A320/319/321 9 0.42 Fokker F100 5 0.75 Boeing 747-400 3 0.75 McDonnell Douglas MD-11 5 3.45 Canadair Regional Jets CRJ-700/-900 0 0.0* Airbus A340 0 0.0* Airbus A330 0 0.0 Boeing 777 0 0.0 Boeing 737-600/-700/-800/-900 0 0.0 Boeing 717 0 0.0* Fokker F70 0 0.0* Total Hull Losses 719 1.62
0 3 6 9 12 15 Hull-loss Accident Rate per Million Departures * These types have accumulated fewer than one million departures. ** The Comet, CV-880/-990, Caravelle, Concorde, Mercure, Trident and VG-10 are no longer in commercial service, and are combined in the “Not fl ying” bar.
Source: Boeing Commercial Airplanes
suffi cient departure data available) had fatalities. Among the phases of fl ight, the “in-fl ight collision or near-collision with lower hull-loss rates (an average of less highest percentage of fatalities occurred terrain, water or obstacle without indica- than one per million departures) than 11 in accidents during climb following re- tion of loss of control.” The second larg- earlier-generation types that remained in traction of the fl aps, a phase that com- est category was loss of control in fl ight commercial service (an average of three prised 14 percent of fl ight time. Accidents (LOC-I in the CAST-ICAO taxonomy), per million departures). during climb resulted in 28 percent of defined by CICTT as “loss of aircraft fatalities and 9 percent of accidents. control while in fl ight.” LOC-I was re- Data for hull-loss accidents and/or fatal sponsible for 2,524 fatalities (26 percent accidents by phase of fl ight for the 10- Fatal accidents in the 1987–2004 period of the total) and 36 fatal accidents (16 year period 1995–2004 (Figure 4, page were categorized according to a tax- percent of the total). 22) show that approach and landing onomy of causal factors devised by the accounted for 4 percent of typical fl ight U.S. Commercial Aviation Safety Team Other categories, ranked in descending time (“exposure” based on an assumed (CAST) and the International Civil order of on-board fatalities, were system/ fl ight duration of 1.5 hours); approach- Aviation Organization (ICAO) Common component failure or malfunction (non- and- landing accidents comprised 51 Taxonomy Team (CICTT; Figure 5, page powerplant), fi re/smoke (non-impact) percent of the total and resulted in 16 23).5 The largest number of on-board fa- and system/component failure or mal- percent of the fatalities. talities (3,631, or 38 percent of the total function (powerplant). of 9,541) and the largest number of fatal Takeoff and initial climb — 2 percent of accidents (56, or 25 percent of the total of For the first time in the 1983–2004 fl ight time — were the phases of fl ight for 226) were attributed to controlled fl ight period, no large commercial jet was 20 percent of accidents and 25 percent of into terrain (CFIT), defi ned by CICTT as subject to sabotage or terrorist acts,
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 21 S TATISTICS
Figure 4 Accidents and On-board Fatalities by Phase of Flight, Hull-loss and/or Fatal Accidents, Worldwide Commercial Jet Fleet, 1995 Through 2004 Percentage of Accidents and Fatalities 20% 51% Taxi, Load, Initial Climb Initial Final Parked Takeoff Climb (Flaps Up) Cruise Descent Approach approach Landing
Accidents 6% 14% 6% 9% 5% 2% 7% 6% 45%
Fatalities 0% 10% 15% 28% 10% 7% 14% 14% 2%
25% 16% Exposure = percentage of flight time based on flight duration of 1.5 hours Initial Final Approach Approach Fix Fix 1% 1% 14% 57% 11% 12% 3% 1%
Distribution of Accidents and Fatalities 100 87 2,000 1,550 80 1,500
Fatalities Fatalities 60 865 1,000 807 797 40 539 27 543 406 500 Fatal Accidents 17 Hull Loss and/or 20 12 11 10 13 11 3 4 102 0 0 Taxi, Load, Takeoff Initial Climb Cruise Descent Initial Final Landing Parked Climb Approach Approach
Hull Loss and/or Fatal Accidents On-board Fatalities
Source: Boeing Commercial Airplanes
categorized as hostile actions. It was the Ground operations comprised fi ve events were excluded because of the unavailability second successive year when there were in which an airplane was damaged while of operational data. no on-board fatalities caused by hostile taxiing, by striking another airplane, a 2. A hull-loss accident was defi ned as one actions; the last such act occurred May ground vehicle or a jetway; four events in resulting in “airplane damage that is 7, 2002, when a China Northern Airlines which an airplane was damaged by foreign substantial and is beyond economic repair. McDonnell Douglas MD-82 struck the object debris; one fatality caused by engine Hull loss also includes events in which the sea near Dalian, China, with 112 fatali- ingestion; and three events in which crew- airplane is missing; search for the wreck- ties, following a cabin fi re believed to be members or maintenance personnel fell. age has been terminated without it being located; [or the] airplane is substantially the result of arson. damaged and inaccessible.” Emergency evacuations resulted in minor Non-hostile events in 2004 (excluded injuries in three events. ■ 3. The publication, Statistical Summary from this article) were responsible for of Commercial Jet Airplane Accidents, Worldwide Operations, 1959–2004, injuries, aircraft damage and one fatality, Notes can be downloaded on the Internet at Boeing said. Severe turbulence resulted in
22 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 S TATISTICS
Figure 5 Fatalities by CAST/ICAO Taxonomy Accident Category, Fatal Accidents, Worldwide Commercial Jet Fleet, 1959 Through 2004 4,000 3,631 3,500
3,000
2,524 2,500
2,000
1,500
Number of On-board Fatalities 1,000 862 618 489 500 204 181 165 159 152 144 129 124 110 48 10 0 CFIT LOC-I SCF-NP F-NI SCF-PP RE OTHR ICE MAC USOS ARC UNK FUEL RI WSTRW ADRM LOC-G Accident Category Number of Fatal 56 36 12 10 15193 6 2 10 392 8 3 3 1 1 Accidents 266 TTotal
CAST = U.S. Commercial Aviation Safety Team ICAO = International Civil Aviation Organization Note: CAST/ICAO accident categories are as follows: ARC = abnormal runway contact; ADRM = aerodrome; CFIT = controlled fl ight into terrain or toward terrain; F-NI = fi re/smoke (non-impact); FUEL = fuel-related; ICE = icing; LOC-G = loss of control — ground; LOC-I = loss of control — in fl ight; MAC = midair/near-midair collision; OTHR = other; RE = runway excursion; RI = runway incursion; SCF-NP = system/component failure or malfunction (non-powerplant); SCF-PP = system/component failure or malfunction (powerplant); USOS = undershoot/overshoot; UNK = unknown or undetermined; WSTRW = wind shear or thunderstorm.
Source: Boeing Commercial Airplanes
Douglas DC-8; and Sud Aviation Caravelle. Second — 5. The U.S. Commercial Aviation Safety Team Boeing 727, British Aircraft Corp. BAC 1-11; Douglas (CAST), which includes regulatory officials DC-9; Boeing 737-100/-200; Fokker F28; Hawker and aviation industry representatives, and the Siddeley Trident; and Vickers VC-10. Early wide-body International Civil Aviation Organization (ICAO) — Airbus A300; Boeing 747-100/-200/-300/SP; chartered the CAST/ICAO Common Taxonomy Lockheed L-1011; and McDonnell Douglas DC-10. Team (CICTT). CICTT includes specialists from Current — Airbus A310, A300-600, A330, A340; British air carriers, aircraft manufacturers, engine Aerospace (BAe) 146, RJ-70/-85/-100; Boeing 757, 767, manufacturers, pilot unions, regulatory authori- 737-300/-400/-500/-600/-700/-800/-900, 717, 747-400, ties, accident investigation boards and other 777; Canadair Regional Jets CRJ-700/-900; Fokker F70, interested parties. The CICTT Internet site is F100; and McDonnell Douglas MD-80/-90, MD-11.
STATS
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 23 PUBLICATIONS RECEIVED AT FSF JERRY LEDERER AVIATION SAFETY LIBRARY
Ethics Is a Safety Issue
‘Data smoothing,’ ‘pencil whipping,’ ‘normalization of deviance’ — they’re all tempting shortcuts against which aviation personnel must take a principled stand in a safety culture.
—FSF LIBRARY STAFF
Books challenges can be categorized under three gen- eral headings: Safety Ethics: Cases from Aviation, Healthcare and Occupational and Environmental Health. • Data smoothing. Patankar describes this tech- Patankar, Manoj S.; Brown, Jeffrey P.; Treadwell, nique as “falsify[ing] data so that it is within Melinda D. Aldershot, England: Ashgate certain allowable limits. For example, when Publishing, 2005. 246 pp. Figures, tables, a mechanic torques a bolt to 20 inch-pounds appendix, index. when the manual clearly states that the torque should be 21–23 inch-pounds. The mechanic n their preface, the authors say that in studying limited his torque to 20 inch-pounds because Ithe industries that are their respective special- he could not physically torque it to the pre- ties, they discovered that day-to-day decision scribed range, or in a previous attempt when making involved ethical issues at the personal, he did torque it to the prescribed level, the organizational and public-policy levels. bolt sheared. Instead of reporting this prob- lem to the supervisor, he decided that it was Despite working in one of the most heavily regu- okay to under-torque the bolt.” lated industries in the world, where there seems to be a law, procedure or company policy that applies • Pencil whipping. “‘Pencil whipping’ is sign- to every situation, aviation professionals still face ing for a job that has not been performed,” ethical decisions — most related to “confl icting says Patankar. “In part, pencil whipping is an priorities such as safety versus economic survival unintentional snowballing of a longstanding or speed versus accuracy,” says Patankar, author industry norm. … However, acute resource of the introduction and the three chapters about limitations and poor organizational safety ethics in aviation. “In general, the industry pro- culture have led to severe cases of pencil whip- vides the safest mode of transportation, but it is ping, wherein multiple job/task cards have plagued by the ferocious need to survive in the been falsely and intentionally signed off as face of harsh economic pressures.” complete. Such large-scale or routine pencil whipping takes place mainly due to lack of In his chapter, “Ethical Challenges in Aviation resources. In a desperate need to keep the air- Maintenance,” Patankar says that the ethical planes flying on schedule while fighting the
24 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 R ESOURCES
gruesome fare wars, managers are forced to “In general, the practice of ethical behavior seems ‘accomplish’ maintenance checks in a fraction to be associated with the notion of trust building,” of the required time and also with a fraction says Patankar. “Alaska Airlines, for example, goes to of the human resources and parts required to great lengths to emphasize the importance of ethi- accomplish such checks in accordance with cal behavior throughout their organization and the manufacturer’s recommendations.” presents such conduct as imperative to the survival of the individual as well as the organization.” • Not knowing when to act. Patankar says, “Procedural violations in aviation maintenance Group Interaction in High Risk Environments. are inevitable because (a) there are just too many Dietrich, Rainer; Childress, Traci Michelle procedures, (b) maintenance procedures are (editors). Aldershot, England: Ashgate part of federal regulations, (c) it is practically Publishing, 2004. 299 pp. Figures, tables, impossible for management or the FAA to en- appendixes, bibliography, index. sure consistent compliance [and] (d) increased emphasis on on-time performance rather than he book is the product of an interdisciplin- safety has encouraged shortcuts. So, procedural Tary project, Group Interaction in High Risk violations occur on the part of all parties: me- Environments (GIHRE), underwritten by the chanics, managers, stores personnel, planners, Gottlieb Daimler and Karl Benz Foundation. utility personnel [and] ramp agents.” Its purpose was to investigate group behavior in four representative workplaces, including the fl ight Patankar credits another researcher, Diane Vaughan, deck of a commercial airliner. with coining the term normalization of deviance to describe a gradual drift from published procedures “The general scientifi c aim [was] to describe the or required procedures that is reinforced each time interrelation between conditions of high task load a slight deviation creates no immediate negative and threat, as well as team members’ behavior in consequence. It then becomes a baseline for further such situations,” say the editors. deviations that in turn become norms. The availability of a large body of cockpit voice “Many mechanics tend to complain about a drastic recorder (CVR) transcripts from simulator ses- deterioration of safety ethics — everything seems sions and accident investigation reports provides to be focused on survival, trying to make the com- raw material to researchers for the many types of pany last for one more quarter or fi scal year,” says analysis described in the book. Patankar. Robert L. Helmreich and J. Bryan Sexton discuss Nevertheless, despite the pressure that some say the use of problem-solving communications on they work under, the maintenance technicians the flight deck. Problem-solving communica- interviewed by the author were adamant in as- tions, described as “task-related communica- serting that they maintain the ethical standards tions regarding the management of threats and of their profession. errors during a fl ight,” include such sentences as the following: In another chapter that discusses the ethical • “And if we execute a missed approach, we have responsibilities of aviation educators, regulators two procedures we could follow”; and organizations, Patankar notes that regula- tory authorities, trade unions and pilot unions • “I don’t want to dump any fuel, in case we have professional codes of conduct that they take might need it”; and, seriously. And he notes that airline management’s steps to transform a “blame” culture into a “re- • “Got a little bit of crosswind, not much, 240 porting” culture through programs such as the at eight I believe he said.” U.S. industry’s Aviation Safety Action Program (ASAP) have helped labor, management and The researchers say, “Problem-solving communi- regulators work together so that they can all be cations are a prime example of what distinguishes “in the picture” rather than engage in an adver- superior [performance] from substandard perfor- sarial situation. mance. For example, captains of high-performing
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 25 R ESOURCES
crews used problem-solving utterances seven to when fumes are present, since it may spread the eight times more often than their low-performing spillage or increase the rate of fuming.” counterparts. Furthermore, there were no differ- ences in how high-performing captains used prob- Both basic and expanded checklists are included lem-solving utterances as a function of workload. for fl ight crewmembers and cabin crewmembers High-performing captains consistently devoted a to consult in dangerous-goods incidents. The main third of their utterances to problem solving, part of the document is a chart of 11 emergency- whether it was a routine or an abnormal fl ight. response drills, describing the source of risk each In fact, the more frequent use of problem-solving is designed for, the nature of the risk (e.g., “high utterances was not unique to outstanding captains fi re risk if any ignition source [is] present”), the — outstanding fi rst offi cers and second offi cers spill or leak procedure and the fi re-fi ghting pro- used problem-solving utterances in approximately cedure. Each dangerous-goods item number lists one-third of their overall communications.” the correct drill to perform in response.
In another chapter, Manfred Krifka discusses re- Relationship of the Aircraft Mix Index search about familiarity among crewmembers. With Performance and Objective Workload Evaluation Research Measures and Controllers’ “Members of crews can be rather familiar with Subjective Complexity Ratings. U.S. Federal each other (as, typically, doctors and nurses in a Aviation Administration (FAA) Offi ce of hospital or operators in a power plant are), or they Aerospace Medicine. DOT/FAA/AM-05/16. Final might be working together for the fi rst time, as is report. August 2005. Pfl eiderer, Elaine M. 16 pp. often the case with pilots in big airlines,” the author Tables, references, appendixes. Available via the says. “Familiarity among crewmembers is advan- Internet at
26 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 R ESOURCES the results might not be generally applicable. It he NRP is a joint FAA and Nav Canada suggested that the aircraft mix’s contribution to Tprogram, whose objective is to harmonize and complexity might be mis-attributed by control- adopt common procedures, to the extent possible, lers, or that it might be a relevant factor in only a applicable to random-route fl ight operations at few sectors, but that in those sectors it might be a and above Flight Level 290 (about 29,000 feet) major contributor to complexity. within the United States and Canada. The program allows aircraft operators to select operationally Regulatory Materials advantageous routings, based on factors such as minimum time, cost, fuel, weather avoidance and aircraft limitation. Occupational Health and Safety On-board Aircraft: Guidance on Good Practice. U.K. This AC describes the approved procedures for fl ight Civil Aviation Authority (CAA). Civil Aviation operation according to the NRP. Aircraft participat- Publication (CAP) 757. August 2005. 22 pp. ing in the NRP remain limited to a route that can References. Available on the Internet at be fl own in accordance with the communication
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 27 ACCIDENT/INCIDENT BRIEFS
Flight Crews Cleared for Near-simultaneous Takeoffs From Intersecting Runways
A preliminary report from the U.S. National Transportation Safety Board quotes the first officer as saying that the captain delayed rotation of their Boeing 737 as an Airbus A330 passed overhead with ‘very little separation.’
— FSF EDITORIAL STAFF
he following information provides an “The copilot of [the B-737] reported that he had
awareness of problems through which called ‘V1’ [critical engine failure speed] and then such occurrences may be prevented in noticed the [Airbus] rotating just prior to the in- Tthe future. Accident/incident briefs are tersection of [Runway] 15R and [Runway] 9,” the based on preliminary information from govern- report said. “He told the captain to ‘keep it down’ ment agencies, aviation organizations, press infor- and pushed the control column forward. mation and other sources. This information may not be entirely accurate. “He further stated, ‘The Airbus passed overhead our aircraft with very little separation, and once clear of the intersection, the captain rotated, and Clearances Issued by we lifted off toward the end of the runway. I re- ported to departure control that we had a near Two Controllers miss, at which time [a fl ight crewmember in the Airbus A330. No damage. No injuries, Airbus] reported, ‘We concur.’” Boeing 737. No damage. No injuries. AIR CARRIER
aytime visual meteorological conditions Landing Airplane Dprevailed at an airport in the United States Departs Runway After when two controllers in the airport’s air traffi c Uncommanded Turn control tower cleared the crews of two airplanes for departure from intersecting runways. Boeing 737. No damage. No injuries.
At 1939:10 local time, one controller cleared the aytime meteorological conditions prevailed Airbus crew for takeoff on Runway 15R for a fl ight Dfor the landing at an airport in Sweden. After to Ireland; fi ve seconds later, the other controller the airspeed decreased to about 60 knots and the cleared the Boeing crew for takeoff from Runway captain took control of the airplane to taxi to the 9 for a domestic fl ight. terminal, the airplane yawed right. The captain
28 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 A CCIDENTS/INCIDENTS used nosewheel steering, rudder and differential After the incident, the ground-handling agent braking but was unable to steer the airplane back “issued a notice to its entire staff about the use of onto the runway centerline. the ‘stop’ button,” the report said.
The airplane departed the runway to the right. The crew shut down the airplane, and passengers deplaned using the stairs. Crew Incorrectly Identifi ed ‘Rapid-exit’ Taxiway The report said that the incident occurred “be- Bombardier Dash 8 Q400. Minor damage. cause the design of the nosewheel steering on this No injuries. aircraft type permits a spontaneous turn without operation by the pilots. A contributory factor is aytime visual meteorological condi- that the aircraft manufacturer considers the mal- Dtions prevailed for the domestic fl ight in function to be acceptable if the failure rate is lower Denmark — the last of fi ve fl ights for the fl ight AIR TAXI/COMMUTER than [one per 100,000 fl ights].” crew that day — and the landing runway and taxiways at the destination airport were wet. The captain fl ew the airplane on an instrument Airplane Strikes landing system (ILS) approach; when the airplane Passenger Steps crossed the runway threshold at 50 feet, the indi- Boeing 767-200. Minor damage. cated airspeed was 134 knots, or 13 knots higher No injuries. than recommended. The airplane touched down at an indicated airspeed of 131 knots, or 10 knots fter a flight from Russia to England, the higher than recommended. Afl ight crew was told to taxi the airplane to Stand [Gate] 32M, one of three parking positions “Just before vacating Runway 22L, the fl ight crew available at Stand 32. Before the airplane’s arrival, was not sure that the present speed versus the motorized passenger steps were positioned left of remaining distance to Taxiway B5 was appropri- Stand 32, with adequate clearance for the aircraft ate for vacating the runway,” the report said. “At to be taxied to Stand 32M, and parking aids were that time, it was the opinion of the fl ight crew put in place. that Taxiway B5 was a rapid-exit taxiway. The commander [captain] initiated the turnoff at As the airplane was taxied to the area, the crew Taxiway B5.” turned toward Stand 32L, instead of Stand 32M. Ground personnel, believing that the parking aids The airplane’s groundspeed when being turned had been positioned incorrectly, then moved the off the runway was about 60 knots. On the taxi- aids from Stand 32M to Stand 32L. way, the captain selected full reverse thrust on the left engine and partial reverse thrust on the The incident report said, “With the aircraft now right engine. The airplane departed the side of approaching Stand 32L, the aircraft’s left wing was the taxiway at a groundspeed of 34 knots and overhanging the inter-stand clearway on which the traveled about 26 meters (85 feet) across soft motorized steps were parked. The driver of the grass before stopping. Passengers remained in steps realized that the aircraft was approaching their seats until a bus arrived to transport them the wrong stand; he moved away from the steps to the terminal. and attempted to … attract the pilot’s attention, without success.” An investigation found that the “design and the presentation of Taxiway B5 in the operator’s OM The leading edge of the left wing struck the hand- [operations manual] … might lead fl ight crews to rail of the motorized passenger steps. think that Taxiway B5 is a rapid-exit taxiway,” the accident report said. “The Danish AIB [Accident The report said that during the incident, ground Investigation Board] believes that commuter air- personnel failed to activate a “stop” button craft often vacate [the runway] at Taxiway 5B … that would have told the fl ight crew to stop the and that commuter fl ight crews consider Taxiway airplane. B5 to be a rapid-exit taxiway.”
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 29 A CCIDENTS/INCIDENTS
The OM did not discuss taxi speed limitations but correct part was being installed. A rigging check said that aircraft should not turn from a slippery was not completed, which likely would have estab- runway “until the speed was reduced to a safe lished that the roller was undersized.” level,” the report said. “The Danish AIB does not fi nd a fi nal turnoff speed of 60 knots safe.”
The report said that the crew’s opinion that the Pilot Reports No Braking taxiway was a rapid-exit taxiway, “combined with Action Before Runway Overrun a decision making based on standard routines [in- Cessna 525 CitationJet. Substantial stead of considering all operational parameters, damage. One minor injury. such as the wet runway, high touchdown speed and calm wind] and a high turnoff taxi speed most he pilot was fl ying the airplane in daytime likely caused the aircraft to run off the taxiway.” Tvisual meteorological conditions on a busi- ness fl ight in the United States. As he conducted
The report also said that fatigue “might have in- a visual approach, clouds formed over the airport CORPORATE/BUSINESS fl uenced” the captain’s decision making. in association with a thunderstorm about 1.0 stat- ute mile (1.6 kilometers) to 2.0 statute miles (3.2 kilometers) north of the airport. The pilot told Incorrect Part Cited in air traffi c control that he was conducting a missed Landing-gear Collapse approach and requested a global positioning sys- Fairchild SA227-AC Metro III. tem (GPS) approach to Runway 24. Minor damage. Three minor injuries. After the approach, he landed the airplane “on t the end of a scheduled domestic fl ight in the numbers,” extended the fl aps and applied full ACanada, the fl ight crew completed the ap- wheel brakes. The pilot said that braking action proach and landing checklists and confi rmed the was “nil” and that he “could feel no braking at all.” landing-gear-down indication. They landed the air- About one-third of the way along the runway, he plane in a crosswind, with touchdown about 1,000 attempted to reject the landing, but “the airplane feet (305 meters) beyond the runway threshold. did not accelerate as he expected,” a preliminary accident report said. As the airplane touched down, the left wing lowered and the propeller struck the runway. The airplane The airplane rolled off the departure end of the veered left, despite the crew’s use of full right rudder runway and struck a fence. and full right aileron. The crew applied maximum right wheel braking and shut down the engines as Weather conditions at the time of the accident the airplane departed the runway and continued included winds from 160 degrees at 11 knots with about 300 feet (92 meters) into a nearby grassy area. gusts to 14 knots. The nose landing gear and the right main landing gear were “torn rearwards,” and the left main land- ing gear collapsed into the wheel well. Turbulence Cited in Landing Accident An investigation found that an incorrect roller, “of Piper PA-46-500TP Malibu Meridian. a smaller diameter and type,” had been installed Substantial damage. No injuries. on the left main landing gear bell-crank assembly, the report said. aytime visual meteorological conditions pre- Dvailed for the landing of the business fl ight The maintenance technician (aviation mainte- at an airport in the United States. The pilot was nance engineer [AME]) believed that the roller conducting a fi nal approach to land when, because had been “re-designed to alleviate roller breakage,” of turbulence, he initiated a go-around. the report said. In addition, “the AME did not fol- low established industry [practices] or company During the second approach, the pilot again en- practices in checking the part number against the countered turbulence. A loss of control occurred, manufacturer’s parts manual to ensure that the and the airplane departed the runway to the right.
30 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 A CCIDENTS/INCIDENTS
Both main landing gear collapsed, and the propel- After completion of the pass, as the fi rst offi cer ler struck the runway. attempted to return the airplane to straight-and- level fl ight, he encountered “a strong resistance” to aileron control inputs, the accident report said. As the fi rst offi cer and the captain worked to resolve Airframe Parachute System the problem, they found that excessive force was Credited With Averting required to maintain the airplane in straight fl ight. Fatal Accident They fl ew the airplane to 1,000 feet, where they Cirrus Design SR20. Substantial damage. found that turns to the right required normal con- No injuries. trol force, but returning the airplane to a wings- level attitude required “excessive effort when the ighttime visual meteorological conditions control yoke was some three degrees to fi ve degrees Nprevailed for the fl ight in Canada. The pilot left of the central position,” the report said. was fl ying the airplane through 8,800 feet when it veered left; the pilot corrected the heading and The captain took control of the airplane, declared OTHER GENERAL AVIATION continued the climb. pan-pan, an urgent condition, and landed the air- plane at a nearby airport. About 45 seconds later, the airplane again veered left, and the pilot corrected the heading. Three min- “The control diffi culties continued during the utes later, after the pilot leveled the airplane at 9,500 approach, with corrections to the left requiring feet, the airplane rolled 90 degrees left. The pilot considerable effort,” the report said. disconnected the autopilot as the airplane entered a spiral dive. The pilot was unable to recover the After the landing, the pilots encountered the same airplane from the dive, so he shut down the engine resistance on the controls until the fi rst offi cer felt and deployed the airframe parachute system. The “a jolt, and the control restriction disappeared,” the airplane descended to a steep mountainside; the report said. pilot and three passengers were rescued the next morning by personnel in a military helicopter. The crew suggested that a small object might have restricted movement of a related bell crank, lever An investigation revealed that the airplane had or cable quadrant. No such object was found, been overweight during departure on a previous however. leg of the fl ight and for part of the occurrence leg and was “being operated outside of the envelope An investigation revealed that all four aileron attach- established by the manufacturer’s fl ight testing,” ment bearings were “stiff in operation,” and that the the report said. Investigators did not determine race bearings were corroded, but there was no indi- what caused the 90-degree roll. cation that the race bearings had seized or that their condition was responsible for the control restriction. The report said that the airframe parachute system Nevertheless, the manufacturer planned to issue a probably prevented fatal injuries. service bulletin for periodic inspections of aileron bearings and rudder bearings, the report said.
Pilots Encounter Aileron Landing Gear Fails Control Resistance After Repairs for Previous During Flight Wheels-up Landing Reims F 406. No damage. No injuries. Glasair RG. Substantial damage. No injuries. aytime visual meteorological conditions pre- Dvailed for the fi sheries patrol fl ight off the he owner-pilot was conducting an an- coast of Scotland in the North Sea. As the airplane Tnual permit-renewal fl ight test following the was fl own over a fi shing vessel at 200 feet, the fi rst completion of repairs after a wheels-up landing offi cer banked the airplane 30 degrees left to allow seven months earlier. An inspector had signed off another crewmember to take photographs. the airplane as fi t to fl y.
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • OCTOBER 2005 31 A CCIDENTS/INCIDENTS
After takeoff from an airport in England, the pilot the helicopter toward a tower, which was atop a observed that the nose landing gear indicator light ridge, and planned — because of the high tem- was green, indicating that the nose landing gear perature and high density altitude — to begin a was still extended. Observers on the ground said fi nal approach in ground effect. in radio transmissions that the landing gear ap- peared to be fully retracted and offered to take a As he turned the helicopter right, the main- closer look if the pilot conducted a low pass over rotor revolutions per minute (rpm) decreased, the airport. and an audio warning sounded. The rate of descent increased during the turn. The pilot “He accepted,” the final accident report said. realized that there was insufficient altitude “However, on the downwind leg, before doing to complete the turn into the wind; he leveled the fl y-by, the pilot decided to recycle the landing the rotors before touchdown. The main-rotor gear down and then up to see if the fault would blades struck the tail boom during the hard clear. On doing so, the nose gear remained green landing. throughout and both main landing gear func- tioned correctly. The report said that the probable cause of the accident was that “the pilot attempted a landing “The pilot then decided that there was little point in mountainous terrain, [and] while maneuver- in doing the fl y-by, so he selected the landing gear ing the aircraft to land into wind, he allowed the down and, on obtaining three greens, said that he main-rotor rpm to decay. He was unable to recover was returning to land. As he had indications of from the condition due to limited height being the landing gear being down, he did not use the available, aggravated by rocky terrain, resulting emergency lowering system.” in a hard landing and the main rotor contacting the tail boom.” Observers on the ground twice said that the landing gear appeared to be extended. After a normal approach, the airplane touched down on Helicopter Strikes Terrain the main landing gear. The nose descended until the propeller struck the runway, and the airplane After ‘Uncontrollable’ Yaw slid to a stop. Eurocopter AS 350B2. Substantial damage. One serious injury, one An inspection found that the nosewheel “failed to minor injury. make its geometric lock due to the undercarriage pump motor locking out early when the nose- aytime visual meteorological conditions wheel [indicator light] indicated green and had Dprevailed for the law enforcement fl ight thus folded up under the aircraft.” in a mountainous region of the United States. The pilot and passenger were conducting an The report said that there was no explanation aerial search when the pilot fl ew a descent into of why the indicator light remained green after the search area and began a shallow right turn, the landing-gear lever was moved to the up which placed the helicopter in a downwind posi- position. tion. The helicopter rotated fi ve or six times to the left and struck the ground at an elevation of ROTORCRAFT 4,900 feet above mean sea level. Hard Landing Follows The pilot said that he had encountered an “un- Approach in Ground Effect controllable left yaw.” Robinson R44 Raven II. Minor damage. No injuries. Other law enforcement personnel said that winds at the time of the accident were from the south- aytime visual meteorological conditions west at 14 knots to 20 knots with higher gusts. Dprevailed for the fl ight in South Africa to The temperature was 86 degrees Fahrenheit (30 inspect cellular-telephone towers. The pilot fl ew degrees Celsius). ■
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