The Deadliest Crash – do Pilots make better captains?

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TECHNICAL Contributor
Oct 3, 2006
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Wisconsin - Winnebago Pool chain of lakes
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280 Sundancer, Westerbeke MPV generator
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twin 5.0's w/BIII drives
Last night I watched the documentary “The Deadliest Plane Crash”

The documentary lays out a series of mistakes and unusual situations that combined to result in the deadliest plane crash in history.

In summary, the Tenerife airport disaster was the collision of two Boeing 747 airliners on the runway of Los Rodeos Airport (now known as Tenerife North Airport) on the Spanish island of Tenerife, one of the Canary Islands. With 583 fatalities, the crash remains the worst accident in aviation history.

The #1 issue was pilot error.

The documentary moves onto lessons learned and changes in pilot training.

At the core of the lessons learned is training that the airplanes captain accept and encourage crew to question and point out mistakes rather than remain silent.

OK, we have several pilots amongst us. Is the documentary correct that the commercial pilot training now places an emphasis on accepting crews concerns and if so, could this also apply to making boating safer?
 
I think so.

I can't remember how many times, someone on my boat has brought my attention to something I didn't notice.
Sometimes it's been something, sometimes it's been nothing. But I always welcome input from crew or guests. It's their comfort level or safety too!
Ultimately it's my decision, but I take differing points of view to make as best a decision as I can. This ranges from where "we" dock/anchor the boat to it's safe handling/operation.
 
Doug,

Besides number of occasions from the past I think this is covered in safety courses (at least in my class it did). I don't recall 100% about the situation with good visibility, but our instructor had suggested always having extra pair of eyes in poor visibility (day or night). Although, it’s obvious in poor visibility, but it also implies that extra pair of eyes only helps. Just like islandhopper00, I always welcome any input from my crew, even the kids. Believe it or not my daughter (about 8-9yrs at the time) helped to save the day few years ago. The information you get from the crew can cause a distraction, but it can also save you. So, captain makes the final decision on how to react to the given information. I think this applies to anything moving on the road, water or flying.

Alex.
 
This is true. The problem, historically, has been that the most arrogant of Captains/Pilots are usually the ones that need the most assistance. They get tired of constantly being corrected by others - and the other person being right. My experience is that the most capable are the most open to input. Maybe that's how they get that way.

CRM (Cockpit/Crew resource management) is at the forefront of all respected aviation training programs. The human animal makes mistakes. Let's minimize the impact of those mistakes.
 
This is true. The problem, historically, has been that the most arrogant of Captains/Pilots are usually the ones that need the most assistance. They get tired of constantly being corrected by others - and the other person being right. My experience is that the most capable are the most open to input. Maybe that's how they get that way.

CRM (Cockpit/Crew resource management) is at the forefront of all respected aviation training programs. The human animal makes mistakes. Let's minimize the impact of those mistakes.

"CRM (Cockpit/Crew resource management)" Wow, I love that term.

When we have guests onboard I have a printed / laminated pre-departure safety briefing. I don’t include stuff like “Don’t flush tampons.” The briefing is 100% safety with some humor added for effect to aid in the guests attention.

I have read suggestions from others on things to add but so far I never have added items since the suggestions are not focused on safety, more like protecting the boat from damage or general common courtesy.

This is real. Any suggestions on what to say to convey bringing safety related concerns to the attention of the captain?
 
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I watched a different documentary on a plane crash in England. (if I remember correctly). I'm sure some one will correct the story, but the jist of the story was that one engine caught fire and the crew ended up shutting down both engines, then re-started the engine that caught fire leaving the good engine shut off. The plane never made it and everyone died. The lesson in that crash was that passengers knew which engine caught fire and new that the wrong engine was shut down but never reported or complained to the captain because they figured that the captain and crew knew what they were doing.

I was a on plane that landed and it sounded as if a tire had a broken belt or a flat spot. It was vibrating and thumping all they way down the runway. When I was getting off the plane I waited to speak to the captain to report it directly to him. He was not aware of any issue. Not sure what the outcome was.

I think all smart captains will take as much feedback and information as possible and investigate all issues. (providing they have the time to do so and are not in the middle of landing a plane )
 
Come to think of it, my lovely wife does an excellent job of pointing out every mistake I make.

Now if I could get her to focus on safety related issues.
 
One other thing not mentioned. Flight training and recurrent training stresses being ready for "events." They are anticipated, risks mitigated, and corrective action practiced. Contrast this with the typical boater who doesn't even think about what could go wrong or brushes off risks with, "Yeah, but that couldn't happen to me."

The guy who has a few drinks before or while at the helm.
The guy with people sitting on the foredeck while the boat is running.
The guy running too fast in conditions (night, fog, rain) where he has little experience.
Etc.

Best regards,
Frank
 
Is the documentary correct that the commercial pilot training now places an emphasis on accepting crews concerns and if so, could this also apply to making boating safer?

Like the others said, yes, this accident and others changed how things are done. That happened in 1977. That accident also lead to more standardized radio communication, but that's another story.

Most majors now train under a program the FAA introduced in the late 70's called the "Advanced Qualification Program," or AQP. As mechanical machines became more reliable, it became apparent that humans were to blame for an increasing percentage of the accidents. One of AQP's main differences in training is that they got away from maneuvers-based training and emphasized line-oriented training centered around Crew Resource Management, or CRM.

Now our debriefs in recurrent training start by asking the person in the lowest position how they thought the event turned out. This would be the copilot on a 2-man crew or Flight Engineer with three. Nine times out of ten, the captain will interrupt anyway, but the idea is to demonstrate that even though the captain was right there, he may not have been open to or able to process all the information, which in turn may have lead to errors as they worked through a situation. The captains are often surprised by what they didn't know.

Additionally, captains are given team-building suggestions. A captain who starts the trip by buying the FO a cup of coffee will get better information than the guy who tells the FO, "not another f'ing Navy/AF/helicopter/commuter guy..."

This all comes back to boats--CRM is being taught to shipping captains. Also, you've seen it on your boat. You may be the one in charge, but sometimes somebody else has information you need and it's up to you to keep from building walls and keep the flow of information going. For example, if you tell your wife that she doesn't know anything and that you're tired of hearing from her, she may not share with you that the bilge is overflowing with water and you're seconds from sinking.

-Former AQP Developer
 
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C-5 crashed at Charleston, I believe. One engine had malfunction (thrust reverser?) on takeoff for overseas flight. They pulled that engine back and shut it down. On return for landing, the pilot started using that engine and the two outboard engines (left the middle, good engine at idle). They hit the ground just short of the runway and broke apart. All survived. Engineer knew what pilot was doing. New procedure: After shutting one down, all 2,3 or 4 throttles are matched up (push good and bad engines back up when power is needed).

Aircraft has a light bulb out in landing gear indicator. They fly circles for quite a while trouble shooting the problem. They run out of gas and crash and kill everyone. Flight engineer kept trying, however quitely, to tell the Captain that they were running low on gas and needed to turn inbound to the runway.

F-15 engine catches fire. Pilot shuts it down and heads home. Fire stays burning. Wingman (engineer, by training) tells Emergency Pilot that as he slows down, the fire will "Tend to propogate forward in the fuselage" so he may opt to keep his speed up. Pilot crosses runway threshold fast, lands, can't slow down, runs off the far end and ejects. The HUD catches the ejection on tape as good engine is still running after crash.

People are F'd up. Don't be a people.
 
Bottom line Gentlemen is, you are the owner and Captain. You rule, if you don't, don't do it.
 
No question on who is the captain. The issue is how well of the job does the captain do managing resources such as the crew? Do you alienate them with your greatness, or bring them into your decision-making process?
 
OK, we have several pilots amongst us. Is the documentary correct that the commercial pilot training now places an emphasis on accepting crews concerns and if so, could this also apply to making boating safer?[/QUOTE]

Well speaking as a pilot with a varied career spanning from airplanes to helicopters to tilt-rotors, and as an inexperienced boater wannabe, I can say that not only CRM (crew/cockpit resource mgmt) but ORM (Operational Risk Management) will make boating a safer proposition for me--as soon as I talk the wife into it. CRM deals not only with involving your whole crew in the decision-making process, but also using automation to your advantage. I wouldn't attempt to fly IFR (instruments in the clouds) without a thorough understanding of the CMS (cockpit management system, aka: glass cockpit). Likewise, I wouldn't attempt to navigate without visual references on the surface without a strong working knowledge of my chartplotter. After all those annual safety briefs and case studies, I'd say one thing my background does for me, whether planning a flight from Carolina to SoCal or loading up the Yukon for Hilton Head, is to send out warnings when I start down that slippery slope toward a mishap. Inadequate sleep: I wake up next to a red flag. Last minute change of plan: flag. Convective activity: flag. Equipment anomaly: flag. Non-essential equipment failure: flag. Accepting those failures I wouldn't accept on a more routine mission: flag. Pressure to accomplish the mission against all odds: flag. Pushing it to the end of my crew day: flag. Eventually I'm surrounded by a ring of flags, and see myself becoming a case study. Time to cease, divert, return to base, or whatever gets us home to mama safely.
I'm involved in the type of aviation which is inherently dangerous. V22s wouldn't have a .50 cal and a belly-mounted GAU-17 gatling gun on board if that weren't the case (as of last month; thank you General Conway). That's where ORM comes into play. Raiding an insurgent camp in the middle of an Arabian Night (or Persian Night) to pick up a high-value target is risky. So is boating at night, I'd imagine. With ORM you weigh the risk vs. the gain. Is it worth it to keep pushing, or do we stop here?
I'm thinking of my first week of flight school at NAS Pensacola, one of the few times I'd actually volunteered an answer in a classroom setting... The Navy commander stands up in front of the Aviation Preflight Indoctrination Class as begs the question:
"Do you think safety is our highest priority in Training Wing Five?"
Heads nodded in blind agreement, accompanied by faint whispers of affirmation.
"No." All eyes snap toward the back of the room.
"Training is your highest priority. If it were safety, we'd never leave the ground."
"Correct Lieutenant. Now sit down."

You don't have to be a pilot to benefit from ORM, you just have to allow yourself pause, and then ask: is it worth it?
Sometimes it is.:thumbsup:

BTW, I'm not completely green on the subject of boating. I did serve on the USS Bataan (LHD5), USS Kearsarge (LHD3) and USS Ponce (LPD15), spending over a year of my life at sea. I just wasn't the guy at the helm--but I've been to some pretty awesome ports!
 
Welcome aboard MarineGuy! As a retired "Nasal Radiator" I enjoyed your post. Yes, I remember a lot of night cat shots with red flags. But sunrises over the Bering sea in the 747 at FL 350 were fun too (avatar pic).

Hope you are not "boatless" for too long.
 
Marineguy,

Welcome and thank you for your service to our country.

I look forward to reading more of your posts.

Three post up, Hamptom (John) is a military pilot and has been kind enough to share a his perspective on various boating situations as well and I love reading his posts.

Again, welcome!
 

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