If you follow my column at all, you will recognize that I often use aviation investigations as a reference. I believe that the Crew Resource Management (CRM) that is practiced in today’s modern aviation parallels the same CRM we should be using when acting as an IC or when directing task level work as a company officer. My department is fortunate to have a close working relationship with MedTrans – Air Medical Transport and this quarter’s reference comes from an article written by David Carr, the Director of Safety with MedTrans.
On October 4, 2004, a Canadian Regional Jet (Bombardier CRJ200) crashed 2.5 miles from the Jefferson City airport. Prior to the control inputs performed by the pilots, there was absolutely nothing wrong with the plane. The flight was intended to reposition the aircraft from one airport to another and as a result, there were no passengers on the plane and the crew consisted of only the two pilots. Given the light load that the plane would be carrying, the two pilots agreed prior to departure that they would use the opportunity to become members of the elite “410 Club.” The CRJ200’s maximum operating altitude was 41,000 feet (flight level 410). The CRJ200 was a little underpowered and since most flights had a lot of passengers and luggage on board, it was virtually impossible to join the 410 club in a CRJ200 unless it was empty.
Their flight plan had them established for a cruising altitude of 33,000 feet; however, shortly after takeoff, the crew requested the higher altitude (41,000). The flight data recorder (FDR) and cockpit voice recorder (CVR) documented several aggressive aircraft pitch ups and continued chatter in the cockpit about what a great time the pilots were having. As they passed through 38,000 feet, despite having full power selected, the aircraft began to trade off speed for altitude. Slowly they inched the aircraft towards their goal. As they leveled off at flight level 410, the air traffic controller called them: “Are you an RJ200? I’ve never seen you guys up at 41.” The pilots replied, “Yeah, we don’t have any passengers on board so we decided to have a little fun and come on up here.”
As the aircraft continued to bleed off airspeed in an attempt to hold its maximum service altitude, it began to warn the pilots. First, the stick shaker went off which vibrated the control yoke to warn the pilots that they were flying too slow for their altitude. Still at maximum power, it could not go any faster. Next, the aircraft activated the stick pusher which nosed the aircraft down automatically in an attempt to increase airspeed. The pilot overrode the stick pusher and continued to raise the nose of the aircraft well above the horizon. The turbulent air entering the engines due to the high angle of attack caused the engines to reach 2,200 degrees Celsius (600 degrees above redline). Both engines then flamed out. The pilots initially reported to air traffic control that they had a single engine flameout, despite both engines being inoperative. They initially attempted a “windmill re-start” but did not get the aircraft to a high enough speed in its descent. At 20,000 feet, they frantically tried to use the Auxiliary Power Unit (APU) to start the engines, but the excessive heat caused by running the engines well above redline had melted the engine components and prevented them from functioning properly. Finally, after admitting their dire circumstances, the captain declared an emergency and started a descent to one of six airports within power off glide distance. Twelve minutes after flameout, the crew finally admitted to air traffic control that they had a dual engine flameout. While attempting to trade altitude for airspeed and glide the plane to the nearest airport, they came up short. Both pilots were killed in the crash. Thankfully, no one on the ground was injured.
Whether we are shopping at the store while on duty, checking our apparatus, or part of an interior suppression crew, we must recognize the lessons learned from this case study. In this case, a perfectly functioning aircraft was made into a glider by a series of bad decisions. In all of the activities mentioned above, we often face similar decisions with the potential for catastrophic consequences when we choose poorly. It could be as simple as us not returning the cart to the drop off point in the parking lot or not helping the elderly woman with loading her groceries into her vehicle. The consequence of our decisions may only be that we portray our department in a negative way. Should we choose to “pencil-whip” our check sheet during apparatus checks without properly ensuring our equipment is functional, it could result in that equipment failing us at an emergency. During fire suppression activities, if we choose to remain in a place where we should not be, one that we were not prepared to go and despite recognizing the hazards, we do not correct our position, we could end up in a similar outcome as these two pilots.
As an incident commander or as a company level officer, we sometimes make bad decisions. As Chief Brunacini would say, “Be careful of reinforcing an already bad operating position. This often results in us doing the wrong thing harder.” We have to recognize when we are in a bad position, whether organizationally at the grocery store or tactically inside a structure fire. Once we recognize our position, we need to make better decisions to improve it.
Whether you are a career or volunteer firefighter, we should maintain a professional discipline that considers David Carr’s conclusions and attributes to live by cited in his article. Don’t find yourself somewhere you aren’t prepared to go. Resist peer pressure and do what is right regardless of what the culture is. Pride yourself on being disciplined, especially when no one is watching. It is the sign of a true professional. Exercise sound judgment. Never write yourself a waiver for this just to have some fun. Maintain your technical knowledge and skills — at least enough to know how to get out of what you put yourself into. Practice rigorous integrity.
We should always consider what we are doing and what the perception of it will be to the public. More importantly, we need to consider what we are doing and if it is going to harm us. While recognition is important, it is the decisions we make after this recognition that will ultimately improve our outcome. This could be as simple as avoiding a negative perception of the fire service or as complicated as avoiding a line of duty death (LODD) funeral. By maintaining professional discipline, we hope to avoid the situation entirely. Do what’s right, even when no one is watching.
Be safe and do good.