Popular Mechanics examines Air France Flight 447, which was flying from Rio de Janeiro to Paris on 1 June 2009 when it crashed into the Atlantic Ocean, killing the 228 passengers and crew.
The incident happened after a build-up of ice caused the autopilot to completely disengage. Two equally-ranked first officers safely took manual control of the plane and tried to increase the altitude. However in doing so the plane began to signal an audible stall alarm (which occurred 75 times during the course of the incident), which was seemingly ignored. After they had gained altitude and speed one of the pilots then tried climbing again – reverting back to rules for gaining altitude during take-off or aborting landings, but not applicable at higher altitudes – signalling the stall alarm again. When the pilots tried to take remedial action to increase speed, they took opposite actions on their respective yokes, one pulling down (the correct action) and one pulling up – the plane’s duel yoke controls weren’t synchronous (i.e. there was no feedback between the two) making competing actions possible. By the time the captain came back from his rest break he was unable to take corrective action until it was too late, only realising in the last few seconds that one of the pilots was still pulling back on his yoke.
A number of human factors issues can be identified, many of which can be classed as non-technical skills (skills supplemental to technical skills, but vital to effective working in high hazard industries):
- Poor communication between the first officers, resulting in counterproductive actions.
- Lack of leadership – the captain was not present for much of the incident, and the two first officers were of equal rank. It was not clear who was in charge.
- Poor decision making – being a highly stressful situation the pilots reverted to ‘rule-based’ thinking and were unable to understand why the plane was not responding.
- Lack of situation awareness – the captain entered into the situation late and so did not have adequate situation awareness to make a decision on time. It was also suggested in subsequent BEA recommendations that the stall alarm was unclear, consisting of an aural alarm but with ambiguous visual cues. If the stall alarm coincided with an instruction (i.e. “pull down”) then this may helped the pilots understand what they needed to do.
Comparisons with the energy sector
There are synergies between this incident and those typical of the energy sector, e.g. within control rooms. Indeed, these sorts of non-technical skill issues are common to major incidents in many sectors, including the energy sector.
For example, during the Longford incident (1998), due to lack of communication it was unclear what the production manager’s intentions were as he tried to solve an issue with a heat exchanger. This led to an issue when an instruction to open valve TC3 was misheard as PC3 – if the operator understood the manager’s intentions it’s possible this error may been avoided.
During the Macondo incident (2010) is was reported that an anomalous pressure reading was explained away as a ‘bladder effect’ by the drill crew, which was accepted by the well site leaders. Later on, a decision to jettison mud overboard from the riser was not made – if this was made “the consequences of the accident may have been reduced” (Source: Deepwater Horizon: Accident Investigation Report). Both of these actions (or inactions) may suggest problems with situation awareness and leadership.
Crew resource management training
Crew resource management (CRM) training has been mandatory for aircrews since the early 1990’s. CRM basically teaches non-technical skills to enable air crews to work together safely and effectively (focusing on teamwork, leadership, communication, situation awareness, etc.). It is being used more in the marine sector, and the Health and Safety Executive explored its use in the offshore oil and gas sector in 2003. Interestingly, Air France Flight 447 is an example of when it wasn’t enough – however the Hudson River crash is an example where non-technical skills and CRM training resulted in a successful outcome (watch the 60 minutes interview with Captain Sullenberger discussing this incident).
Recognising the significance of CRM/non-technical skills to major incidents in the energy sector, the EI Human and Organisational Factors Committee (HOFCOM) is producing guidance on the implementation of CRM-type training in the energy sector. It will focus on what non-technical skills CRM-type training should include, an assessment of the impact of CRM-type training, the practicalities of implementing CRM-type training (including in selecting the non-technical skills needed in the organisation), and integration of CRM skills in the safety management system. This will allow managers in the energy and related process industries determine if, why and how they should implement CRM-type training in their own organisations. For more information visit the EI human factors website.