CRM and acc.invest.
Hugo Oscar Leimann Patt (hleimann_at_houseware.com.ar)
Sun, 02 Aug 1998 11:48:15 -0500
Dear CRM gang (and Mike),
Talking on night flying and being here near the end of the
investigation of the worst aviation accident in our history (a DC9-32
killing 74), and a new press leak in today's newspaper, was thinking on
the difficulties Accident Investigation Boards have.
Pressures from all the parts involved (company, manufacturer,
pilots assoc., administration, journalism, lawyers, etc.) transform the
process in a real night flying, particularly when the black boxes are
old style and you don't have all the elements to come to an indubitable
decision. Leaking to the press corp. through the process generate false
expectancies in victim's families and public at large.
Investigators themselves are not objective robots. They are human
beings and likely to be influenced by those biassed opinions and
agendas.
In the middle of this process I recall the excellent thriller by
Michael Crichton, Airframe, and can see how the same scenarios, millions
of dollars more or less, are recreated again and again.
Was thinking, this rainy sunday morning, about the importance of
investigation board members to be fully aware of the fifth generation
CRM principles and Maurino- Reason- Lee- Johnston (Beyond Aviation Human
Factors) approach, and ICAO Digest on CRM for Accident Investigation
Boards stressing particularly the subtle pressure on pilot decision
making process played by the culture of the company, the unwritten but
normal and usual procedures and way of doing things.
Just an example extracted from this case. In the company there was a
"prevac" department where, among others things, a control of the fuel
consumed by each captain at the end of each month was performed, and a
list of the top consumers down to the top JP1 savers were make, and
occasionally spender captains were called to know their position in the
table (no explicit sanctions anyway)...
Do you believe that in a stormy night, with two hours delay, being
the six and last flight of the day, would not the pilot be,
subconsciously, predisposed to take the most speedy and fuel saving
route through the storm, instead of a 30 min. longer behind that cold
front?. (sorry for be too simple telling the complexity of the
situation).
Well, this is but one point in conflict alone. Some investigators
say no, some say yes.
And this is important, my friends.
After all, their accident reports are one of our principal sources
of fuel for our CRM flame. Why is so difficult to reproduce a Virgil
Moshansky team and way of doing things?
How badly we need more Dryden like reports!!!
Greetings from a rather melancholic Sunday in Buenos Aires.
Hugo
http://www.house.com.ar/users/hf_crm