Crew Resource Management


CarolinaFireJournal - Dr. David Greene
Dr. David Greene
01/31/2017 -

On 1 June 2009, Air France Flight 447 (AF447), an Airbus A330, crashed into the Atlantic Ocean killing all 228 passengers and crew on board. The investigation ultimately revealed that nothing was wrong with the airplane. While I hesitate to jump on board with those that blame the pilots every time a plane goes down, in this case the black boxes that record instrumentation and voices in the cockpit demonstrated that the crash was a result of ineffective crew resource management. 

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On 1 June 2009, Air France Flight 447 (AF447), an Airbus A330, crashed into the Atlantic Ocean killing all 228 passengers and crew on board. The investigation ultimately revealed that nothing was wrong with the airplane.

AF447 was travelling from Rio de Janeiro, Brazil to Paris, France. As the flight passed through the equator, it encountered the outer extremities of a tropical storm system. Just a few minutes after 2:00 a.m., the captain of the plane leaves the flight deck to take a nap, leaving the controls in the hands of two co-pilots. The captain was unaware that in just 15 minutes, everyone on board would be dead. The two co-pilots are 32-year-old Pierre-Cedric Bonin and 37-year-old David Robert, who has more than double Bonin’s total flight hours. Despite being more experienced, the captain leaves Bonin in charge of the plane.

Because the plane is still “heavy” with fuel, climbing above the storms they encounter is not possible. Just five minutes after the captain has left the flight deck, a noise is heard in the cockpit indicating that the autopilot has disconnected. This is a result of the plane’s pitot tubes, externally mounted sensors that determine air speed, that have iced over. This means that the pilots will have to fly the plane by hand and are unable to rely on the autopilot. Neither Bonin nor Roberts have received training in how to handle this type of situation. Bonin unexpectedly pulls back on the stick and puts the plane into a steep climb. Shortly after, the plane’s cricket and voice “stall” warnings begin to alert. Airbus designed this system to be impossible to ignore or miss. Nevertheless, both pilots pay the alerts no attention despite the alerts going off 75 times during the next five minutes.

A “stall” is when a plane is not generating enough forward speed across its wings to generate lift. Normally, to recover from a stall, the pilot should push forward on the stick to generate forward speed, which may have to initially be traded for altitude.  Bonin, however, continues to pull back on the stick causing AF447 to climb at a blistering 7,000 feet per minute. AF447 is soon only traveling at 93 knots, a speed that is more typical of a small Cessna and not a jumbo jet. The pitot tubes are de-iced and begin working again, which means there is now absolutely nothing wrong with the airplane. Despite this fact, Bonin continues to apply thrust to maximum power and pulls back on the stick. As the aviation investigation revealed, “Intense psychological stress tends to shut down the part of the brain responsible for innovative, creative thought. Instead, we tend to revert to the familiar and the well-rehearsed.”

Bonin is trying to fly the plane as if it were close to the ground, but the thinner air translates to less thrust from the engines and less lift by the wings. AF447 reaches its maximum altitude, moves horizontally for an instant, and then begins to descend with the nose still pitched high in the air. Robert recognizes that they need to lower the nose of AF447 and begins to push his stick down, but with Bonin still pulling his stick backwards, the computer aggregates the two inputs and keeps the nose of the aircraft pitched upwards. Because there are two co-pilots on the flight deck, there is no clear line of authority as neither is superior or subordinate, like when the captain is on the flight deck. Robert, the more senior of the pilots, begins to see the altitude spilling off rapidly and makes the same mistake as Bonin. He begins pulling back on the stick. The plane is now descending at 10,000 feet per minute and is travelling less than 60 knots. This causes the computer to think that the airspeed inputs are invalid and it silences the “stall” warnings.

While the pilots may have thought their situation was improving, the reality was very much the opposite. The captain re-appears in the cockpit and is quickly briefed by the co-pilots. He urges the co-pilots to climb to which they reply that they have been the entire time. The captain then realizes the problem and instructs Robert to lower the nose in an attempt to recover from the stall. Unfortunately, the plane is now passing through 2,000 feet and a new warning arises, the ground proximity warning system (GPWS). There is not enough time left to build up speed and generate lift by pushing the nose down. AF447 hit the water at 108 knots with its nose still pitched in the air. The aircraft broke up on impact and there were no survivors, despite the plane being in perfect working order.

This example of a failure in crew resource management is applicable to many line of duty death reports.  Even if our crews do not arrive at the scene on the same apparatus, they must work together to complete the tasks that they are assigned. This starts with a clear line of authority and is something that we may be missing. Let’s take a lesson from the military. We frequently designate these four firefighters as Company 1 or Engine 1 and we designate that the captain or lieutenant will be in charge of that group. But what happens if the captain of that group is the one that gets lost, is gravely injured or has a medical emergency? Who is in charge of the company then? We may not be clearly defining that or training on that, but it is something we need to consider. As in the case of AF447, the more senior and experienced pilot did not take command of the aircraft when it first encountered the temporary icing and failure of its pitot tube speed indicators. Who will take command of our crew when its senior most member is incapacitated? We need to be thinking about that before it happens. 

Next, we need to remember what the aviation investigators say about psychological stress. It tends to shut down the brain’s creative thinking centers and causes us to revert to the familiar and well rehearsed. Next time you hear a member of your department complain about training on the same tactics “yet again,” tell them it is because you read an article about a plane that crashed that had nothing wrong with it. The co-pilots of AF447 had received no training on the situation with which they were dealt. As a result, they reverted to what they were familiar with, which ultimately doomed the souls on board. In order to combat this, we also have to train on the creative and obscure situations in order to make them our default knowledge. Try this: next time you have a company of four people working in a training scenario, grab their company officer and tell the rest that their company officer has collapsed. See how many ideas come up on how to get them out.

Crew resource management also requires the feedback and input of everyone involved. If you are an incident commander, you rely on the reports of your crews to continue with or change your strategies.  Think about AF447, when did the captain realize what the problem was? It was when he urged the co-pilots to climb and one stated that they had been the entire time. It was then that the captain realized that they needed to lower the nose in order to recover from the stall. This also reinforces the need for focus when acting as an incident commander. Even though the captain was only missing from the flight deck for 10 to 12 minutes, it was a critical window of opportunity that could have prevented the tragedy.

Finally, we need to consider our interpersonal communications with one another and how it might affect our crew resource management. Have you ever asked a question of someone and been pre-disposed to accepting or rejecting their answer based on your established opinion of that person? Let me answer that for you. Yes, you have. We do it on a daily basis. On the fire ground however, we must not. Anyone, even those whose opinions may be the “least important” to us, may have a critical piece of information that will allow us to make a critical decision. Would any of the pilots of AF447 paid attention to one of the stewardesses in regard to flying the plane? Probably not. But consider this, shortly before AF447 encountered the weather, the pilots advised the stewardesses that they should sit down and buckle up because they were concerned about turbulence. If one of the stewardesses, looking out the window from their seated, buckled position, had called the flight deck and said, “Hey, there is a significant amount of ice accumulating on the windows back here, I just wanted to let you know,” that could have triggered the pilots to activate the pitot tube heaters, which could have prevented the loss of air speed indicators. This could have prevented the entire disaster.

If you have a 16 year old junior firefighter/explorer on the fire scene and they tell you (as the I.C.) that it looks like “the roof is moving downward” on the fire building, then you had better pay attention to what they are saying. To ignore a critical piece of information like that at the wrong time could have disastrous results. Crew resource management (CRM) is often defined as a set of training procedures for use in environments where human error can have devastating effects and focuses on interpersonal communications, leadership and decision-making. In the end, we are all part of “the crew.” Whether we are a member of a crew of four, a company officer leading a crew of four, or the incident commander coordinating companies or groups, we all have to work together, communicate, and be “on the same page” if we are to effectively mitigate the incident.

Be safe and do good.

Dr. David A. Greene has over 25 years of experience in the fire service and is currently the deputy chief with Colleton County (S.C.) Fire-Rescue. He holds a PhD in Fire and Emergency Management Administration from Oklahoma State University and an MBA degree from the University of South Carolina. He is a certified Executive Fire Officer through the National Fire Academy, holds the Chief Fire Officer Designation from the Center for Public Safety Excellence, holds Member Grade in the Institution of Fire Engineers, is an adjunct instructor for the South Carolina Fire Academy and is a Nationally Registered Paramedic. He can be reached at [email protected]
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Issue 32.2 | Fall 2017

Keeping First Responders Safe
Ideas to improve safety on the job, leadership, serving our community and keeping the desire to serve others...