A Report to Congress from the United Chapter of the Air Line Pilots Association (ALPA)

Inadequate Pilot Training and Compromised Safety by United Airlines Within the Process of Merging the Continental and United Airlines’ FAA Operating Certificates into a Merged Single Operating Certificate (SOC)

Updated November 10, 2011 SUMMARY

The United pilots are deeply concerned about inadequate pilot training and the compromise in safety brought about as a result of the merger between legacy United Airlines and legacy Continental Airlines, as the airline seeks a Single Operating Certificate (SOC) from the FAA. The adoption of harmonized aircraft operation procedures must occur when two large and complex airlines such as United and Continental merge. It is important to note that on the fleets of concern, the B757/767 and B777, that legacy United pilots are adopting 80 percent of the changes in procedures. The new management of United Airlines has chosen to train pilots on this large volume of flight related procedures through computer-based training (CBT). This training is broken down into four phases; Phase 1, Phase 2, Phase 3A/3B and Phase 4. Historically, such a large volume of procedural changes, some of which are quite complex, would have required practice in a learning environment such as a simulator or classroom that allow for peer review and discussion. Computer- based training is acceptable for introduction or review, but unacceptable for cognitive absorption and development of the muscle memory required to produce practiced and proficient performance. United’s CBT via the internet has caused confusion and distractions, and pilots are now conducting on-the-job training on revenue flights with passengers aboard rather than in a simulator or classroom environment. This is akin to two surgeons watching a new surgical procedure power point and then practicing it together on an unsuspecting patient. United ALPA, representing the legacy United pilots, has appealed to all levels of United management and the FAA to resolve this issue, but to no avail.

We, the pilots of United Airlines, are perplexed by the FAA’s process in accepting and approving what we deem to be inadequate training. The FAA typically requires a complete indoctrination course for pilots learning to operate airliners using procedures under a new FAA operating certificate, as is the case for legacy United B757/767 and B777 pilots. It also seems illogical that the FAA would assign an official who was recommended for suspension to approve the transition plan, integration and issuance of a Single Operating Certificate (SOC) for combining two airlines that will form the world’s largest airline, United Airlines. Less than three years ago, the same FAA Administration recommended Bobby Hedlund, the head of the UAL/CAL Joint Transition Team, for suspension for dereliction of duty in allowing Southwest Airlines to fly hundreds of flights with aircraft in an unsafe condition.1 Congress and its Committee on Transportation and Infrastructure held hearings on the Southwest situation, during which this FAA official’s misconduct was brought to light.2 United Airlines proved incapable of completing even the truncated portion of the already deficient SOC transition plan and were subsequently allowed, by this same official, to modify and further reduce the required portion of the operational integration. This approval will result in an operation in which only half of the flight procedures for the

1 Reukauf, William E., Associate Special Counsel ltr. to President of the United States dtd. 3/18/10 re. OSC File No. DI-08-1750. 2 http://www.youtube.com/watch?v=xmkYzwzKxgI&feature=email

[i] common fleets, few of the procedures of the other fleets and almost none of the maintenance procedures will be integrated prior to United Airlines receiving a SOC from the FAA. The training program for the new procedures for the first half of the flight through the cruise portion has yet to be developed for the B757/767 and B777 fleets.

Why the rush to SOC? For United management it would seem that executives’ personal compensation, in the form of poorly designed financial incentives, compromises safety. Why would the FAA not protect the interests of the flying public against such a conflict of interest? And why would the FAA appoint an inspector, known to have been previously deficient in his safety oversight of Southwest Airlines, oversee such critically important certificate integration? Why would these same officials, including United’s Principal Operations Inspector (POI), dismiss United ALPA’s safety concerns, which include this rush to SOC, the inadequacy of training and a number of other ongoing and disturbing safety concerns (Exhibits A & A2)

United ALPA has tried to bring the deficiency of the SOC training to the attention of the new United management; every level of the FAA (Exhibits B-E), including the Administrator himself; the federal courts; and now Congress. Everyone is hiding behind the FAA. A number of stakeholders, including the public and their representatives in Congress, have been working under the assumption that the FAA is the top cop on the airline beat and ensures the highest levels of safety. We have found during UAL’s rush to receive an SOC that the FAA often isn’t effective or even methodical in its monitoring of airlines’ self- regulation due to limitations in the data it receives or chooses to analyze. The FAA is at best a weak safety monitor and at worst compliant and compromised when working with airline managers whose goals are cost-cutting at the expense of safety and for their own personal benefit.

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TABLE OF CONTENTS

1. History of a strong collaborative management/ALPA culture with regard to flight training and safety at legacy United Airlines, p.1

2. Former Continental managers who control the merged United Flight Operations do not value or collaborate with ALPA and their safety and training subject matter experts (SMEs), p.1

3. New United management has failed to properly plan, manage and train B757/767 and B777 pilots during the first two phases of the SOC process, p. 3

4. FAA oversight of United’s SOC process has been wholly inadequate, p.9

5. Pilot reports show great reason for concern, p.13

6. ALPA’s attempted TRO against United Airlines, p.15

7. Actions necessary to correct training and SOC deficiencies, p.16

Addendum:

Exhibit A: Letter from UNITED ALPA to FAA Administrator Babbitt, 9/1/11, p. 18 Exhibit A2: Letter from UNITED ALPA to FAA Administrator Babbitt re. Aircraft Magnetic Reference Data, 9/6/11, p. 39 Exhibit B: Letter from UNITED ALPA to FAA POI John Martin, 9/2/11, p. 45 Exhibit C: Letter from FAA Asst. Director Gilligan to UNITED ALPA, 9/8/11, p. 47 Exhibit D: Letter from FAA POI Martin to UNITED ALPA, 9/27/11, p. 49 Exhibit E: Letter from UNITED ALPA to FAA Administrator Babbitt, 10/14/11, p. 52 Exhibit F: Exhibit F: Letter from FAA POI Martin to UAL VP Corporate Safety Quiello, 9/12/2011, p.65 Exhibit G: Letter from Associate Special Counsel William E. Reukauf to the President of the United States, 3/18/2010, p.67 Exhibit H: Resignation Letter from Line Check Airman (LCA), 8.26.2011, p. 70 Exhibit I: Resignation Letter from Line Check Airman (LCA), p. 75 Exhibit J: Partial Chronology of United ALPA/FAA Communications, p.76 References:

Evolution of Crew Resource Management Training in Commercial Aviation, p. 77 United Airlines Flight 173 Accident Narrative, p. 88 Safety Management System (SMS) Explained, p. 91 2010 UAL Proxy statement, 4/22/11 (excerpted), p. 92 House Transportation and Infrastructure Committee hearing on 6/16/10 (excerpted), p. 94 UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK- ALPA v. UNITED AIRLINES, p. 95

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Glossary

ALPA Air Line Pilots Association is the largest airline pilot union in the world and represents more than 53,000 pilots at 37 U.S. and Canadian airlines. ATP Airline Transport Pilot is the highest level of aircraft pilot rating/certificate. CAR Corrective Action Request is a formal request to an airline and the FAA to fix serious threats to safety identified in FSAP or other reports. CBA Collective Bargaining Agreement is a labor contract. CBT Computer-based Training is internet-based audio-visual slide show best suited for introductory or cursory pilot training or review. CMO Certificate Management Office is responsible for the certification, surveillance, and inspection of major air carriers and their Training Centers. FAA Federal Aviation Administration is the national aviation authority of the United States. FAR Federal Air Regulations are rules prescribed by the FAA governing all aviation activities in the United States. FBS Fixed-based Simulator is a device that duplicates relevant aspects of the aircraft and the cockpit environment, but is immobile. FMS Full-motion Simulator is a high-fidelity training device that duplicates relevant aspects of the aircraft and its cockpit environment, including motion simulation. FOQA Flight Operations Quality Assurance is a method of capturing, analyzing and/or visualizing the data generated by an aircraft. Applying the information learned from this analysis helps to find new ways to improve flight safety and increase overall operational efficiency. FSAP Flight Safety Awareness Program is a reporting system designed to identify and resolve flight safety concerns. JTT Joint Transition Team is the FAA group responsible for approving a SOC transition plan and integration. LOSA Line-oriented Safety Audit utilizes observers riding in cockpit jump seats to evaluate several aspects of crew performance. LCA Line Check Airman is a pilot who is qualified, and permitted, to conduct flight checks or instruction in the airplane. MEC Master Executive Council is the governing body for an ALPA represented pilot group. PDR Pilot Data Report is a United ALPA system for reporting operations, training and safety problems to the union’s leadership and committee structure. PC Proficiency Check is a periodic evaluation for pilots in a flight simulator. PMG Pilot Merger Guide is a brochure that provides an overview of the flight operations changes for a particular SOC integration phase. POI Principal Operations Inspector is the FAA’s primary operations interface between assigned air carriers, air operators, air agencies, airmen, and designees. Has program responsibility to assure that assigned organizations meet Federal Aviation Regulations with respect to operations programs. PT Proficiency Training a periodic simulator-training event for pilots

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QRH Quick Reference Handbook is a manual easily accessible in flight delineating procedures for managing non-normal and emergency procedures. SOP Standard Operating Procedures include all the procedures for operating an aircraft in a safe and standardized manner. SMS Safety Management System is the formal approach to managing safety risk, which includes a systemic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. SOC Single Operating Certificate is the FAA operating certificate for the merged and integrated operations of more than one airline. UAP United as Professionals is a class designed by United Flight Operations to attempt to address the change presented by the merger ULN United Learning Network is an online site containing a variety of operational training material for United personnel.

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1. History of a strong collaborative management/ALPA culture with regard to flight training and safety at legacy United Airlines

Legacy United Airlines management and the United Master Executive Council of the Air Line Pilots Association (United ALPA) collaborated to initiate the first comprehensive Crew Resource Management (CRM) in 1981.[1] The impetus for United and ALPA’s CRM collaboration was the crash of UAL Flight 173 in which the DC-8 ran out of fuel while the crew fixated on a relatively minor landing gear malfunction. CRM is a time-critical decision- making methodology and interpersonal communication training program that is considered to be one of, if not the most important safety innovation in the last 50 years. CRM has been so effective in reducing errors and saving lives in commercial aviation that the FAA has adopted its principles in its Safety Management System (SMS), a new program that is being implemented throughout the industry. CRM has also been adapted for use in myriad fields, including the U.S. medical community to combat the 100,000 preventable patient mortalities each year.

Since the mid-1980s United Airlines has had a history of sometimes-acrimonious relationships with its labor groups in terms of contracts. Despite this, all previous management teams have understood and valued the safety and training expertise, independence and advocacy that ALPA brought to the enterprise. This created a safety culture widely regarded by the industry, NTSB, FAA and the traveling public as superior. The United Master Executive Council of ALPA has a safety and training committee structure with more than 100 members who each contribute a wealth of expertise, experience and continual mentoring. These safety advocates have roots in the U.S. military, other airlines, governmental organizations, the legal field and from within management at United Airlines. United Airlines has not had a single pilot-caused fatality in nearly 33 years (since 1978). Professional safety experts and advocates agree that this is due in large part to the involvement of the Air Line Pilots Association.

2. Former Continental managers who control the merged United Flight Operations do not value or collaborate with ALPA and their safety and training subject matter experts (SMEs)

It is obvious and unfortunate that the new United Airlines management, primarily composed of senior Continental executives and Continental flight operations managers, are trying to dismantle the equal partner approach to safety, an approach that has resulted in a collaborative safety culture at United. Contrary to their words, these managers demonstrate by their actions their intent to stifle ALPA’s safety advocacy. These cavalier and potentially dangerous actions are in direct contradiction to the underpinnings of CRM (Cockpit Resource Management) and SMS (Safety Management Systems). CRM and SMS

[1] University of Texas at Austin Human Factors Research Project: 235 Helmreich, R.L., Merritt, A.C., & Wilhelm, J.A. (1999). The evolution of Crew Resource Management training in commercial aviation. International Journal of Aviation Psychology, p. 2.

[1] depend on partnership and a willingness of all parties to identify threats to the operation and appropriately manage those threats. Integral to these safety management systems is the precept that dismissing individuals or safety partners (such as ALPA) can be disastrous. There is no virtue more important to a United pilot than a culture that ensures the safety of the traveling public through well-established and proven training methods. The Air Line Pilots Association at United has been raising its hand emphatically in an attempt to bring attention to a proven collaborative safety culture that is currently under siege in direct contradiction to the new United Airlines’ SMS philosophy stated as follows in its FAA approved Flight Operations Manual.

"Under the SMS program, each employee is responsible for safety and should support an informed, reporting, and learning culture at our airline. SMS empowers the employee to be the Company's frontline, safety resource by reporting threats in a non-punitive environment. Existing safety programs such as the Flight Safety Investigations, FOQA, FSAP/ASAP, and LOSA work in concert with a comprehensive threat reporting system, and are the building blocks of an effective SMS. This combination of reactive, proactive and predictive safety programs provides a layered approach to identifying current or predicted issues which carry risk to our operation, and provides the data needed to put into place litigations which are tracked and modified as needed to ensure risk is effectively managed."

Why would the “new” United managers act in such a counterproductive and shortsighted fashion?

ALPA was removed from the property at Continental Airlines under Frank Lorenzo (who subsequently was denied an air carrier certificate by the FAA) after the pilots’ failed strike in 1983. Pilots who supported ALPA were purged from the flight operations management ranks, and the Association was not voted back onto the property until 2001. As a result, Continental Airlines lacked a strong counter-balancing advocate for safety and management developed a far different view of how to interact with ALPA upon its return. Continental Flight Operations managers operate with a top-down, dictatorial management style, and they do not value ALPA’s contributions or expertise regarding safety and pilot training. Immediately following the merger with United, a Continental VP in the Human Resources department stated that Continental’s view of unions is that they are there to negotiate a contract and then go away until next time. This philosophy is antithetical to the whole philosophy of CRM, SMS and running an effective airline safety program.

Some from management have cast these philosophical differences as merely differences of opinion. ALPA has repeatedly attempted to bring documented, concrete “red flags” to the attention of the new United Flight Operations management. Such concerns are rooted in hundreds of pilot reports, concerns of FAA-designated Line Check Airmen (Exhibit H & I), who are United pilots authorized by FAA to conduct checking and training of other United pilots, and of course ALPA’s safety experts. The managers repeatedly dismiss virtually all of these concerns while charging full steam ahead toward a Single Operating Certificate. One of the fundamental differences between the Association and the new management is the level of risk that the two parties find acceptable as a result of the [2] enormous and complex changes in operating procedures. The Company contends that it has completed all the necessary risk assessments. Yet, what have been shown to both the FAA and the Association are at best superficial summaries. Requests from the Association for the complete risk assessments and the underlying data have been met with resistance or have simply gone unanswered.

3. New United management has failed to properly plan, manage and train B757/767 and B777 pilots during the first two phases of the SOC process

United Airlines and Continental Airlines announced their intention to merge the airlines on May 3, 2010. Later that year, United Airlines submitted a Transition Plan that was required to be in compliance and accordance with FAR 8900 guidance to the FAA’s Joint Transition Team (JTT). This FAA team for overseeing the UAL/CAL merger is being led by Inspector Bobby Hedlund. According to Mr. Hedlund, the company submitted its plan and, under his direction, the JTT approved it with few if any substantial changes. This plan included giving UAL an FAA SOC upon demonstrating that UAL could manage the first three of four phases of the integration. These three phases included the integration and melding of Continental and United flight operations procedures of their common fleets, the B757/767 and the B777. United management set an internal goal of receiving the SOC on or about 11/11/11. It should be noted that United CEO Jeff Smisek stands to receive up to $4M in contractual incentives for “achieving integration goals,” according to the 2010 UAL proxy statement[2] and senior management would have certain restricted stock units (RSUs) vest under similar circumstances. While incentives for achievement are generally positive, United has incentivized expediency over the careful and conservative planning and execution necessary in bringing about the massive and complex changes required by this operational integration.

The integration of the Continental and United operations will create the world’s largest airline and will set the standard for airline safety and training in the United States, if not the world. Unfortunately, the former Continental flight managers who control the new United management opted to dismantle much of the progress and the safety culture that the United pilots produced. 80 percent of all changes fall on the legacy United pilots. These changes are often complex and, in our opinion, require more sophisticated methodologies of training than sitting at a computer and viewing a slide show.

In understanding some of the philosophical and evolutionary differences between legacy United and Continental airlines, one needs to look at their aircraft operating philosophies. It should also be noted that all airliner manufacturers supply basic operating manuals and procedures that are approved by the FAA. These manuals and procedures form the basis for any airline’s operating procedures. Airlines may tailor manuals and procedures to suit their specific requirements but must receive FAA approval for any such changes.

[2] 2010 UAL Proxy statement dtd. 4/22/11, p. 51.

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From a pilot’s perspective, it is surprising how differently the two airlines operate. When Gordon Bethune implemented his plan to turn the struggling Continental Airlines around, he parked older aircraft, many of which were manufactured by different companies. In modernizing the fleet, he opted for a newer, all -Boeing fleet of only three aircraft types (B737, B757/767 {considered one fleet} and B777). Continental essentially threw out disparate and evolved procedures and manuals and instead relied on the standard manufacturer manuals and operating procedures. These aircraft also included virtually all of the currently accepted advanced avionics required for Next Generation Air Transportation System (NextGen) operations throughout the world. The all -Boeing fleet was also certified for maximum allowable takeoff gross weights and ranges. In a laudable effort to standardize their operations and fleet, after the airline’s transformation under CEO Gordon Bethune, Continental depended substantially on the Boeing procedures of operating their aircraft.

Legacy United has been one of, if not the, largest airlines in the world for nearly a century. The airline has experienced a more evolutionary development in terms of standardizing its flight operations procedures, in part because it acquired a far more complicated and diverse fleet from several aircraft manufacturers. Currently, United operates a fleet of both Boeing aircraft (B757/767, 777, 747) and Airbus aircraft (A319/320). It wasn’t all that long ago that the airline also operated McDonnell Douglass DC-10s and DC-8s. As a result of this more evolutionary approach toward building operating manuals and procedures, United has worked to create standardization where none existed in terms of operating aircraft of different manufacturing origin. These manuals and operating procedures have resulted in a certain, stable operating environment for United pilots in terms of flight safety and training. United ALPA has been an equal partner for nearly 80 years in innovating and developing United’s training and flight safety procedures. This is well known throughout the industry. In fact, the FAA Administrator recently acknowledged to the UAL-MEC Chairman the significance of United’s superior safety record and programs.

Digging into more specifics, the first major flight operations merger decision was to use the Continental FAA operating certificate as the surviving certificate. It was a decision to escape from the more stringent regulatory requirements of United’s certificate that resulted from tough lessons learned, FAA regulatory action, and safety and training innovations made at United over decades. United’s stringent regulatory requirements resulted from incidents, accidents, and pilot-generated flight safety reports. United and ALPA, learning from past mistakes, modified aspects of the operation to avoid future disasters.

One of the most significant differences between United and Continental in terms of device training philosophies is the intended use of fixed-base simulators (FBS) for checking of pilots. For United this is a clear regression. It has been industry standard best practice to use full-motion simulators for line-oriented flight training and evaluations. One airline deviates from this practice, Continental. At Continental, by their management’s own admission, the airline broke with convention some years ago and in an effort to save money purchased simulators that do not have motion. The airline convinced the FAA to allow them to use these FBSs to conduct certain check rides on pilots. It is the position of the Air [4]

Line Pilots Association, as well as virtually every safety and training advocacy group worldwide, that full motion simulators should always be used for checking events. Another example of diminished training standards being implemented at the new United is that many pilots will go for proficiency training once every 12 months instead of once every nine months. Currently, all United pilots are on a training cycle that grants a proficiency training (PT) event at nine months, and a proficiency check (PC) at 18 months. Under the new policies, pilots will have a single PC once every 12 months.

An example of a significant procedural change that legacy United pilots are now responsible for is the company telling the B757/767 pilots that they may leave the autopilot on if desired during a wind shear recovery maneuver. It is our firm belief that this procedure can lead to a substantial degradation in aircraft performance at the least opportune time. But even if this change was not in and of itself a concern, a change of this magnitude certainly requires hands-on training in a full-motion simulator. At a time when the industry has suffered from at least two recent accidents in which pilot training deficiencies were noted (Colgan 3407 and Air France 447), it seems counter-intuitive for the new United management to be lowering the training and safety bar in so many dramatic ways at United.

The UAL FAA Principal Operations Inspector (POI), John Martin, claims that the FAA regulates to “achieve the highest level of safety.” The unfortunate reality is that most of the evidence contradicts this. Privately, Mr. Martin, as well as other FAA officials, claim that meeting the minimum FAA standard is all the FAA can enforce, and when pressed on what “highest level of safety” means, Mr. Martin concedes that it is dependent on “whatever the carrier is capable of accepting economically.” If United Airlines is highly profitable, has the best route structure in the world, over $8B in the bank and it cannot accept the industry’s best practices economically, can the FAA believe that any air carrier should actually be regulated to the “highest level of safety?”

In recent years, the FAA as represented by Mr. Martin has brought about some significant safety improvements at United through Corrective Action Reports (CARs). When deficiencies are noted, studies are done and actions are taken to improve safety. Some of the most notable include Mr. Martin personally ordering that United Airlines;

 Include a revised fuel cross-feeding procedure for the B757/767 to avoid inadvertent engine flameouts.  A requirement for Captains and Flight Dispatchers to verbally brief prior to long- haul international flights to help avoid areas of severe turbulence and possible passenger and crew member injuries.  A requirement that pilots visually check that the wings of the aircraft are free and clear of ice and snow under certain conditions.

These are but three of the most significant outcomes of CARs or have resulted from real life incidents that either led to injuries or incidents. Amazingly, these three requirements have been removed from the operations manuals at the new United.

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The flight training provided for the United B757/767 and B777 pilots who are required to learn the new Continental procedures is wholly inadequate and, in the opinion of ALPA’s training and safety experts as well as that of countless United pilots, of serious and significant concern in terms of safety. United management’s original estimate that all the SOC pilot-related changes could be completed in just four hours of computer-based training (CBT) was absurd to anyone with any understanding of aviation safety and training. Later, in an effort to demonstrate that they were taking action to correct for deficiencies in the training program, United Flight Operations management announced that it would enhance the SOC training for pilots. The result, rather than training all pilots properly in long established practices and principles before the pilot was to operate the aircraft using the new procedures, was to institute an unproven training scheme.

United management first announced that it would provide a day of training to line pilots who could then instruct their fellow pilots in the new procedures. Despite such pilots not being officially recognized as instructors by the FAA, it took extraordinary effort to convince the new United management that this idea met no reasonable standard. Next, the new United management decided that it would add a smorgasbord of voluntary and haphazard training offerings in the pilot domiciles wherein pilots would be allowed, on their own time, to sit with an instructor, if available, and discuss the new procedures. In some instances the “instructors” were actually Line Check Airmen whose duties do not include class room type instructing, and who in a significant number of cases were not trained on, or familiar with, the new procedures themselves.

There were numerous instances of the instructor and the student struggling through the material together trying to figure it out. In other cases, United allowed pilots to sit in the cockpit of aircraft parked at the gate and attempt to learn the new procedures as the aircraft were being serviced and awaiting their next flights. When pilots virtually begged United management to be allowed to go to the training center and learn the procedures in a simulator, they were told, “No, but you can do whatever you’d like in your domicile. We do not have any kind of approval from the FAA for simulator training.” Here United was blaming the lack of adequate training on the FAA. When the concern was brought to the FAA, it blamed United.

The truth is that United has previously allowed any pilot who did not feel adequately trained to receive extra training from qualified instructors at the training center and in a flight simulator. In this instance, when pilots brought their concerns to Flight Operations management and expressed that they did not feel adequately trained to operate revenue flights, management responded by removing the pilots from schedule without pay. It was only after extensive discussions between the Association and the company that ALPA was able to get most of those docked pay made whole. Never before in the history of United Airlines has ALPA witnessed such a draconian and disciplinary attitude on the part of management when pilots raise training or safety concerns. The Air Line Pilots Association at United Airlines has never witnessed such a wholesale and blatant disregard for the best practices of training and safety as it has in recent months.

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While all of this was going on, United ALPA safety and training SMEs did everything possible to advocate for adequate SOC pilot training as soon as it became apparent exactly how inadequate the training would be. Contrary to management claims of ALPA involvement in SOC, United ALPA was not involved in the development of training for Phases 1 or 2. The Association was granted a minority observatory role and consulting position after the training regimen had already been set. When ALPA brought concerns to management, they were generally ignored or dealt with in the most minimal fashion, an example being the “domicile training scheme” previously discussed. Shortly after 9/11, United purchased Tasers to deal with the potential terrorist threat. At that time United gave each pilot a full day of classroom training, far more training than the company has given the pilots for the SOC integration of flight procedures that include how we handle emergency and irregular procedures.

In addition to dismissing United ALPA’s concerns, the company failed to meet its own original low training standards, requirements and goals. First, the company’s Introductory and Pilot Merger Guides (PMG) stated that the appropriate level of training for procedures involving new cognitive/motor skills would be trained by live briefing or in a flight simulator. As discussed, live briefings were only offered on a voluntary ad-hoc basis; often times by untrained “instructors.” Today, none of the dramatic cognitive and motor skill changes made on the United B757/767 and B777 fleets have been trained in flight simulators, even when requested by pilots who were uncomfortable with the training they received. This is in direct contradiction to what lawyer Robert Siegel, representing UAL, testified to a federal judge in court when he said, “When there was some discussion that perhaps some individual pilots thought they should have additional training or different types of training to make them comfortable, United Airlines said we will do that.”[3]

In response to these concerns, United’s flight management tortures logic by claiming that changing the manner, methodology and nomenclature by which B757/767 and B777 pilots handle non-normal and emergency procedures is not a new cognitive skill. In addition, they fail to even acknowledge all of the new motor skill and muscle memory changes included in the procedural changes, such as the significant change to procedures in which the pilot may choose whether or not to utilize the autopilot in a windshear encounter. The highly developed and trained coordination that goes on between pilots in the cockpit is much like the elegance of trapeze artists. Pilots cannot afford to “miss” by even an inch during certain critical maneuvers such as a microburst escape maneuver. United’s training scheme is the equivalent of the Ringling Brothers Circus introducing a new trapeze routine and training the artists via computer.

Further, the evidence contradicts management’s assertions that the new procedures do not involve cognitive changes. In fact, in actual emergencies following Phase 1 changes, United pilots stated in reports that they were unable to find the appropriate checklist in the Quick Reference Handbook (QRH) in a timely manner, and some stated that they were never able

[3] Siegel, Robert, Esq., p. 17, line 25 of transcript of testimony in Air Line Pilots Association v. UAL, United States District Court, Eastern District of New York, 9/28/11.

[7] to find the correct emergency checklist. The QRH, itself a significant change in the way that United pilots are to handle emergencies and irregular procedures, is a manual containing instructions for how to deal with such situations. Historically, United pilots work through such emergency scenarios in the classroom, FBSs and full-motion simulators so that they learn the intricacies of how switches, manuals, procedures and even their fellow pilots function to such emergencies. Learning often occurs through making mistakes. The problem with United’s training scheme is that it is now relying on learning (and mistake making) to occur in the cockpit on revenue flights with United passengers aboard. Most of the pilots who had problems during actual emergencies or irregularities had never seen or touched a QRH prior to flying the flights in question. The manuals were not available prior to the implementation of the new procedures. The nomenclature and categorization of various situations and emergencies changed to such an extent that even some of the Association’s most experienced Captains and safety experts stumbled through the manual for up to 15 minutes trying to find the proper procedure for a time critical operation. If United had simply provided the manuals a few weeks in advance of their implementation, it could have at least allowed the pilots to familiarize themselves with, or practice searching through, them prior to the fumbling that went on during an actual emergencies.

United and its pilots participate in a voluntary program called the Flight Safety Awareness Program (FSAP). Through the FSAP program, pilots self-disclose virtually any safety- related issue they feel appropriate. In exchange for the sharing of information and the positive effect it has on safety, FAA grants pilots immunity from FAA certificate action if a violation occurs that is not intentional. In the wake of the Phase 1 implementation, FSAP reports increased 43 percent from June to July 2011 and 55 percent from July 2010 to July 2011 for all the fleets. This spike in, as well as the intensity and nature of, FSAP reports is UNPRECEDENTED at United Airlines. Increases in the number of incidents of a certain nature, for example, unstabilized approaches, altitude deviations and other incidents are acknowledged by air safety experts to be precursors of potential accidents or incidents.

In the seven days following Phase 2 implementation, there were three 757 crews who reported being so distracted that while attempting to accomplish the new, untrained procedures, they had nearly forgotten to put the landing gear down during the final approach phase of flight. In one case, the crew noticed the mistake before it became a real issue. In the other two cases, the automatic warning system onboard the aircraft alerted the pilots to their unsafe aircraft state just seconds before landing. It is significant to note that such landing gear events are virtually non-existent if they happen at all. United may have had one such incident last year out of hundreds of thousands of flights. After Phase 2, United has three incidents out of just several thousand flights. Statistically speaking, this is of serious concern.

In that same week, three other crews were so distracted trying to complete their “new” after-landing checklists and procedures (called “flows”) that they taxied onto or across active runways without FAA Air Traffic Control permission. The FAA calls these “Runway Incursions” and it is considered one of the most dangerous situations in aviation as evidenced by numerous disasters.

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Pilots don’t “cry wolf,” nor, by and large, do they admit weakness. These are not opinions, but rather acknowledged psychological attributes in the makeup of a successful airline pilot. When ALPA has a mountain of data from pilots who are begging for training, indicating that they feel unsafe in the cockpit, that they believe what little training was offered is wholly inadequate, that they believe that there will be an accident unless these deficiencies are addressed; the Association strongly urges that the company must address these issues. Unfortunately, the Continental managers who are running the operation choose to ignore the pilots and their representatives. Those few remaining legacy United managers appear to be powerless or afraid to affect any change that enhances safety if it might slow the SOC process. They are afraid that if they speak up they will be “sent back to the line” and lose their positions as managers. The “new United” managers understand that there is a problem, they know what the solution is, but they choose to ignore it instead, hoping everything will turn out all right.

United’s SOC process became mired in one serious problem after another, forcing United to split Phase 3 into a minor portion 3A and a major portion 3B (the latter includes the new procedures for the entire first half of the flight for the B757/767 and B777). United management hasn’t even developed the Phase 3B training yet and has planned its implementation for some time in the first quarter of 2012. The splitting of Phase 3 into two separate parts runs counter to the FAA’s original approval of United’s SOC training. The contention is that because such serious concerns are being raised, and because it is becoming more and more apparent that United will have to do training in simulators, that pushing Phase 3B off into the post SOC timeline will allow United to gain SOC and do the heavy lifting (training) after the fact. As of today, the FAA is going along with this plan and states that it is on track to grant United SOC in 2011, even before Phase 3B procedures are developed. This is despite the fact that half of the new flight procedures remain to be completed and almost none of the integrated maintenance procedures are to be addressed until Phase 4. FAA will grant United a Single Operating Certificate with only 50 percent of the new flight procedures for the common fleets developed and/or trained.

4. FAA oversight of United’s SOC process has been wholly inadequate

When asked in a House Transportation and Infrastructure Committee hearing on June 16, 2010 about the lack of adequate pilot training that contributed to the fatal crash of Continental Connection (Colgan) Flight 3407, Continental Airlines CEO Jeff Smisek admitted that it was not to his satisfaction, but that it was “the FAA’s responsibility,” not his.[4]

The U.S. Federal Court in the Eastern District of New York, in response to ALPA’s request for a temporary restraining order to delay the activation of Phase 2 procedures, stated, “In light of the FAA’s regulatory authority and on-going oversight of all phases of the United and Continental merger, the Court has no choice but to deem the increase risk to safety ALPA

[4]House Transportation and Infrastructure Committee hearing on Jun 16, 2010 p. 25

[9] alleges as being too “remote and speculative” to lift the Union’s TRO application off the ground. The Court further notes that ALPA’s inability to substitute the FAA’s determination concerning the adequacy of United’s computer-based training with its own assessment is not irreparable harm.”[5]

And now United Airlines, under the leadership of CEO Jeff Smisek, is again saying that this substandard pilot SOC training is FAA-approved and therefore sufficient and safe. Everyone seems to be satisfied with the minimum FAA safety standard except for ALPA and its pilots.

The FAA gives the impression to the public that it is the top cop on the airline beat, but it doesn’t regulate airlines. The FAA actually monitors airlines regulating themselves. Unfortunately, the FAA often isn’t effective or even methodical in its monitoring of airlines’ self-regulation due to limitations in the data it receives to analyze. It is therefore more important than ever, under the increased self-policing of SMS systems, that managements, FAA and others embrace ALPA and other safety advocates, not distance them.

The United Airline’s POI, Mr. John Martin, has been found to be unaware of spikes in FSAP reports. This is dereliction of duty and simply unacceptable. Through the FSAP program, pilots have reported not just air safety concerns but also training irregularities. After Phase 1 training was implemented, more than 50cases of incomplete training were signed off as complete in pilot training records by an overseas help desk were reported. It wasn’t until United ALPA informed Mr. Martin of this problem that he acknowledged it. Mr. Martin further claims to not know of the existence of certain safety corrective action requests (CARs) with the UAL FSAP (Flight Safety Awareness) program to correct serious safety threats that were uncovered by the system.

This “see no evil, hear no evil” approach to monitoring company compliance is in stark contrast to Mr. Martin’s recent letter to UAL VP of Safety, Mike Quiello. In his letter, Mr. Martin advises United Captains of potential violations of certificate action for reverting back to previous procedures of positioning flight attendants near emergency exits during the safety video briefing rather than standing in the front of the economy class section (Exhibit F). By way of explanation, United has always ensured that flight attendants stand nearby the exits that they are supposed to help passengers evacuate from in the event of an emergency while starting engines and taxiing. This is a prudent and safe procedure. For some unknown but presumably “customer service/public relations” reason, Continental has all of the flight attendants stand near the front of the aircraft far away from the exits that they should be stationed near. Questions have since arisen as to whether or not Continental is satisfying the original certification requirements for evacuations with their procedure as it stands. In any case, United’s procedure in this matter is unquestionably

[5] Johnson Jr., Sterling, Senior U.S. District Judge, Memorandum and Order in Air Line Pilots Assoc., v. UAL dtd. 9/29/11. https://crewroom.alpa.org/ual/DesktopModules/ViewDocument.aspx?DocumentID=4809 5

[10] safer, yet the new United has adopted Continental’s procedure. Some United pilots have chosen to revert to the old way of doing business, thus abandoning a public relations gimmick in favor of a safer operation. For this Mr. Martin was quick to threaten the United Captains with FAA violations. We ask where he has been on all of our very real safety concerns?

United has argued to ALPA, the FAA and even in Federal Court that it would be imprudent and potentially unsafe to train pilots, have them revert to their old procedures and then turn on the new procedures later. ALPA has argued that a modified version of this plan could safely be implemented as it has in the past and that it could solve so many of the current problems with training. Nonetheless, after implementing the Phase 2 procedures, United failed to promptly stock all of the aircraft with the new required manuals. For a six- day period (October 1-6, 2011) in an email to United pilots, the airline asked them to do exactly that which it vehemently objected to, even to a Federal Judge:

DSPNOT TITLE:/ CMT UPDATE SEPT 29/LET TYPE/ / EFFDTE:/ 093011 AUTHOR: /ELLIS,BO /ADDRS /ORDFO /EXPDTE:/ 101411 *PHASE 2 CHANGES ARE IN EFFECT ON FRI-SEPT 30TH *JEPPESON HAS ADVISED THAT NEW SHIPSETS W/PHASE2 CHANGES ARE ENROUTE. PLEASE CHECK FOR SEPT 30 REVISION IF, NOT ON YOUR SPECIFIC AIRPLANE, PLEASE OPERATE IN ACCORDANCE WITH CURRENT SHIPSET ONBOARD. ALL NEW SHIPSETS SHOULD BE IN PLACE BEFORE OCT 6 AT 0900UTC. IF YOU FIND A SHIPSET THAT GOES NON-CURRENT ON 10/6. PLEASE CONTACT FODM FOR METER ALLOWING OPERATION OF THAT SPECIFIC AIRCRAFT UP TO 10/14.THIS METER IS AIRCRAFT SPECIFIC AND AUTHORIZES MORE THAN ONE FLIGHT SEGMENT AS PER ESTABLISHED PRACTICES. *PHASE 3A ULN TRAINING STARTS 9/30. CBTS WILL BE AVAILABLE ON 9/30. THIS PHASE IS SMALLER IN SCOPE AND GENERIC AMONG FLEETS.

The airline ordered the pilots, in other words, if you have the old manuals use the old procedures. If you have the new manuals, use the new procedures. It was possible that a pilot flying a 757 from Boston to Chicago, to Denver, to Los Angeles, could have reverted between old and new procedures (that were never trained) three times in one day. This is in complete contradiction to what United said its own safety risk analysis indicated it should do.

Of even more concern is that Mr. Martin claims that he was unaware, until informed by ALPA on October 3, 2011, of United’s non-compliance. Did United fail to inform Mr. Martin, or did Mr. Martin choose to ignore this significant safety question? That Mr. Martin would look the other way on a safety matter of such significance while at the same time threatening pilots who attempted to look out for the safety of their passengers by having flight attendants stand near the emergency exits they are responsible for, is also problematic.

Another significant area of concern is Mr. Bobby Hedlund, the head of the United/Continental merger JTT (Joint Transition Team). Mr. Hedlund of the FAA is responsible for approving the company’s transition plan and granting the SOC. Mr.

[11]

Hedlund, it appears, still plans on granting United a SOC this year despite United’s failure to achieve its own benchmark of completing all of Phase 3 by October 28.[6] When United Airlines fell significantly behind its transition plan, it cut Phase 3 into 3A & 3B. The bulk of the integration (the first half of the phase of flight: pushback to cruise integration) will occur in Phase 3B, a plan that has yet to be developed, and is estimated to be implemented sometime in Q1 2012, after SOC has been granted.

Why would the FAA, the JTT and Mr. Hedlund grant UAL an SOC when it is only halfway through the operational integration and it has failed to comply with even its own transition plan?

When Mr. Hedlund was the manager of the Southwest Certificate Management Office in 2008, he was embroiled in controversy. He failed to properly monitor Southwest Airlines’ compliance with maintenance procedures. This resulted in the Special Counsel’s office detailing Mr. Hedlund’s dereliction of duty in a letter to the President of the United States (Exhibit G). FAA leadership recommended that Hedlund be suspended for his actions.[7] How could it be that an FAA official with a track record which includes such a profound safety related failure be promoted, much less promoted into a position where he is in charge of FAA oversight responsible for the melding of two airline operations into the largest airline in the world?

Airline Transport Pilot (ATP) certificated pilots are legally mandated to notify the FAA when safety deviations are discovered whether they are acting as a crewmember or not. Essentially the FAA Act of 1958 mandated their cooperation in the safety process. Many United pilots, all of whom have ATPs, have expressed grave concerns regarding the subjects in this presentation as well as others, and have fully participated in many direct meetings with United management and technical personnel in an effort to remedy the perceived safety defects. United pilots have filed an alarming 6,000+ FSAP reports under the NASA Aviation Safety Reporting System this year to date, well above historical averages. Some individual United pilots have contacted the FAA directly expressing their concerns, and after many formal attempts to correct issues in-house failed, United ALPA has also reached out to the FAA as required in an unsuccessful effort to address perceived safety threats. United ALPA’s efforts to engage the FAA include countless reports, phone calls, letters and meetings with personnel throughout the Administration including the senior officials and the Administrator himself. (Exhibits A-E)

As the peoples’ representatives in charge of FAA oversight and protection of public safety we are bringing these issues to your attention, especially given your significant participation on the U.S. House of Representatives Committee on Transportation and Infrastructure 2008 investigation, “Critical Lapses in Federal Aviation Administration

[6] United Pilot Merger Guide (PMG), Introduction Phase, eff. 4/1/11, p. 1.10.2 & United PMG Phase 1, May 2011, 1.1.10.2. [7] Reukauf, William E., Associate Special Counsel ltr. to President of the United States dtd. 3/18/10 re. OSC File No. DI-08-1750.

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Safety Oversight of Airlines: Abuses of Regulatory Partnership Programs.” We appreciate your work on that investigation and are saddened to see that personnel you expected to be suspended from the FAA are now in control of the FAA UAL/CAL Joint Transition Team handling the merger.

5. Pilot Safety data show great reason for concern

In any safety program there are data reporting systems for the operators to report safety concerns. At United there are two systems to which the pilots report their concerns—Flight Safety Awareness Program (FSAP) that representatives from the FAA, United and the United ALPA monitor, analyze and, when necessary, issue corrective actions based on reports. United ALPA also has a Pilot Data Reporting (PDR) system that is internal to the United Master Executive Council (UAL-MEC). Both systems have had recent spikes in the volume of reports stemming from the vast amount of procedural changes associated with United’s SOC Phase Training.

Listed below are the numbers of FSAP total reports received as compared to previous months and years. This was accomplished to establish a historical baseline for any abnormal “spikes” in reporting. Phase 2 training material was introduced on the ULN (United Learning Network) in July of 2011.

FSAP Report Period One month comparison Reports Submitted Percent Change June 2011 659 baseline July 2011 943 43% increase Annual Comparison July 2010 608 baseline July 2011 943 55% increase Post Phase 2 “turn on” date 09/30/11-10/5/11 193 98%*

*Extrapolating 5 days of reports to a one month period, and comparing to 10/2010

It can be noted that there was a significant increase in reports, and approximately 95 percent of the increase was attributed to issues with Phase 2 training.

A review of the reports highlighted the following safety concerns associated with the SOC training. The following areas of concern were of particular importance to the reporters:

1. The current training methodology compromises safety 2. United Learning Network Training was inadequate for the amount and type of material presented 3. Training presented required more than a CBT presentation. More specifically, it requires either simulator or FBS training, or also some “Stand Up” or classroom instructor training [13]

4. Training information is not accurate 5. Difficulties with, and lack of training, on the Quick Reference Handbook (QRH) 6. Distractions - crews referring to manuals to perform fundamental duties 7. Mixing of old and new procedures after 9/30/2011 Phase 2 turn on 8. There are “specific” procedural changes that should require training in a classroom environment to include either simulator or FBS i. Windshear Recognition and Recovery ii. Go Around iii. Autobrake usage iv. Transfer of control on landing v. Setting missed approach altitude on non-precision approaches and speed bug terminology vi. Taxi in and taxi out flows and procedures vii. Changes to stabilized approach criteria 9. CRM breakdown 10. FAA issues –regulatory versus oversight of the magnitude of changes. Consequences of “fallback” to old procedures 11. ULN problems such as internet browser requirements and system lockups

There were also a number of issues with flight office management “guidance” for pilots who were uncomfortable with the training of the new procedures. One example was the recommendation to fly the revenue flight and “learn” the procedural changes en route.

Further statistics:

 70 percent of the reports indicate that the training was inadequate, deficient or substandard as compared to previous Legacy United training programs.

 55 percent reported a reduced level of safety as compared to operating prior to the introduction of the new procedures.

 Of the 70 percent that reported the training was inadequate, virtually all suggested that training of this magnitude should be accomplished in a simulator or FBS, and that simply looking at slides on a CBT without actual “practice” was inappropriate.

Excerpted statements from the reporting systems:

“I have been a check airman for 20 yrs and an FAA examiner. The completion of this course in no way will allow the crews to integrate the new procedures and manuals without undue errors, stress and problems upon activation without further training and practice. I believe the changes to be unsafe and dangerous if implemented in the manner proposed described.”

“Windshear recovery SOP significantly differs from that of current United SOP in that autoflight is recommended to be left engaged. This is a major change in philosophy regarding windshear recovery technique and is brushed over like it's insignificant.”

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“The notion that the FAA is ok with so many of these changes collectively is mind boggling”

“I will admit I was somewhat distracted because I was mentally reviewing the pending Phase 2 changes to the after landing flows and thinking about what I have to start doing on 30 Sept. That distraction at a critical time led to me not backing up the Captain and us missing the left turn onto taxiway A.”

“I think that had if I had received training in a LOFT type scenario with another Captain practicing and running these new non-normal procedures, it would have made this in-flight emergency easier and safer to deal with”

“I cannot proceed with a clear conscience without pointing out that UAL's SOC Training is fundamentally flawed from both a human factors and safety standpoint.”

“I am extremely disappointed and concerned about the quality of training provided by the United Learning Network”

6. ALPA’s attempted TRO against United Airlines

Repeated attempts in seeking help and resolution were ignored by the company, the FAA and others, yet the magnitude of the problem and concerns of the United pilots to receive proper training continued to grow. The Association concluded, based on information from our safety experts, as well as other means including Flight Safety Awareness Reports (FSAP) and the Association’s Pilot Data Reporting System (PDR), that something had to be done to get the pilots trained before United implemented the new procedures.

United made overtures that it would consider utilizing a program called United as Professionals (UAP) as a device to deliver classroom training. UAP was to be negotiated and developed with the Association to deal with “workplace distractions and professionalism” during a merger. There were two problems with United’s methodology. First and most importantly, United refused to provide the training to the pilots before implementing the new procedures on September 30, 2011. The Association could not endorse two classes of pilots flying United’s aircraft, those who were properly trained and those who could go several months flying the new procedures before being trained. The second issue, while not a primary matter, was that the agreement with the Association for UAP did not cover the nature of training that was envisioned and United management refused to negotiate any new terms to the letter or even use the letter as a template for a new letter.

The Association was thus left with no alternatives in seeking proper training for the pilots. To that end, a decision was made that the Association would employ a two-step process to attempt to convince United to properly train the pilots. First, the Association would file a grievance through the collective bargaining process for the company’s violation of improperly instituting new training requirements without following Collective [15]

Bargaining Agreement (CBA) provisions. Because the normal grievance process takes time and the deadline for the Phase 2 changes was rapidly approaching, the Association requested and the company rejected expediting the grievance arbitration. Therefore, ALPA decided to seek an injunction/TRO in Federal Court to force United to delay implementation of the Phase 2 changes until the grievance could be heard. It is important to realize that while the judge found the Association’s arguments compelling, he made it clear that he was limited to ruling strictly on points of law. He concluded that while ALPA’s contention that irreparable harm could occur in the form of an aircraft accident, it was supposition and conjecture and not imminent. He therefore failed to issue a TRO.

7. Actions necessary to correct training and SOC deficiencies

The training for Phase 1 and Phase 2 for the B757/767 and B777 fleets has been woefully inadequate. This has been supported by strong data and feedback from Line Check Airmen (LCA) and training managers. What little support there has been outside of the CBT and PMG, in terms of voluntary instruction available in the domiciles, is being pulled down. The company refuses to allow anyone seeking additional training to go to the Denver Training Center, a historically unprecedented change. As a result, United pilots are attempting to be professional by teaching themselves what they think are the proper Standardized Operating Procedures (SOP), approach callouts, profiles and procedures. While they are being heroic in their efforts to learn the proper way, this leads to a loss of standardization, which is the foundation of safe line operations. This happened with the Northwest pilots who tried to learn the Delta procedures on their own and were checked by Northwest LCAs. It wasn’t until a year later when Delta LCAs began observing them and saw they were not doing it the way Delta had in mind and they had to relearn how to do it the correct way. Additionally, the legacy United pilots’ trust of their training and safety systems has been shaken.

Presently, the United pilots, and thus the airline operation and its passengers, are in a window of vulnerability where it may be up to six months before they are all properly trained. Since management refuses to offer mandatory classroom instruction, the pilots are coping on their own. They will eventually get proper training by attending a PT (Proficiency Training) or a PC (Proficiency Check) or if not scheduled within six months an interim training session, but this will take six months before all are trained. They may get a line check and learn from an LCA if there is time during the flight. Or they may learn by flying with another crewmember that has been properly trained. But until this happens, they are in jeopardy of an FAA violation should an FAA inspector be aboard their airplane, and they will have to deal with the distractions of learning on the job. This clear potential for an accident or incident must be addressed now. Management could easily institute the needed training in the domicile. The syllabus is developed and the instructors are already knowledgeable of the new procedures. This training could be deployed in short notice to rectify the inadequacies of Phase 1 and Phase 2 training.

To address the long-term SOC deficiencies, a comprehensive analysis of the training management and delivery system needs to be undertaken. While there has been much [16] discussion concerning the appropriate input into what changes have to be made in the merging of the flight procedures of two different airlines, the salient point is the new procedures need to be properly trained. The proper training programs, methodologies and materials need to be developed and successfully implemented. This has not been the case.

The SOC management team has been carved out of various flight operation sections and became an autonomous fiefdom whose main goal was to reach an SOC deadline of November 11, 2011. This was its overarching goal, not that of creating and implementing proper training. Developing “Best Practices,” which was the originally stated goal, quickly was superseded by expediency to reach the deadline. While the SOC team employed instructors from the fleets, they excluded the Training Captains from meaningful input. There was no credible alternative view as to how these changes should be taught other than from ALPA, and the SOC team ignored ALPA when it strongly recommended that additional instruction methods were required. The very successful and experienced team of United Training Management and ALPA were locked out of significant input.

To make this process work in the future, the development and the implementation of this merger training needs to be put back into the hands of the Fleet Training Captains who have expertise in training systems and have a stake in the quality of the training since they will be managing these programs for years to come. They know the training process, personnel and procedures, and have a history of successfully collaborating with ALPA to produce historically industry-leading training. The SOC team’s misplaced goal of reaching deadlines over quality training and its structural flaw of systematically preventing the Fleet training experts and their partner ALPA from meaningful input needs to be put to an end.

To summarize:

1. United pilots have not received any formalized training other than the computer- based training (CBT) for any of the related SOC training. 2. Numerous pilot reports have been filed, including to the FAA, indicating a compromise to passenger safety as a result of the improper SOC pilot training. 3. Mandatory classroom or procedural trainer training must be accomplished immediately to ensure a consistent level of safety. 4. The FAA must conduct more rigorous scrutiny over United’s SOC training rather than accepting compliance with self-regulation. 5. Serious concerns abound regarding FAA oversight and personnel.

[17]

Exhibit A: Letter From United ALPA to FAA Administrator Babbitt- 9.1.11

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[19]

[20]

[21]

[22]

[23]

[24]

[25]

[26]

[27]

[28]

[29]

[30]

[31]

[32]

[33]

[34]

[35]

[36]

[37]

[38]

Exhibit A2: Letter from UNITED ALPA to FAA Administrator Babbitt re. Aircraft Magnetic Reference Data, 9/6/11

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[40]

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[42]

[43]

[44]

Exhibit B: Letter from United ALPA to FAA POI John Martin- 9.2.11

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[46]

Exhibit C: Letter from FAA Asst. Director Gilligan to United ALPA - 9.8.11

[47]

[48]

Exhibit D: Letter from FAA POI Martin to United ALPA—9.27.11

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[50]

[51]

Exhibit E: Letter from United ALPA to FAA Administrator Babbitt- 10.14.11

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[53]

[54]

[55]

[56]

[57]

[58]

[59]

[60]

[61]

[62]

[63]

[64]

Exhibit F: Letter from FAA POI Martin to UAL VP Corporate Safety Quiello, 9.12.2011

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[66]

Exhibit G: Letter from Associate Special Counsel William E. Reukauf to the President of the United States, 3.18.2010

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[68]

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Exhibit H: Resignation Letter from Line Check Airman (LCA), 8.26.2011

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[71]

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Exhibit I: Resignation Letter from Line Check Airman (LCA)

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Exhibit J:Partial Chronology of United ALPA/FAA Communications

6/14/11 Letter with questions to POI John Martin, no response to date 6/30/11 Meeting with POI John Martin, Houston, TX 7/14/11 Letter to Peggy Gilligan, Associate Administrator for Aviation Safety 7/19/11 Letter with questions to Rebecca MacPherson, Office of Chief Counsel, no response to date 8/5/11 ALPA Meeting in FAA headquarters with Associate Administrator for Aviation Safety, Peggy Gilligan, and Deputy Director of Flight Standards, Ray Towles; presented multiple issues in writing, but still no determination of who is addressing issues, no response to date 8/16/11 Letter with questions to POI John Martin, no response to date 9/1/11 Letter with questions to Administrator Babbitt, no substantive response to date 9/2/11 Letter with questions to Rebecca MacPherson, Office of Chief Counsel, no response to date 9/2/11 Letter with questions to POI John Martin, incomplete response 9/6/11 Letter with questions to CMO Manager Jack Grossman, no response to date 9/6/11 Letter to FAA Administrator Randy Babbitt advising of safety issue, no response to date 9/6/11 Letter received from POI John Martin assigning Dave Burnham (DEN CMFO) to FWZ issues 9/26/11 Letter received from Dave Burnham (DEN CMFO) offering to meet us and discuss all FWZ issues 9/27/11 Letter to Dave Burnham (DEN CMFO) asking for answers to questions in letters of 6/14/11 and 8/16/11, none received to date 10/3/11 Phone conversation with Deputy Director of Fight Standards, Ray Towles in which he stated that all four phases of SOC training and integration would have to be complete prior to UAL getting a SOC 10/5/11 Phone conversation with POI John Martin in which he stated that UAL would likely get a SOC after Phase 3A and before Phase 3B with only half of operational training and integration complete 10/11/11 Phone conversation with the head of the UAL/CAL JTT, Bobby Hedlund, in which he explained the supposed logic behind awarding an SOC to United Airlines with only half of the SOC training and integration complete 10/14/11 Letter to FAA Administrator Babbitt, no substantive response to date 10/15/11 Letter to Dave Burnham offering meeting location, no meeting held to date 10/15/11 Letter with questions to Ray Towles, FAA Deputy Flight Standards, no response to date 10/17/11 Letter from Dave Burnham indicating interest in meeting on FWZ issues, no response to date 10/18/11 Conversation with Ray Towles in which he indicated Manager Hedlund or POI Martin would call with a response, no call received to date

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1 The Evolution of Crew Resource Management Training in Commercial Aviation Robert L. Helmreich, Ashleigh C. Merritt & John A. Wilhelm Department of Psychology Aerospace Crew Research Project The University of Texas at Austin Abstract Changes in the nature of CRM training in commercial aviation are described, including its shift from Cockpit to Crew Resource Management. Validation of the impact of CRM is discussed. Limitations of CRM, including lack of cross-cultural generality are considered. An overarching framework that stresses error management to increase acceptance of CRM concepts is presented. The error management approach defines behavioral strategies taught in CRM as error countermeasures that are employed to avoid error, to trap errors committed, and to mitigate the consequences of error. The roots of Crew Resource Management training in the United States are usually traced back to a workshop, Resource Management on the Flightdeck sponsored by the National Aeronautics and Space Administration in 1979 2 (Cooper, White, & Lauber, 1980). This conference was the outgrowth of NASA research into the causes of air transport accidents. The research presented at this meeting identified the human error aspects of the majority of air crashes as failures of interpersonal communications, decision making, and leadership. At this meeting, the label Cockpit Resource Management (CRM) was applied to the process of training crews to reduce “pilot error” by making better use of the human resources on the flightdeck. Many of the air carriers represented at this meeting left it committed to developing new training programs to enhance the interpersonal aspects of flight operations. Since that time CRM training programs have proliferated in the United States and around the world. Approaches to CRM have also evolved in the years since the NASA meeting. The focus of this paper is on the generations of CRM training that reflect this evolution and on the problems that have been encountered in changing the attitudes and behavior of flight crews. CRM training in the military has followed its own path of growth and evolution and will not be addressed here (see Prince & Salas, 1993, for a discussion of military CRM programs). We use the term ‘evolution’ in describing the changes in CRM over the last two decades. Evolution, as formally defined refers to the process of growth and development, a description that aptly fits CRM. Similarly, the very different content and foci of programs called CRM justifies

1 This work was supported by FAA Grant 92-G-017. Portions of this paper were presented at the International Air Transport (IATA) Human Factors Seminar, Warsaw, Poland, October 31, 1996, and the International Civil Aviation Organization (ICAO) Regional Safety and Human Factors Seminar, Panama City, Panama, November 20, 1997. We would like to thank two anonymous reviewers who made cogent and helpful comments on an earlier draft of the manuscript. Additional information and data collection forms can be found on our Internet Homepage: http//www.psy.utexas.edu/psy/helmreich/nasaut.htm 2 In Europe, the research of Elwin Edwards (1972) was translated into human factors training at KLM Royal Dutch airlines in the late 1970s.

______University of Texas at Austin Human Factors Research Project: 235 Helmreich, R.L., Merritt, A.C., & Wilhelm, J.A. (1999). The evolution of Crew Resource Management training in commercial aviation. International Journal of Aviation Psychology, 9(1), 19-32. Evolution of CRM 2

[77] defining them in terms of generations (although temporally a CRM generation is closer to that of the Drosophila than the human). Our focus is on the most recent approaches to CRM training. Early generations are described briefly to show their context and emphases (see Helmreich & Foushee, 1993, for a more complete description of early programs). FIRST GENERATION COCKPIT RESOURCE MANAGEMENT The first comprehensive U.S. CRM program was initiated by United Airlines in 1981. The training was developed with the aid of consultants who had developed training programs for corporations trying to enhance managerial effectiveness. The United program was modeled closely on a form of training called the ‘Managerial Grid’ developed by psychologists Robert Blake and Jane Mouton (Blake & Mouton, 1964). The training was conducted in an intensive seminar setting and included participants’ diagnoses of their own managerial style. Other airline programs in this era also drew heavily on management training approaches. These programs emphasized changing individual styles and correcting deficiencies in individual behavior such as a lack of assertiveness by juniors and authoritarian behavior by captains. Supporting this emphasis, the National Transportation Safety Board (NTSB, 1979) had singled out the captain’s failure to accept input from junior crewmembers (a characteristic sometimes referred to as the “Wrong Stuff”) and a lack of assertiveness by the flight engineer as causal factors in a United Airlines crash in 1978. First generation courses were psychological in nature, with a heavy focus on psychological testing and general concepts such as leadership. They advocated general strategies of interpersonal behavior without providing clear definitions of appropriate behavior in the cockpit. Many employed games and 3 exercises unrelated to aviation to illustrate concepts. It was also recognized that CRM training should not be a single experience in a pilot’s career and annual recurrent training in CRM became part of the program. In addition to classroom training, some programs also included full mission simulator training (Line Oriented Flight Training) where crews could practice interpersonal skills without jeopardy. However, despite overall acceptance, many of these courses encountered resistance from some pilots, who denounced them as “charm school” or attempts to manipulate their personalities. SECOND GENERATION CREW RESOURCE MANAGEMENT NASA held another workshop for the industry in 1986 (Orlady & Foushee, 1987). By this time a growing number of airlines in the U.S. and around the world had initiated CRM training and many reported on their programs. One of the conclusions drawn by working groups at the meeting was that explicit (or stand alone) CRM training would ultimately disappear as a separate component of training when it became imbedded in the fabric of flight training and flight operations. At the same time, a new generation of CRM courses was beginning to emerge. Accompanying a change in the emphasis of training to focus on cockpit group dynamics was a change in name from Cockpit to Crew Resource Management. The new courses, typified by the program developed by Delta Airlines (Byrnes & Black, 1993) dealt with more specific aviation concepts related to flight operations and became more modular as well as more team oriented in nature. Basic training conducted in intensive seminars included concepts such as team building, briefing strategies, situation awareness and stress management. Specific modules addressed decision making strategies and breaking the chain of errors that can result in catastrophe. Many of 3 As an example, one of the most widely used exercises or games was called ‘Lost on the Moon’--requiring participants to prioritize supplies necessary for survival. Another game was called ‘Win as much as you can’.

______University of Texas at Austin Human Factors Research Project: 235 Helmreich, R.L., Merritt, A.C., & Wilhelm, J.A. (1999). The evolution of Crew Resource Management training in commercial aviation. International Journal of Aviation Psychology, 9(1), 19-32. Evolution of CRM 3

[78] the courses still relied on exercises unrelated to aviation to demonstrate concepts. Participant acceptance of these courses was generally greater than that of the first generation, but criticisms that the training was heavily laced with “psycho-babble” continued (for example, the notion of ‘synergy’ in group dynamics was often condemned by participants as representative of irrelevant jargon). Second generation courses continue to be used in the U.S. and other parts of the world. THIRD GENERATION CRM - BROADENING THE SCOPE In the early 1990s, CRM training began to proceed down multiple paths. Training began to reflect characteristics of the aviation system in which crews must function, including the multiple input factors such as organizational culture that determine safety. At the same time, efforts began to integrate CRM with technical training and to focus on specific skills and behaviors that pilots could use to function more effectively. Several airlines began to include modules addressing CRM issues in the use of flightdeck automation. Programs also began to address the recognition 4 and assessment of human factors issues. Accompanying this was the initiation of advanced training in CRM for check airmen and others responsible for training, reinforcement, and evaluation of technical and human factors. Accompanying this greater specificity in training for flight crews, CRM began to be extended to other groups within airlines such as flight attendants, dispatchers, and maintenance personnel. Many airlines began to conduct joint cockpit-cabin CRM training. A number of carriers also developed specialized CRM training for new captains to focus on the leadership role that accompanies command. While third generation courses filled a recognized need to extend the concept of the flight crew, they may also have had the unintended consequence of diluting the original focus on the reduction of human error. FOURTH GENERATION CRM – INTEGRATION AND PROCEDURALIZATION The Federal Aviation Administration introduced a major change in the training and qualification of flight crews in 1990 with the initiation of its Advanced Qualification Program (AQP: Birnbach & Longridge, 1993). AQP is a voluntary program that allows air carriers to develop innovative training that fits the needs of the specific organization. In exchange for this greater flexibility in training, carriers are required to provide both CRM and LOFT for all flight crews and to integrate CRM concepts into technical training. Most of the major U.S. airlines and several regional carriers are transitioning into AQP from the older model expressed in Federal Aviation Regulations, Parts 121 and 135. To complete the shift to AQP, carriers are required to complete detailed analyses of training requirements for each aircraft and to develop programs that address the human factors (CRM) issues in each aspect of training. In addition, special training for those charged with certification of crews and formal evaluation of crews in full mission simulation is required (Line Operational Evaluation or LOE). As part of the integration of CRM, several airlines have begun to proceduralize the concepts involved by adding specific behaviors to their checklists. The goal is to ensure that decisions and actions are informed by consideration of “bottom lines” and that the basics of CRM are observed, particularly in non-standard situations. On the surface, the fourth generation of CRM would seem to solve the problems of human error by making CRM an integral part of all flight training. It would also appear that the goal of 4 By assessment, we mean understanding how well specific behaviors are enacted, not formal evaluation of human factors skills.

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[79] making explicit CRM training “go away” is starting to be realized. Although empirical data are not yet available, there is general consensus among U.S. airlines that the AQP approach yields improvements in the training and qualification of flight crews. However, the situation is more complex and the resolution not so straightforward. Before considering the latest iteration of CRM, it may be valuable at this point to pause and examine what has been accomplished in the past two decades of CRM training. SUCCESSES AND FAILURES OF CRM TRAINING Validation of CRM. The fundamental question of whether CRM training can fulfill its purposes of increasing the safety and efficiency of flight does not have a simple answer. The most obvious validation criterion, the accident rate per million flights, cannot be used. Because the overall accident rate is so low and training programs so variable, it will never be possible to draw strong conclusions about the impact of training during a finite period of time (Helmreich, Chidester, Foushee, Gregorich, & Wilhelm, 1990). In the absence of a single and sovereign criterion measure, investigators are forced to use surrogate criteria to draw inferences more indirectly (Helmreich & Foushee, 1993; Helmreich & Wilhelm, 1991). Reports of incidents that do not result in accidents are another candidate criterion measure. However, incident reporting is voluntary and one cannot know the true base rate of occurrences, which is necessary for validation. We will discuss new developments in incident reporting later. The two most accessible and logical criteria are behavior on the flightdeck and attitudes showing acceptance or rejection of CRM concepts. Formal evaluation during full mission simulation (LOE) is a start. However, the fact that crews can demonstrate effective crew coordination while being assessed under jeopardy conditions does not mean that they practice these concepts during normal line operations. We feel that the most useful data can be obtained from line audits where crews are observed under non-jeopardy conditions (Helmreich & Merritt, in press; Hines, 1998). Data from such audits has demonstrated that CRM training that includes LOFT and recurrent training does produce desired changes in behavior (Helmreich & Foushee, 1993). This finding is congruent with participant evaluations of training. Crews completing course evaluations report that it is effective and important training (Helmreich & Foushee, 1993). Attitudes are another indicator of effect as they reflect the cognitive aspects of the concepts espoused in training. While attitudes are not perfect predictors of behavior, it is a truism that those whose attitudes show rejection of CRM are unlikely to follow its precepts behaviorally. The attitudes that have been measured to assess the impact of CRM were ones identified as playing a role in air accidents and incidents (Helmreich & Foushee, 1993; Helmreich, Merritt, Sherman, Gregorich, & Wiener, 1993). Data from a number of organizations show that attitudes about flightdeck management also change in a positive direction (Helmreich & Wilhelm, 1991). CRM does not reach everyone. From the earliest courses to the present, a small subset of pilots have rejected the concepts of CRM (Helmreich & Wilhelm, 1991). These CRM failures are found in every airline and are known to their peers and to management. Any chief pilot can identify these individuals, who have come to be known by a 5 variety of names – Boomerangs, Cowboys, and Drongos to mention a few. Efforts at remedial training for these pilots have not proved particularly effective. While CRM is endorsed by the majority of pilots, not all of its precepts have moved from the classroom to the line. For example, a number of airlines have introduced CRM modules to address 5 The Drongo label comes from Australia and is perhaps the most appealing. A Drongo is a small bird that flies around and defecates on the heads of unsuspecting passersby.

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[80] the use of cockpit automation. This training advocates verification and acknowledgment of programming changes and switching to manual flight rather than reprogramming Flight Management Computers in high workload situations or congested airspace. However, a significant percentage of pilots observed in line operations fail to follow these precepts (Helmreich, Hines, & Wilhelm, 1996). Acceptance of basic concepts may decay over time. We have surveyed pilots in a number of organizations several years after they received initial CRM training. A disturbing finding from this research is a slippage in acceptance of basic concepts, even with recurrent training (Helmreich & Taggart, 1995). Figure 1 shows shifts in 6 CRM-related attitudes over time within two airlines. The reasons for the decay in attitudes are not immediately apparent, but it is possible to speculate about likely causes. One candidate is a lack of management support for CRM and a failure by evaluators such as line check airmen to reinforce its practice. Another is the broadening of training to include flight attendants and other personnel, because a program stretched to fit all groups may lack the 7 specificity needed to change behavior. As training has evolved from one generation to the next, the original, implicit goal of managing error may have become lost. Proceduralizing CRM (that is, formally mandating the 8 practice of CRM precepts) might also obscure the purpose of the behavior. Support for this view comes from informal interviews of crews asked “What is CRM?” A typical response is “Training to make us work together better.” While this is certainly true, it only represents part of the story. It seems that in the process of teaching people how to work together we may have lost sight of why working together well is important. The overarching rationale for CRM, reducing the frequency and severity of errors that are crew-based has been lost. CRM did not export well. As first and second generation CRM training programs began to proliferate, many airlines in the U.S. and around the world began to purchase courses from other airlines or training organizations. Even in the U.S., courses imported from other organizations had less impact than those that were developed to reflect the organizational culture and operational issues of the receiving carrier. The situation was much worse when training from the U.S. was delivered in other nations. In many cases, the concepts presented were incongruent with the national culture of the pilots. 6 The data are also interesting in showing the impact of initial training. The airlines from which data are shown did not stress the effects of stress on behavior and the scores stayed relatively flat across the measurement period. 7 We strongly endorse joint training as a means of enhancing overall performance. Our concern is with the dilution of meaning. 8 This is not a criticism of proceduralizing CRM, which can aid in making the practices part of the culture.

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______Command RespComm/CoordRecog. Stressors405060708090100BaselinePost-CRM1994 ______Command RespComm/CoordRecog. Stressors405060708090100Airline 1Airline 2Scale scores (range 0- 100) Figure 1. Changes in CRM attitudes over time in a two major U.S. Airlines. The Dutch scientist, Geert Hofstede (1980) has defined dimensions of national culture, several of which are relevant to the acceptance of CRM training. High Power Distance cultures, such as China and many Latin American countries, stress the absolute authority of leaders. Subordinates in these cultures are reluctant to question the decisions and actions of their superiors because they do not want to show disrespect. Exhortations to junior crewmembers to be more assertive in questioning their captains may fall on deaf ears in these cultures. Many cultures which are high in Power Distance are also collectivist. In collectivist cultures where emphasis is on interdependence and priority for group goals, the concept of teamwork and training which stresses the need for effective group behavior may be readily accepted. In contrast, highly individualistic cultures such as the U.S. stress independence from the group and priority for personal goals. Individualists may cling to the stereotype of the lone pilot braving the elements and be less attuned to the group aspects of flightdeck management. A third dimension, Uncertainty Avoidance, refers to the need for rule-governed behavior and clearly defined procedures (Merritt, 1996). High Uncertainty Avoidance cultures such as Greece, Korea, and many Latin American countries, may be much more accepting of CRM concepts that are defined in terms of required behaviors. The U.S. is low in Uncertainty Avoidance, which is reflected operationally in greater behavioral flexibility, but also weaker adherence to Standard Operating Procedures (Helmreich, Hines, & Wilhelm, 1996). Management of cockpit automation is also influenced by national culture. Pilots from high Power distance and/or Uncertainty Avoidance cultures show more unquestioning usage of automation while those from cultures low in Power Distance and/or Uncertainty Avoidance show a greater willingness to disengage (Sherman, Helmreich, & Merritt, in press). The low Uncertainty Avoidance of U.S. pilots may account, in part, for frequent failure to complete checklists and the imperfect acceptance of proceduralized CRM in this country. There is a growing trend for carriers outside the U.S. to include national culture as part of CRM training and to customize their programs to achieve harmony with their own culture. This is

______University of Texas at Austin Human Factors Research Project: 235 Helmreich, R.L., Merritt, A.C., & Wilhelm, J.A. (1999). The evolution of Crew Resource Management training in commercial aviation. International Journal of Aviation Psychology, 9(1), 19-32. Evolution of CRM 7

[82] an important development that should enhance the impact of CRM in those organizations. Malaysian Airlines, for example, has made national culture a part of its program (Helmreich & Merritt, in press). Considering both the observed limitations of CRM in the United States and the differing reactions to the training in other cultures, let us now turn to the fifth generation of CRM training --one which we believe addresses the shortcomings of earlier training approaches. FIFTH GENERATION CRM – SEARCH FOR A UNIVERSAL RATIONALE We have been searching for a rationale for CRM training that could be endorsed by pilots of all nations--including the Drongos. Returning to the original concept of CRM as a way to avoid error, we concluded that the overarching justification for CRM should be error management (Helmreich & Merritt, in press; Merritt & Helmreich, 1997). In reaching this position, we were much influenced by the work of Professor James Reason (1990, 1997). While human error was the original impetus for even the first generation of CRM, the realization and communication of this was imperfect. Even when the training advocated specific behaviors, the reason for utilizing them was not always explicit. What we advocate is a more sharply defined justification that is accompanied by proactive organizational support. CRM as error management. Underlying the fifth generation of CRM is the premise that human error is ubiquitous and inevitable--and a valuable source of information. If error is inevitable, CRM can be seen as a set of error countermeasures with three lines of defense. The first, naturally, is the avoidance of error. The second is trapping incipient errors before they are committed. The third and last is mitigating the consequences of those errors which occur and are not trapped. This error management troika is shown in Figure 2. The same set of CRM countermeasures apply to each situation, the difference being in the time of detection. For example, consider an advanced technology aircraft which experiences a controlled flight into terrain (CFIT) because an improper waypoint is entered into the Flight Management Computer (FMC). A careful briefing on approach procedures and possible pitfalls, combined with communication and verification of FMC entries would probably avoid the error. Cross-checking entries before execution and monitoring of position should trap erroneous entries. Finally, as the last defense, inquiry and monitoring of the position should result in mitigating the consequences of an erroneously executed command before CFIT. To gain acceptance of the error management approach, organizations must communicate their formal understanding that errors will occur, and should adopt a non-punitive approach to error. (This does not imply that any organization should accept willful violation of its rules or procedures.) In addition to normalizing error, organizations need to take steps to identify the nature and sources of error in their operations. The U.S. Federal Aviation Administration has announced a new initiative, Aviation Safety Action Programs, to encourage incident reporting within organizations to deal with safety issues proactively (FAA, 1997). For example, American Airlines is participating in the program with the cooperation of the pilots’ union and the FAA. This confidential, non- jeopardy reporting system allows pilots to report safety concerns and errors. The program has proved to be a resounding success, with nearly six thousand reports received in a two year period. Data generated by this system allow the company to take steps to prevent or minimize the recurrence of incidents.

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Figure 2. The error troika. Considerations for fifth generation CRM. Instruction in the fifth generation has at its aim the normalization of error and the development of strategies for managing error (Helmreich, 1997). Its basis should be formal instruction in the limitations of human performance. This includes communicating the nature of cognitive errors and slips as well as empirical findings demonstrating the deleterious effects of stressors such as fatigue, work overload, and emergencies. These topics, of course, require formal instruction, indicating that CRM should continue to have its own place in initial and recurrent training. These can be dramatically illustrated with examples from accidents and incidents where human error played a causal role. Indeed, the analysis of human performance is common to all generations of CRM training. We would argue, however, that even more powerful learning may result from the use of positive examples of how errors are detected and managed. Pilots from all regions of the world have been found to hold unrealistic attitudes about the effects of stressors on their performance -- the majority feel, for example, that a truly professional pilot can leave personal problems behind while flying and that their decision making ability is the same in emergencies and normal operations (Helmreich & Merritt, in press; Merritt & Helmreich, 1997a). This attitude of personal invulnerability is a negative 9 component of the professional culture of pilots and physicians (Helmreich & Merritt, in press). Training that demonstrates that these are erroneous or over-confident beliefs and that every individual is subject to stress can foster more realistic attitudes by reducing the onus attached to personal vulnerability. In turn, pilots who recognize the performance degradation associated with stress should more readily embrace CRM training as an essential countermeasure. In theory, the error management approach should provide a more compelling justification for CRM and human factors training, but the impact remains to be evaluated empirically. Continental Airlines has refocused both the basic awareness and recurrent components of CRM as error management. As part of their commitment to this approach, all pilots were given the new basic course. Data on the outcomes of this program should help determine the effectiveness of the fifth generation approach. At the same time that error management became the primary focus of CRM training, Continental introduced a new program to train instructors and 9 There are many positive aspects of pilots’ professional culture such as pride in job and motivation that contribute strongly to safety.

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evaluators in the recognition and reinforcement of error management (Tullo, in press). This training stresses the fact that effective error management is the hallmark of effective crew performance and the well-managed errors are indicators of effective performance. As part of our development of strategies for using the line audit as an organizational assessment strategy, we have modified the Line/LOS Checklist, which is used to measure team performance to include data on error types and error management (Helmreich, Butler, Taggart, & Wilhelm, 1994). In preliminary observations at a U.S. airline, we found that observers could readily identify errors, their sources, and management strategies. Examples were found of errors avoided, errors trapped, and errors mitigated. Instances of errors never detected by crews and errors whose consequences were exacerbated by crew action were also found. We feel that a focus on error management both in LOFT and in line checking can provide valuable feedback and reinforcement for crews. HOW DOES ERROR MANAGEMENT CRM RELATE TO EARLIER GENERATIONS? Fifth generation CRM is compatible with earlier generations. Special training in the use of automation and the leadership role of captains as highlighted in the third generation can be neatly subsumed under this model. The error management approach should strengthen the AQP approach to training by providing an all-important demonstration of the reasons for stressing CRM in all aspects of flight training. In the same vein, the integration of CRM into technical training and the proceduralization of CRM also fit under this umbrella, and are likely to be better understood and accepted when the goals are clearly defined and organizationally endorsed. Pilots should also be better able to develop effective strategies for error management in situations where procedures are lacking and 10 provide a focal point for CRM skills which are not amenable to proceduralization. Training modules such as situation awareness and the nature and importance of briefings can be seen as basic error management techniques. Similarly, joint training of cabin and cockpit crews can be seen as extending the scope of error management to all employees in a safety culture (Merritt & Helmreich, 1997b). Finally, clarification of the basic goals of CRM training may be the best way to reach the Drongos who should find it difficult to deny the importance of error management. CRM IN CONTEXT CRM is not and never will be the mechanism to eliminate error and assure safety in a high risk endeavor such as aviation. Error is an inevitable result of the natural limitations of human performance and the function of complex systems. CRM is one of an array of tools that organizations can use to manage error. The safety of operations is influenced by professional, organizational, and national cultures and safety requires focusing each of these toward an organizational safety culture that deals with errors non-punitively and proactively (Helmreich & Merritt, in press). When CRM is viewed in the context of the aviation system, its contributions and limitations can be understood. What we do know is that the rationale for human factors training is as strong now as it was when the term CRM was first coined. REFERENCES 10 Leadership represents a critical area where training can be effective but a set of rote procedures will not lead to optimum performance (Pettitt & Dunlap, 1997).

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Birnbach, R., & Longridge, T. (1993). The regulatory perspective. In E. Wiener, B. Kanki, & R. Helmreich (Eds.), Cockpit Resource Management (pp. 263-282). San Diego, CA: Academic Press. Blake, R. R. & Mouton, J. S. (1964). The managerial grid. Houston: Gulf Press. Byrnes, R. E., & Black, R. (1993). Developing and implementing CRM programs. In E. Wiener, B. Kanki, & R. Helmreich (Eds.), Cockpit Resource Management (pp. 421-446). San Diego, CA: Academic Press. Cooper, G. E., White, M. D., & Lauber, J. K. (1980). Resource Management on the Flightdeck: Proceedings of a NASA/Industry Workshop. (NASA CP-2120). Moffett Field, CA: NASA-Ames Research Center. Edwards, E. (1972). Man and machine: Systems for safety. In Proceedings of the British Airline Pilots Association Technical Symposium (pp. 21-36). London: British Airline Pilots Association. [85]

Federal Aviation Administration (1997). Aviation safety action programs. Advisory Circular 120-66. Author. Helmreich, R. L. (1997). Managing human error in aviation. Scientific American, pp. 62-67. Helmreich, R. L., & Foushee, H. C. (1993). Why Crew Resource Management? Empirical and theoretical bases of human factors training in aviation. In E. Wiener, B. Kanki, & R. Helmreich (Eds.), Cockpit Resource Management (pp. 3-45). San Diego, CA: Academic Press. Helmreich, R. L. & Merritt, A. C. (in press). Culture at work in aviation and medicine: National, organizational, and professional influences. Aldershot, U.K.: Ashgate. Helmreich, R. L., & Taggart, W. R. (1995). CRM: Where are we today? In Proceedings of the CRM Industry Update Workshop. Seattle, WA, September 12-13, l995. Helmreich, R. L., & Wilhelm, J. A. (1991). Outcomes of Crew Resource Management training. International Journal of Aviation Psychology, 1(4), 287-300. Helmreich, R. L., Hines, W. E., & Wilhelm, J. A. (1996). Common issues in human factors and automation use: Data from line audits at three airlines. Austin, TX: NASA/University of Texas/FAA Technical Report 96-1. Helmreich, R. L., Merritt, A. C., & Sherman, P.J. (1997). Research project evaluates the effect of national culture on flight crew behaviour. International Civil Aviation Organization (ICAO) Journal, 51(8), 14-16. Helmreich, R. L., Butler, R. E., Taggart, W. R., & Wilhelm, J. A. (1994). The NASA/University of Texas/FAA Line/LOS Checklist: A behavioral marker-based checklist for CRM skills assessment. NASA/UT/FAA Technical Report 94-02. Revised 12/8/95. Austin, TX: The University of Texas. Helmreich, R. L., Chidester, T. R., Foushee, H. C., Gregorich, S. E., & Wilhelm, J. A. (1990). How effective is Cockpit Resource Management training? Issues in evaluating the impact of programs to enhance crew coordination. Flight Safety Digest, 9(5), 1-17. Arlington, VA: Flight Safety Foundation. ______University of Texas at Austin Human Factors Research Project: 235 Helmreich, R.L., Merritt, A.C., & Wilhelm, J.A. (1999). The evolution of Crew Resource Management training in commercial aviation. International Journal of Aviation Psychology, 9(1), 19-32. Evolution of CRM 11 Helmreich, R. L., Merritt, A. C., Sherman, P. J., Gregorich, S. E., & Wiener, E. L. (1993). The Flight Management Attitudes Questionnaire (FMAQ). NASA/UT/FAA Technical Report 93-4. Austin, TX: The University of Texas. Hines, W. E. (1998). Teams and technology: Flightcrew performance in standard and automated aircraft. Unpublished doctoral dissertation at The University of Texas at Austin. Hofstede, G. (1980). Culture’s consequences: International differences in work related values. Beverly Hills, CA: Sage. Merritt, A. C. (1996). National Culture and Work Attitudes in Commercial Aviation: A Cross-Cultural Investigation. Unpublished doctoral dissertation. The University of Texas at Austin. Merritt, A. C., & Helmreich, R. L. (1997a). CRM: I hate it, what is it? (Error, stress, culture). In Proceedings of the Orient Airlines Association Air Safety Seminar (pp. 123-134). Jakarta, Indonesia, April 23, 1996. Merritt, A. C., & Helmreich, R. L. (1997b). Creating and sustaining a safety culture: Some practical strategies. In B. Hayward & A. Lowe (Eds.), Applied Aviation Psychology: Achievement, change, and challenge (pp. 135- 142). London: Avebury Aviation. National Transportation Safety Board. (1979). Aircraft Accident Report: United Airlines, Inc., Douglas DC-8-54, N8082U, Portland, Oregon, December 28, 1978. (NTSB-AAR-79-7). Washington, DC: Author. Orlady, H. W., & Foushee, H. C. (1987). Cockpit Resource Management Training. (NASA CP-2455). Moffett Field, CA: NASA-Ames Research Center. Pettitt, M. A., & Dunlap, J. H. (1997). Cockpit leadership and followership skills: Theoretical perspectives and training guidelines. Washington, D.C: Federal Aviation Administration, AAR-100.

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Prince, C., & Salas, E. (1993). Training and research for teamwork in the military aircrew. In E. Wiener, B. Kanki, & R. Helmreich (Eds.), Cockpit Resource Management (pp. 337-366). San Diego, CA: Academic Press. Reason, J. (1990). Human Error. New York: Cambridge University Press. Reason, J. (1997). Managing the risks of organizational accidents. Aldershot, U. K: Ashgate. Sherman, P. J., Helmreich, R. L., & Merritt, A. C. (in press). National culture and flightdeck automation: Results of a multi-nation survey. International Journal of Aviation Psychology. Tullo, F. (in press). Instructor/evaluator training in error management. In R.S. Jensen (Ed.), Proceedings of the Ninth International Symposium on Aviation Psychology. Columbus, OH: The Ohio State University.

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UNITED AIRLINES FLIGHT 173 ACCIDENT NARRATIVE:

United Airlines Flight 173, departed New York-JFK on a scheduled flight to Portland International Airport (PDX), with an en route stop at Denver (DEN). The DC-8-61 took off from Denver about 14:47. The planned time en route was 2 hrs 26 min. The planned arrival time at Portland was 17:13. There was 46,700 lbs of fuel on board the aircraft when it departed the gate at Denver. This fuel included the Federal Aviation Regulation requirement for fuel to destination plus 45 min and the company contingency fuel of about 20 min.

At 17:05, Flight 173 called Portland Approach and advised that its altitude was 10,000 ft and its airspeed was being reduced. Portland responded and told the flight to maintain its heading for a visual approach to runway 28. Flight 173 acknowledged the approach instructions and stated, "...we have the field in sight." At 17:07, Portland Approach instructed the flight to descend and maintain 8,000 ft. Flight 173 acknowledged the instructions and advised that it was "leaving ten." At 17:09, Flight 173 received and acknowledged a clearance to continue its descent to 6,000 ft.

When the DC-8 was descending through about 8,000 ft, the first officer, who was flying the aircraft, requested the wing flaps be extended to 15 degrees, then asked that the landing gear be lowered. As the landing gear extended, an unusual sound was heard and the aircraft yawed. At 17:12, Portland Approach requested, "United one seven three heavy, contact the tower, one one eight point seven." The flight responded, "negative, we'll stay with you. We'll stay at five. We'll maintain about a hundred and seventy knots. We got a gear problem. We'll let you know." Portland Approach replied, "United one seventy-three heavy roger, maintain five thousand. Turn left heading two zero zero." The flight acknowledged the instructions. At 17:14, Portland Approach advised, "United one seventy three heavy, turn left heading, one zero zero and I'll just orbit you out there 'til you get your problem." Flight 173 acknowledged the instructions. For the next 23 min, while Portland Approach was vectoring the aircraft in a holding pattern south and east of the airport, the flightcrew discussed and accomplished all of the emergency and precautionary actions available to them to assure themselves that all landing gear was locked in the full down position. The second officer checked the visual indicators on top of both wings, which extend above the wing surface when the landing gear is down-and-locked. About 17:38, Flight 173 contacted the United Airlines Systems Line Maintenance Control Center in San Francisco. The captain explained to company dispatch and maintenance personnel the landing gear problem and what the flightcrew had done to assure that the landing gear was fully extended. He said they were planning to land in about twenty minutes.

About 17:44, the captain and the first flight attendant discussed passenger preparation, crash landing procedures, and evacuation procedures. At 17:46, the first officer asked the flight engineer, "How much fuel we got...?" The flight engineer responded, "Five thousand." About 17:50, the captain asked the flight engineer to "Give us a current card on weight. Figure about another fifteen minutes." The first officer responded, "Fifteen minutes?" To which the captain replied, "Yeah, give us three or four thousand pounds on top of zero fuel weight." The flight engineer then said, "Not enough. Fifteen minutes is gonna really run us low on fuel here." Some calculations were made and at 17:52 the flight engineer talked to Portland and discussed the aircraft's fuel state, the number of persons on board the aircraft, and the emergency landing

[88] precautions at the airport. A fuel check at 17:57 learned that there were 1,000 lbs in each tank, totaling 4,000 lbs of fuel. From 17:57 until 18:00, the captain and the first officer engaged in a conversation which included discussions of giving the flight attendants ample time to prepare for the emergency, cockpit procedures in the event of an evacuation after landing, whether the brakes would have antiskid protection after landing, and the procedures the captain would be using during the approach and landing. At 18:01, the flight engineer reported that the cabin would be ready in "another two or three minutes." At 18:02, the flight engineer advised, "We got about three on the fuel and that's it." The aircraft was then about 5 nmi south of the airport on a southwest heading. Portland Approach then asked Flight 173 for a status report. The first officer replied, "Yeah, we have indication our gear is abnormal. It'll be our intention, in about five minutes, to land on two eight left. We would like the equipment standing by. Our indications are the gear is down and locked. We've got our people prepared for an evacuation in the event that should become necessary." At 18:03 Portland Approach asked that Flight 173 advise them when the approach would begin. The captain responded, "...They've about finished in the cabin. I'd guess about another three, four, five minutes." At this time the aircraft was about 8 nmi south of the airport on a southwesterly heading. At 18:06, the first flight attendant entered the cockpit and reported that they were ready in the passenger cabin. At this time the aircraft was about 17 nmi south of the airport on a southwesterly heading. The captain then said, "Okay. We're going to go in now. We should be landing in about five minutes." Almost simultaneous with this comment, the first officer said, "I think you just lost number four ..." followed immediately by advice to the flight engineer, "... better get some crossfeeds open there or something." At 18:06:46, the first officer told the captain, "We're going to lose an engine..." At 18:06:49, the first officer again stated, "We're losing an engine." Again the captain asked, "Why?" The first officer responded, "Fuel." The captain replied, "Why?" Between 18:06:52 and 18:07:06, the CVR revealed conflicting and confusing conversation between flight crewmembers as to the aircraft's fuel state. At 18:07:06, the first officer said, "It's flamed out." At 18:07:12, the captain called Portland Approach and requested, "...would like clearance for an approach into two eight left, now." The aircraft was about 19 nmi south southwest of the airport and turning left. This was the first request for an approach clearance from Flight 173 since the landing gear problem began. Portland Approach immediately gave the flight vectors for a visual approach to runway 28L. The flight turned toward the vector heading of 010 degrees.

At 18:09:21, the captain advised Portland Approach, "United, seven three is going to turn toward the airport and come on in." After confirming Flight 173's intentions, Portland Approach cleared the flight for the visual approach to runway 28L. At 18:10:17, the captain requested that the flight engineer "reset that circuit breaker momentarily. See if we get gear lights." The flight engineer complied with the request. At 18:10:47, the captain requested the flight's distance from the airport. Portland approach responded, "I'd call it eighteen flying miles." At 18:12:42, the captain made another request for distance. Portland Approach responded, "Twelve flying miles." The flight was then cleared to contact Portland tower. At 18:13:21, the flight engineer stated, "We've lost two engines, guys." At 18:13:25, he stated, "We just lost two engines - one and two." At 1813:38, the captain said, They're all going. We can't make Troutdale." The first officer said, "We can't make anything." At 18:13:46, the captain told the first officer, "Okay. Declare a mayday." At 18:13:50, the first officer called Portland International Airport tower and declared, "Portland tower, United one seventy three heavy, Mayday. We're--the engines are flaming out.

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We're going down. We're not going to be able to make the airport." This was the last radio transmission from Flight 173. About 18:15, the aircraft crashed into a wooded section of a populated area of suburban Portland about 6 nmi east southeast of the airport. There was no fire. The wreckage path was about 1,554 ft long and about 130 ft wide.

PROBABLE CAUSE: "The failure of the captain to monitor properly the aircraft's fuel state and to properly respond to the low fuel state and the crewmember's advisories regarding fuel state. This resulted in fuel exhaustion to all engines. His inattention resulted from preoccupation with a landing gear malfunction and preparations for a possible landing emergency. Contributing to the accident was the failure of the other two flight crewmembers either to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain. "

Follow-up / safety actions: The NTSB made 4 recommendations to the FAA: 1) Issue an Operations Alert Bulletin to have FAA inspectors assure that crew training stresses differences in fuel-quantity measuring instruments and that crews flying with the new system are made aware of the possibility of misinterpretation of gage readings. (Class II--Priority Action) (A-79-32) 2) Emphasize to engineering personnel who approve aircraft engineering changes or issuance of Supplemental Type Certificates the need to consider cockpit configuration and instrumentation factors which can contribute to pilot confusion, such as the use of similar-appearing instruments with different scale factors. (Class II--Priority Action) (A-79-33) 3) Audit Supplemental Type Certificate SA3357WE-D for completeness, especially in the area of system calibration after installation. (Class II--Priority Action) (A-79-34) 4) Issue an operations bulletin to all air carrier operations inspectors directing them to urge their assigned operators to ensure that their flight crews are indoctrinated in principles of flightdeck resource management, with particular emphasis on the merits of participative management for captains and assertiveness training for other cockpit crewmembers. (Class II, Priority Action) (A- 79-47)

Sources: » NTSB Safety Recommendations A-81-14 » NTSB Safety Recommendations A-79-33 » NTSB-AAR-79-7

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Safety Management System- SMS Explained

Safety Management System (SMS) is becoming a standard throughout the aviation industry worldwide. It is recognized by the Joint Planning and Development Office (JPDO), International Civil Aviation Organization (ICAO), and civil aviation authorities (CAA) and product/service providers as the next step in the evolution of safety in aviation. SMS is also becoming a standard for the management of safety beyond aviation. Similar management systems are used in the management of other critical areas such as quality, occupational safety and health, security, environment, etc.

Safety Management Systems (SMSs) for product/service providers (certificate holders) and regulators will integrate modern safety risk management and safety assurance concepts into repeatable, proactive systems. SMSs emphasize safety management as a fundamental business process to be considered in the same manner as other aspects of business management.

By recognizing the organization's role in accident prevention, SMSs provide to both certificate holders and FAA:

 A structured means of safety risk management decision making  A means of demonstrating safety management capability before system failures occur  Increased confidence in risk controls though structured safety assurance processes  An effective interface for knowledge sharing between regulator and certificate holder  A safety promotion framework to support a sound safety culture

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Excerpted From 2010 UAL Proxy statement dtd. 4/22/11

Narrative to 2010 Summary Compensation Table and Grants of Plan-Based Awards Table The following is a description of material factors necessary to understand the information disclosed in the 2010 Summary Compensation Table and the Grants of Plan-Based Awards table.

Employment Agreements with Messrs. Smisek, Rowe, McDonald and Compton and Ms. Foxhall On October 1, 2010, in connection with the Merger, we entered into employment agreements with each of our continuing executive officers, including Messrs. Smisek, Rowe, McDonald and Compton and Ms. Foxhall. Each employment agreement has an initial term of two years (except Mr. Smisek’s employment agreement, which has an initial term of three years) and will renew automatically for additional one-year periods at the end of the initial term and each subsequent term unless notice of non-renewal is provided. The following describes the material terms of the employment agreements with our named executive officers: • Annual base salary. The initial base salary of each named executive officer was set as follows: Mr. Smisek, $975,000; Mr. Rowe, $750,000; Mr. McDonald, $850,000; Mr. Compton, $750,000; and Ms. Foxhall, $650,000. The base salary may not be reduced unless the reduction is the result of a generally applicable reduction imposed on substantially all of the officers of UAL and its affiliates, and in an amount proportionate to the reduction for other officers at substantially the same level as the applicable executive. • Annual bonus. Each of our named executive officers is entitled to participate in the Company’s annual cash bonus programs maintained for senior management. Mr. Smisek’s agreement provides that his annual bonus target opportunity will be equal to 150% of his annual base salary, which may range from 75% to 200% of base salary depending on the achievement of entry, target and stretch goals. For 2011, each of Messrs. Rowe, McDonald and Compton have an annual target incentive compensation opportunity equal to 135% of his annual base salary. Ms. Foxhall has an annual target incentive compensation opportunity for 2011 equal to 125% of her annual base salary. • Long-term incentive plans. Each of our named executive officers is eligible to receive grants under our long-term incentive plans at the discretion of the Compensation Committee. Mr. Smisek’s agreement provides for the grant in 2011 of a long-term incentive award with a grant date value (at target) of $8.4 million and a one-time Merger integration incentive award with a target value of $4 million based on the achievement of integration goals set by the Compensation Committee. • Other benefit arrangements. Each of our named executive officers is entitled to participate in all employee benefit plans, policies and programs maintained by the Company or its affiliates for similarly situated employees, including the Officer Travel Policy. Benefits provided in 2010 are identified in a footnote to the “All Other Compensation” column of the 2010 Summary Compensation Table.

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• Relocation Assistance. For a period beginning on October 1, 2010 and ending on the earliest of (i) October 1, 2012; (ii) the relocation of Mr. Smisek’s family to Chicago; and (iii) Mr. Smisek’s purchase of a permanent residence in Chicago, the Company will provide Mr. Smisek with an aggregate housing allowance of up to $15,000 per month. Messrs. Smisek, Rowe and Compton and Ms. Foxhall are eligible for relocation benefits as described in “Compensation Program Following the Merger—Relocation” above.

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Excerpted From House Transportation and Infrastructure Committee hearing on Jun 16, 2010 p. 24:

BOCCIERI: We expect you to do your job too, sir.

SMISEK: And I expect myself to do this job. And we...

(CROSSTALK)

BOCCIERI: You need to do this yourself. You need to make sure that your domestic carriers, and these international agreements that you're going to be making outsourcing jobs, and outsourcing training, and doing all the other stuff that is going to move this type of level of expertise off our coast needs to be maintained.

I can't sit here and guarantee as a representative of the people from Ohio who fly on your airline, and fly on other airlines, to be certain that this level of training is going to be maintained if we're going to be getting into these big agreements, too big to fail with other international carriers.

SMISEK: We are very focused on safety. The training of pilots across the globe is a responsibility too great for Continental Airlines. We do not have the resources. Each jurisdiction has its federal regulators. Each -- each jurisdiction has its regulation over safety. We participate and share our best practices. But if you take a look at -- at -- at Star Alliance. Star Alliance has rigorous requirements for joining, and rigorous requirements for safety.

And I'm confident in the safety of all the Star Alliance carriers. What you point to was a problem. There's no question about it. And -- and -- and -- and everyone in the aviation business, and I personally, and everyone at Continental regrets that training failure at Colgan.

That's been identified, and -- and -- and -- and we'll be I'm confident, corrected. And we need to make sure we all share your concern with safety. Safety is the most important thing that we have. But we can't possibly be responsible with the limited resources we have for the safety of every carrier in the globe, and every carrier that's out there.

We can be responsible for our own safety. We can certainly share our best practices and we do so. And we support all improvements in pilot training. And we support regulatory reform within the Federal Aviation Administration if that's what's required for oversight for U.S. carriers.

BOCCIERI: Oh, we're going to get that with the reauthorization bill. We're going to make sure that it's mandatory that pilots know how to recover from a full stall.

SMISEK: And I would support that.

BOCCIERI: Thank you.

COSTELLO: The chair thanks the gentleman.

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And -- and I was going to make that very point. Is that -- that that is the reason why we passed legislation through both the committee and -- and out of the House. That when we come out of conference, we are going to have a reauthorization bill that has the airline safety and Pilot Training Improvement Act, which will in course raise the standards for -- for pilots at the regional carriers as well.

We -- we recognize that both United and Continental, and some of the other major carriers do not hire at the lower standard, even though they can. But many of the regionals do. And that's what we found with Colgan. And that's what we have found with other regional carriers.

And I -- I would just interject as well, and agree with the gentleman that while it is the FAA's responsibility, it's also your responsibility as CEOs of -- of airlines that contract with regional carriers to make certain -- not just rely on the FAA, but to make certain that these regional carriers are hiring pilots that have training in excess of the minimum requirements as opposed to the minimum even after we increase the minimum requirements in the conference report.

With that, the gentleman from California, Mr. Garamendi is...

GARAMENDI: Mr. Chairman, thank you.

And -- and thank you for bringing up that last point. It -- you gave me a opportunity to cool down a little bit. I heard the most astounding testimony I've heard in my 34 years. That the chief executive officer of an airline that contracts for services to provide services to that airline -- in this case, Continental. And I -- I did not hear this from United. And pleased I didn't hear it, that it is not your responsibility to ascertain the safety of the pilots with whom you contract.

TILTON (?): Sir, I did not say that.

GARAMENDI: I am delighted to hear you didn't say that. Could you specifically tell me what your responsibility is with regard to the qualifications of those pilots with whom you contract on your flights?

(CROSSTALK)

TILTON (?): We -- we -- we do expect -- we do require all of our regional carriers to be safe carriers. Colgan in this instance had a training failure. It resulted in a terrible accident, which -- which -- which we regret tremendously. We are as focused on safety as you are, sir.

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UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK ------X AIR LINE PILOTS ASSOC., Plaintiff, 11 CV 4661 (SJ) -against- MEMORANDUM & ORDER UNITED AIR LINES, INC., Defendants. ------X A P P E A R A N C E S COHEN, WEISS & SIMON LLP 330 West 42nd Street 25th Floor New York, NY 10036 By: Evan Randall Hudson-Plush Michael Eckstein Abram Thomas N. Ciantra

Attorneys for Plaintiff O’MELVENY AND MYERS LLP 7 Times Square New York, NY 10036 By: Matthew F Damm Robert A. Siegel Attorneys for Defendant

JOHNSON, Senior District Judge:

Presently before the Court is the plaintiff Air Line Pilots Association’s (“ALPA” or “the Union”) application for a temporary restraining order (“TRO”) to enjoin the defendant United Airlines Inc. (“United” or “the Airline”) from “Scheduled Date”), pursuant to United’s complete operational merger with Continental Air Lines, Inc. (“Continental”), and known as the “Phase II changes.” ALPA alleges that the comprehensive nature of United’s Phase II changes far outstrips the actual training United has provided to its pilots. Specifically, ALPA charges that United has offered only computer-based training and maintains that the pilots need actual classroom training and/or use of training devices to fully absorb the regime change. ALPA further charges that the Airline’s plan of moving forward on the Scheduled Date notwithstanding the Union’s expressed concerns about the adequacy of the training amounts to a unilateral decision on the part of United concerning the content of pilot training, in violation of the parties’ collective bargaining agreement under the Railway Labor Act, 45 U.S.C.A. § 151 et seq. (the “RLA”), the regulatory scheme that addresses, among other things, labor-management issues in the railway and airline industries. ALPA filed a contract grievance before an arbitrative panel known as the United Pilots System Board of Adjustment (the “Board”) on September 22, 2011, seeking expedited review and sought United’s consent to stay the implementation of the Phase II changes until a decision from the Board. United refused, and, on September 26, 2011, ALPA filed a motion for a preliminary injunction before this Court seeking to enjoin the effective date of the Phase II changes pending a decision from the Board. On September 27, 2011, the parties consented to convert the motion to one for a temporary restraining order (“TRO”). The Court held a hearing on the application on September 28, 2011. After considering the parties’ submissions and oral argument, and for the reasons set forth below, ALPA’s application for a TRO is DENIED.

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ANALYSIS Injunctive relief “is an extraordinary and drastic remedy, one that should not be granted unless the movant, by a clear showing, carries the burden of persuasion.” Maruzek v. Armstrong, 520 U.S. 968, 972 (1997) (emphasis omitted). Under Rule 65 of the Federal Rules of Civil Procedure, a party seeking a TRO or a preliminary injunction “must demonstrate (1) the likelihood of irreparable injury in the absence of such an injunction, and (2) either (a) likelihood of success on the merits or (b) sufficiently serious questions going to the merits to make them a fair ground for litigation plus a balance of hardships tipping decidedly toward the party requesting the preliminary relief.” Fed. Express Corp. v. Fed. Espresso, Inc., 201 F.3d 168, 173 (2d Cir. 2000) (citations omitted); see also Lynch v. City of New York, 589 F.3d 94, 98 (2d Cir. 2009) (“[w]here the moving party seeks to stay governmental action taken in the public interest pursuant to a statutory or regulatory scheme, the . . . court should not grant the injunction unless the moving party establishes, along with irreparable injury, a likelihood that he will succeed on the merits of his claim”). The Court further notes that the parties agree that the instant dispute is properly characterized as “minor” pursuant to the RLA’s distinction between “major” and “minor” labor-management disputes. See generally Elgin, Joliet & E. Ry. v. Burley, 325 U.S. 711, 723 (1945). In the case of “minor” disputes, the general rule is that a union is not entitled to an order preserving the status quo pending the resolution of the dispute by an arbitrative panel, absent a finding that the union would suffer such irreparable harm from denial of an injunction that a later arbitrative ruling in the union’s favor would be meaningless. See e.g., Brotherhood of Locomotive Eng’rs v. Missouri-K.-T. R.R. Co., 363 U.S. 528, 533-34 (1960); Local 553, TWU v. Eastern Air Lines, Inc., 695 F.2d 668, 675 (2d Cir. 1982); Local Lodge 2144, Brotherhood of Ry., Airline and S.S. Clerks v. Railway Express Agency, 409 F.2d 312, 316-17 (2d Cir. 1969). Here, the Court finds that ALPA cannot bear its burden under the first prong of the test for injunctive relief: ALPA cannot show it will suffer irreparable harm in the absence of this Court enjoining United from proceeding with the Phase II changes on the Scheduled Date. ALPA’s failure to demonstrate such harm is sufficient for the Court to deny ALPA’s application for a TRO, without the need to address the second prong of the test or the balance of the parties’ arguments. See Reuters Ltd. United Press Int’l, Inc., 903 F.2d 904, 907 (2d Cir. 1990) (“a showing of probable irreparable harm is the single most important prerequisite for the issuance of a preliminary injunction.”). ALPA’s case for irreparable harm in the absence of an injunction is two-fold: (1) the purported erosion of the Board’s remedial authority; and (2) the alleged risk of diminished flight safety. The Court finds that both lines of argument are too speculative—and thus insufficient in the Second Circuit where irreparable harm justifying injunctive relief must be “actual and imminent.” Tucker Anthony Realty Corp. v. Schlesinger, 888 F.2d 969, 975 (2d Cir. 1989) (internal quotations omitted); see also Jack Kahn Music Co. v. Baldwin Piano & Organ Co., 604 F.2d 755, 759 (2d Cir. 1979). First, concerning ALPA’s argument that absent an injunction the Board’s jurisdiction would be irreparably harmed, the Court finds it specious. For this assertion to survive scrutiny the following proposition also needs to be true: the failure of a district court to preserve the status quo pending an arbitrator’s ruling on a minor dispute, in and of itself, constitutes irreparable harm. There is, however, no support for this broad proposition in the case-law. The three cases ALPA cites in support of this branch of its irreparable harm argument—Brotherhood of Locomotive Eng’rs, 363 U.S. 528, I.A.M. v. Eastern Air Lines, Inc., 847 F.2d 1014, 1019 (2d Cir. 1988) and Local Lodge 2144, 409 F.2d 312—all pivot upon a finding of “actual and imminent” harm to the union employees in those cases, and not merely on the harm to the jurisdiction of the arbitrative body per se. In Brotherhood of Locomotive Eng’rs, the Supreme Court approved a district court order requiring a rail carrier to maintain the status quo pending arbitration of certain proposed changes that would have eliminated union jobs. Key to that ruling was the lower court’s finding that the loss of union jobs was imminent, and, as such, was an injury so irreparable that a later arbitrative ruling “in the union’s [97] favor would be but an empty victory.” Brotherhood of Locomotive Eng’rs, 363 U.S. at 534. The Supreme Court went on to emphasized that “[f]rom the point of view of these employees, the critical point in the dispute may be when the change is made, for, by the time of the frequently long-delayed [arbitrator’s] decision, it might well be impossible to make them whole in any realistic sense. . . .” Id. Similarly, in I.A.M., the Second Circuit affirmed an order enjoining an airline from decreasing the amount of time a shop steward could work on union-related duties, which included assisting union employees with filing grievances, pending an arbitrative ruling on the issue. Key to the decision was the district court’s finding that the demand for the steward’s assistance in processing employee grievances had significantly increased due to recent layoffs at the airline, and that without his assistance employee grievances would have gone unheard—an actual and imminent harm to those employees. 847 F.2d at 1019. Finally, in Local Lodge 2144, the Second Circuit also affirmed an order restraining a railway carrier from moving its operation pending an arbitrative ruling on whether union employees were entitled to a job transfer. Key to the ruling was the district court’s finding that union employees would suffer irreparable injury in the immediate loss of jobs absent a stay to permit the arbitrator time to decide the issue. 409 F.2d at 317–18. In short, what ties all these cases together is the element missing here: namely a showing that ALPA’s pilots would personally suffer “actual and imminent” injury from this Court’s denial of an injunction, which would render any potential victory for ALPA before the Board meaningless for its members.

Second, concerning ALPA’s argument of irreparable injury in the form of an increased risk to safety, the Court notes that ALPA concedes that the Federal Aviation Administration (“FAA”), the federal agency charged with airline safety, has already approved United’s computer-based training for the Phase II changes. At oral argument, ALPA’s counsel nevertheless suggested that in seeking to enjoin the implementation of the Phase II changes on the Scheduled Date, ALPA simply seeks to hold United to a higher standard of safety than the FAA requires. That may very well be and the Court does not, in theory, disagree with counsel’s statement that when it comes to airline safety we shouldn’t “operate on hope.” However, there is nothing in ALPA’s submissions to support a finding that the FAA has somehow been negligent in carrying its regulatory mandate, or to suggest that the agency’s oversight and/or conduct in the instant action places it outside the orbit of deference it is entitled to under Chevron v. Natural Resources Defense Council, 467 U.S. 837 (1984). See e.g., Southeast Queens Concerned Neighbors Inc. v FAA, 229 F.3d 387, 394 (2d Cir. 2000) (recognized that the FAA is entitled to Chevron deference in aviation matters); J. Andrew Lange. Inc. v. FAA, 208 F.3d 389, 391–92 (2d. Cir. 2000) (same). In light of the FAA’s regulatory authority and on-going oversight of all phases of the United and Continental merger, the Court has no choice but to deem the increase risk to safety ALPA alleges as being too “remote and speculative” to lift the Union’s TRO application off the ground. The Court further notes that ALPA’s inability to substitute the FAA’s determination concerning the adequacy of United’s computer-based training with its own assessment is not irreparable harm.

Therefore, because ALPA has failed to demonstrate irreparable harm, its request for a TRO as to the implementation of the Phase II changes on the Scheduled Date must be DENIED. The Court has considered all of the additional arguments advanced by both parties, and find them unnecessary to dispense with this instant application, as ALPA’s failure to demonstrate irreparable harm is dispositive.

CONCLUSION For the foregoing reasons, ALPA’s motion for a TRO enjoining United from implementing its revised flight operations policies and procedures on Friday September 30, 2011, is DENIED. SO ORDERED. [98]

Dated: September 29, 2011 ______/s/______Brooklyn, NY STERLING JOHNSON, JR. Senior United States District Judge Case 1:11-cv-04661-SJ-SMG Document 11 Filed 09/29/11 Page 8 of 8 PageID #: 491

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