Case Study

CRMDEEN (CRMDEEN_at_aol.com)
Fri, 17 Apr 1998 21:18:46 EDT


This is a test. This past week I was conducted a Facilitator Training
session. When we got to the section where the students present CRM lessons,
and lead debates, one insightful student brought this case study to the class.
He asked everyone to read it, and then he refered to it as he presented his
assigned lesson. It even caused me to lean back and ponder somewhat.
I'd like to present this short story, and ask if anyone in the group
recognizes the event.
It does relate to the discussion of "error management" by organizations, and
teamwork by the crew involved.

CASE STUDY
The mishap crew was making their first transoceanic crossing for a
commercial carrier in a newly introduced equipment type. The equipment was
considered to be the most technologically advanced to date.
The captain had approximately 40 years experience and was consistently
chosen by the carrier to perform command duties when new equipment was
acquired. He was respected by his peers. Crewmembers characterized him as "low
key" and "firm, but fair". Prior to this incident, his safety record was
spotless.
All other crewmembers aboard were highly experienced and respected members
of the company. None had been directly involved in any major incidents.
The equipement in use had been involved in a "normal" course of
Operational Test and Evaluation according to records. Subsequent investigation
called the quality of the OT & E process and findings into question. Comm/Nav
equipment was "state of the art". All required equipment was aboard, in
accordance with policies and regulations, except for one navaid that was
determined to be non-mission essential.
Enroute weather indicated conditions were favorable for icing. Reports
received from other carriers confirmed icing conditions.
Manifested passengers included several Distinguished Visitors, including
the president of the carrier.
During departure, a "minor incident" occurred that caused no damage and
was judged to have no bearing on the mishap. Departure was on schedule.

Which event was this?

Greg Deen
Raytheon