Taken from the FAA Human Factors Homepage:
Cockpit Resource Management Videos
CRM for CRM:
Cockpit Relevant Movies for Cockpit Resource Management
Marvin Karlins, Ph.D.
Professor of Management, University of South Florida
Captain Freddie Koh
Assistant Director of Flight Operations, Singapore Airlines
Captain Len McCully
Assistant Director of Flight Operations, Singapore Airlines
Captain C.T. Chan
Deputy Chief Pilot - A-340 Fleet, Singapore Airlines
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Reprinted with permission of Marvin Karlins, Ph.D.
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ABSTRACT
RECOMMENDED FILMS FOR CRM PROGRAMS:
To get a movie, please see the information by each movie's description.
The Dryden Accident
What the Pilot Didn't Know
Delta 191
Northwest 255
The Wrong Stuff
Why Planes Crash
United Flight 232
Aircrash: The Burning Issue
To Engineer is Human
Automation Asks for Monitoring--Are We Suited to This Role?
Automation and Workload
Against The Clock
"MAC 249, What Are Your Intentions?"
The Public Mind. Image and Reality in America (with Bill Moyers) #4: The
Truth About Lies
Groupthink (revised edition)
Fall From Grace: Patterns of Human Error
(not available to the public)
The Mystery of Flight 163
Fatal Error
Moment of Crisis: There's A Hole in the Plane
SOME FINAL OBSERVATIONS
ACKNOWLEDGMENTS
REFERENCES
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ABSTRACT
Aviation-relevant films (videos) can be useful pedagogical tools in the CRM
context if pilots perceive them to be interesting, informative and relevant
to the topic(s) under consideration. Films which meet these criteria are
identified and reviewed, along with some suggestions for enhancing their
training value. By alerting the aviation community to this select group of
films it is hoped that: (a) their use in CRM programs will increase; and (b)
airlines will save time and money by not "reinventing the wheel:" developing
"in-house" productions when similar products are already commercially
available.
If it is true that a picture is worth a thousand words, then imagine how
many hours of CRM lectures could be condensed with a few well-chosen video
presentations! In fact, the use of films in CRM programs produces
significant benefits beyond time conservation: used appropriately, these
films can encourage process (creative) thinking (Schroder, Karlins & Phares,
1973), while providing a more stimulating, realistic portrayal of the
subject-matter under discussion (Karlins, Koh, McCully & Chan, 1996).
Further, the use of movies seems particularly suited to the learning needs
of adult audiences (Bedker, 1995); the kind of audiences found in CRM seminars.
Unfortunately, not all films enhance learning: many are so aesthetically
impoverished, boring and/or "off target" they actually impede training,
particularly when used to educate professional audiences about complex
topics like effective flight deck management. What, then, constitutes a
"good" CRM film? Based on the opinions of Singapore Airlines Pilots
(expressed in seminar evaluation surveys administered at the end of a
four-day CRM program), such a film would be:
interesting (e.g., good animation, cinematography, acting, dialogue);
informative (subject-matter deemed worthwhile to learn);
accurate (events and problems are correctly portrayed and identified);
relevant to the topic(s) under consideration (there is a clear linkage
between the film and what is being discussed in the seminar); and
thought-provoking (encourages post-film discussion and insights helpful to
the enhancement of flight deck performance and job satisfaction).
Armed with the knowledge of what aviators wanted in a CRM training film, the
authors undertook an exhaustive search to locate suitable cinematic products
for use in future seminars. Films were solicited from airlines, commercial
film production companies, consulting firms, US governmental agencies and
television stations. From these sources, 243 films were identified and
reviewed (full-length feature movies were not included in the review
process). Based on this initial examination, 56 "finalists" were selected as
worthy of further consideration. A second review pared this number down to
20 "winners"--the films we have recommended in this article. Please note
that although the films are numbered for identification purposes, these
numbers should not be construed as a means of ranking the selections in any
way (e.g., film #1 is not "better'" than film #10). All the films that made
the final list are, in the authors' opinion, of superior quality and should
enhance the learning process as long as they fit in with the particular CRM
program or topic for which they were intended.
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Recommended Films for CRM Programs:
1. The Dryden Accident
[Original copyright 1992, Australian Airlines. Currently owned by Qantas
Airways Limited. Address: Flight Training Centre, Qantas Jet Base (M148),
Mascot NSW 2020, Australia. Att: CRM Coordinator.] Running time: 18 min. 40
sec.
A compelling look at the events leading up to the crash of Air Ontario
Flight 363 on March 10, 1989. The film is particularly valuable in the CRM
context, as it emphasizes what can happen when there is a lack of teamwork
and effective communication between cockpit and cabin crew. Also important
is the film's focus on the chain of events that culminated in the tragedy.
This allows the viewer the opportunity to see how an accident develops and,
hopefully, how to recognize and deal with such conditions should they
develop on one of his/her flights. Finally, the documentary describes a
number of factors ( e.g., flight delay, equipment failure, company pressure,
flight time limitations, desire to get home) that may have stressed the
pilot and affected his judgment. Aviators viewing the video will most likely
recognize some or all of those factors as having occurred during their own
flights. Keeping "The Dryden Accident" in mind is a good way for pilots to
remember the potential dangers associated with such factors and the
importance of keeping them in proper perspective (safety first!) should they
occur in future line operations.
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2. What the Pilot Didn't Know
[ABC News, 20-20, October 30, 1992. Address: ABC News, Film and Tape
Practices, 47 West 66th Street, New York, NY 10023-6290.] Running time: 13
minutes.
To intensify the impact and reinforce the message of The Dryden Accident,
follow it up with this documentary. The program describes the final moments
of USAir Flight 405 which crashed on take-off from Laguardia Airport on
March 22, 1992. One factor that makes the USAir crash particularly
disturbing is its striking similarity to the Dryden tragedy ... right down
to the type of aircraft flown, the cause of the crash and the kind of
interaction between cabin staff and cockpit crew before the accident. After
viewing The Dryden Accident and What the Pilot Didn't Know the viewer cannot
help but be reminded of two critical aviation axioms: (1) good crew
coordination and teamwork is vital in maximizing flight safety; and (2)
those who do not learn from the lessons of history are bound to repeat them.
There is another ABC news broadcast devoted to USAir Flight 405 which was
aired May 14, 1992 on Prime-Time Live. This program focuses on the human
dimension in the crash, interweaving personal accounts of crash survivors
with a recreation of the accident scenario (produced by combining film
simulation with actual newsreel footage of the accident). A computer graphic
portraying the takeoff roll is also included (fifteen seconds). The film is
very realistic and provides a definite human interest impact to the Air
Ontario and USAir tragedies ... if such an emphasis is desired by the CRM
coordinator. In addition, there are segments of the film (e.g., the computer
simulation of the runway accident) that might be useful for pilot audiences.
In general, however, this tape is probably better-suited for viewing by the
general public, preferably not as part of an in-flight entertainment package.
3. Delta 191
[Z-Axis Corporation. Address: 116 Inverness Drive East, Suite 110;
Englewood, CO 80112.] Running Time: Tape #1 (54 min. 30 sec.), Tape #2 (38
min. 40 sec.).
Z-Axis is a corporation that produces state-of-the-art computer animation to
re-create events for use in courtroom trials. One such event was the crash
of Delta 191 at Dallas-Fort Worth International Airport on August 2, 1985.
So effective was this new computer-driven re-creation of the crash that it
made the lead story in the December 1989 edition of the American Bar
Association Journal (Marcotte, 1989). As a primer in the study of how a
weather-related accident unfolds, this product has no equal. CRM
coordinators and training pilots might want to study both tapes in their
entirety (90+ minutes), although for training purposes a much shorter
presentation is suggested. To capture the impact of the tapes--and also the
lessons to be learned--the authors recommend using the following sections
from Tape #1 only: (a) Text (first 2:30 minutes of tape). An animated
presentation of the descent profile (from 2,100 ft to impact) with cockpit
and ATC communication (scripted and voice recording). (b) All data
(beginning at minute 8:14 and running through minute 11:26). Instrument
read-outs are provided: wind vector, knots, control column, AOA, EPR and
airspeed. CRM participants have audibly gasped as they watch the instruments
change when the aircraft encounters the violent microburst moments before
the crash. Other sections of the two tapes can be utilized at the discretion
of the CRM coordinator, based on what (and how much) information he/she
wishes to impart concerning the accident. Some coordinators might also want
to provide seminar participants with some background understanding of the
Delta 191 crash before showing the Z-Axis simulations. If so, the authors
recommend use of the film footage beginning at minute 41:45 of Why Planes
Crash (see selection number 6).
A final note: Because the US Department of Justice paid for the production
of this film, the authors were informed that this video is in the public
domain, thus free of charge. Please contact the senior author should you
desire a copy of this tape.
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4. Northwest 255
[Z-Axis Corporation.] Running time: 26 min. 50 sec.
This crash-on-takeoff from Detroit on August 16, 1987 illustrates a
breakdown in crew coordination and departure from SOP [Standard Operating
Procedure]. The computer simulation traces the departure of the aircraft
from the gate to the runway (14 minutes), with scripted and voice dialogue
recording. From 15:00 minutes forward, the take-off roll and ensuing crash
are examined from several different perspectives, including a split screen
technique that affords the viewer the opportunity to simultaneously view a
normal takeoff with the iII-fated attempt (mins. 25:41 through 26:48).
One aspect of Northwest 255 that makes it unique is a view of the accident
as seen from inside the passenger cabin. Using computer animation, the cabin
swings back and forth before turning completely over just before final
impact. Also interesting: a second perspective where the interior of the
cabin is superimposed on the runway, giving the viewer the opportunity to
"see" the takeoff from a runway perspective while also glimpsing the inside
of the cabin as it eventually flips upside down (minutes 19:34 - 24:12).
Z-Axis has produced other computer simulations of aircraft accidents which
are worthy of note, including Avianca Flight 52 (1 hr. 15 min.) and
Continental 1713 (14:45 min.). Additional accident simulations will become
available once litigation involving the airlines in question are completed.
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5. The Wrong Stuff
[BBC Videos for Education and Training (1986). Address: Woodlands, 80 Wood
Lane, London W12 OTT, England.] Running time: 50 minutes.
The title of this film is meant to remind the viewer that what is the
'"right stuff" for a pilot in the single-seat, high performance fighter
aircraft is the "'wrong stuff" when transferred onto the flight deck of the
multi-crew commercial carrier. This documentary focuses on the relationship
between an aviator's personality and aircraft accidents, using the crash of
Air Florida 90 to illustrate the impact of such a relationship on air
safety. The role of the "domineering" captain and the "non-assertive"
co-pilot is also examined ... along with a program (United Airline's CRM)
designed to deal with personality and role conflicts in the cockpit.
Certain segments of this program can be used in a "stand-alone" fashion to
illustrate critical CRM concepts. Some examples: (1) The importance of
teamwork: the NASA experiments on crew variations in teamwork are presented
between minutes 9:08 and 12:50; a second example of teamwork, involving a
three-man crew working together effectively to correct a "loss of all
generators" problem, is highlighted during minutes 28:03-31:50. (2) The
impact of personal behavioral styles in the cockpit: These styles are
examined in the context of the Air Florida crash (between minutes
17:34-28:00). (3) The value of a pilot as a creative decision-maker (why he
won't be replaced by a computer): Excellent example provided by pioneering
aviation expert John Lauber (minutes 46:38-49:58).
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6. Why Planes Crash
[Produced in 1987 by WGBH Educational Foundation and distributed by Coronet
Films & Videos. Address: P.O. Box 2649, Columbus, Ohio, 43216.]
This film, aired one year after release of The Wrong Stuff, provides the
viewer with a second overview of human factor issues in aviation safety. The
two documentaries overlap in some areas; yet, there are enough differences
to make each film worthwhile. For example, this program also has a good
reenactment and discussion of the Air Florida 90 crash (minutes 4:19-12:45)
and the CRM coordinator might want to consider using both renditions (or
segments of them)in seminar discussions of the accident. Other segments of
this documentary can also be utilized in emphasizing CRM-related topics of
importance:
(1) The danger of functional fixation: Loss of situational awareness is
illustrated in a simulated reenactment of the final minutes of Eastern
Flight 401 ... where crew preoccupation with a nose-wheel indicator light
resulted in a fatal crash in the Florida everglades (minutes 22:10-25:32).
(2) Automation complacency: Professor Earl Wiener, a leading authority on
this topic, warns of the dangers of automation using Korean Airlines Flight
007 and Air China's Dynasty Flight 006 to underscore his concerns (minutes
36:32-40:20).
(3) Decision-making: An excellent and thorough examination of the events
leading up to the crash of Delta 191 is presented in minutes 41:45-53:25.
This film sequence is particularly powerful when used in conjunction with
the Delta 191 production by Z-Axis (see film selection number 3.)
In previous seminars, the authors have used the Delta 191 segment of Why
Planes Crash to kick off CRM seminars on decision-making. Followed-up later
with the Z-Axis presentation, it encourages open discussion and insights
into the problem-solving process. Included at the end of the Delta 191
segment in Why Planes Crash is one of the most powerful quotes that can be
used to start or conclude a CRM program. It is worth repeating here.
"Whether any pilot alive could have flown through a wind shear of that
intensity will never be known. But in an enterprise as complicated as our
air transportation system, some accidents will inevitably occur. Pilot error
is once again the weakest link in a long chain of human errors. Perhaps that
flight could have been saved with better weather information, or if someone,
somewhere on the ground had made a better decision than they did. But
ultimately, it is the crew that flies the plane, and must bear the
responsibility for decisions which no one else is in a position to make.
Improved communications ... better management of tasks ... teamwork ....
cockpit resource management by whatever name. All these may not rescue any
given flight, but mightn't they improve the odds on every flight?"
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7. United Flight 232
[United Airlines. Address: Flight Training Center, Stapleton International
Airport, Denver, CO 80207, Att: C/L/R Coordinator (1990).] Running time: 35
minutes (short version), 47 minutes (long version).
A great "CRM save'" story. United Airlines Flight 232 (DC-10) was able to
crash-land at Sioux City, Iowa, on July 19, 1989 after experiencing the
"impossible" ... a loss of all hydraulics. What unfolds in this dramatic
video is how the crew responded to this unprecedented crisis, drawing on
skills learned during CRM training to facilitate the teamwork necessary to
keep the crippled aircraft flying. Actual news footage of the accident is
presented along with cockpit-ground communications and interviews with the
tech crew and flight attendants who were aboard Flight 232 during the
emergency. This tape is suitable for use with tech crews and/or tech and
cabin crews together. Because the long version involves additional cabin
crew focus, it is recommended for seminars involving both pilots and flight
attendants. The shorter, 35 minute production is preferable if only pilots
will be included in training.
To underscore the important role of CRM in the UAL 232 crisis the authors
recommend a short film excerpt (minutes 26:15-29:35) from the NTSB hearings
into the crash. [Tape # VAV 011A: Sioux City, Iowa United Airlines, NTSB
Board Meeting Held 11/1/90.] The film can be ordered for $20.00 from:
General Microfilm, P 0 Box 2360, Wheaton, MD 20915. In the excerpt Dr. John
Lauber praises the United CRM program and its critical role in enhancing
aviator performance in the cockpit.
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8. Aircrash: The Burning Issue
[BBC Videos for Education and Training (1987). Address: Woodlands, 80 Wood
Lane, London W12, OTT, England.] Running time: 50 minutes.
This video makes an excellent SEP training film! After a brief discussion of
some well-known fires aboard commercial aircraft (e.g., the British Airtours
crash at Manchester), the film provides a very graphic description of what
it's like to escape from a burning airplane, as told by a passenger who
experienced the horror first-hand. Also included in this informative film:
(a) some spectacular video footage of experimental aircraft being purposely
crashed to study the effects of different fuels on post-crash fires; (b) a
discussion of scientific efforts to create a less-combustable (volatile)
aircraft fuel; (c) the evolving use of flame-retardant materials in the
aircraft cabin and (d) the use of smoke hoods (masks) to extend passenger
survivability time in the event of an aircraft fire.
Although most CRM instructors will probably not show this entire film to
their participants, several segments will be of particular interest to
pilots; for example: (a) the experimental crashes to study fuel fires; (b)
the controlled study of fire dispersion in an aircraft (minute 25:00+); and
(c) the discussion of fires aboard actual flights (eg., Continental Airlines
at LAX (minute 21:00) and Air Canada 797 (minute 42:00))- (A more complete
study of the Air Canada June 2, 1983 fire is contained in a 12 minute video
entitled Flash Fire: The Story of a Flight.)
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9. To Engineer is Human
[BBC Videos for Education and Training, Woodlands, 80 Wood Lane, London W12
OTT, England. (1987)] Running time: 50 minutes.
This film will give the most jaded engineer a dose of humility ... and
pride. This is a good documentary for any operational staff involved in the
engineering side of aircraft operation. The narrator, an engineer himself,
explains the process by which safe designs evolve into unsafe designs (how
engineers take successful structures and evolve them into failures) and
then, learning from failure, make them safe once again.
Although the subject-matter of the entire film is not specifically relevant
to pilots, there are a few noteworthy segments; particularly those that
involve engineering errors impacting on airline safety. Some examples: (1)
design problems with the Comet aircraft in the 1950s (minute 2:17); (2)
faulty maintenance leading to the crash of a DC-10 in Chicago (minute
34:30). There are also some thought-provoking comments for those aviators
concerned with increasing levels of computer automation in the cockpit.
According to the narrator (minute 43:20+), computers don't do a good job of
anticipating some types of failures, ("they don't think in the failure mode
like human engineers do"), can create a false sense of security, and are
responsible for ushering in a new era of engineering error, the so-called
"computer-aided catastrophes."
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10. Automation Asks for Monitoring--Are We Suited to This Role?
[KLM Airlines (1995). Address: KLM Royal Dutch Airlines, Flight Crew
Training Department (SPL/NT), Flight Services, P O Box 7700, 1117ZL Schiphol
Airport, The Netherlands.] Running time: 19 minutes.
This training film presents an easy-to-understand '"three-phase" model of
behavior (perception phase, judgment phase and execution phase) and then
uses actual airline incidents to show how automation can impair a pilot's
ability to perform effectively on the flight deck. Good introduction to the
potential dangers of cockpit automation.
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11. Automation and Workload
[American Airlines. Address: Commercial Flight Operations, American Airlines
Flight Academy, P 0 Box 619617, DFW Airport, Texas 75261-9617.] Running
time: 19 minutes.
After a discussion of some common mistakes that occur in the automated
cockpit (e.g., programming errors on B-757 flight deck computers) an
automation-related accident is simulated and discussed (minutes
11:00-18:33). The simulation depicts Thai Flight 311 which crashed into
terrain on approach to Katmandu, Nepal on July 31, 1992.
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12. Against The Clock
[BBC Videos for Education and Training (1994). Address: Woodlands, 80 Wood
Lane, London W12 OTT, England.] Running time: 50 minutes.
Many factors can influence a pilot's effectiveness on the job (e.g.,
Karlins, Koh & McCully, 1989). This film examines one such factor, fatigue,
a particularly relevant topic for aircrew who, in the words of the
commentator, "... must work in a constant state of jet lag." Two segments of
this documentary will be of particular interest to tech crew: (1) commercial
pilots flying actual flights are studied to see how well they can perform
perceptual-motor tasks under different conditions of cockpit rest patterns
(minutes 31:30-36:00). (2) Minute 11:00: A powerful warning about the danger
of fatigue in the glass cockpit is sounded by way of analogy: the impact of
old- vs new-style petrochemical control rooms on the operator's ability to
remain alert (and effectively able to monitor) on the job. This film segment
should be required viewing for every person working in flight operations.
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13. "MAC 249, What Are Your Intentions?"
[U.S. Air Force: Produced by 1352nd AVS/DOPV under contract with Aerospace
Audiovisual Service MAC for U.S. Air Force, 607704DF.] Running time: 20 min.
30 secs.
An examination of aircrew coordination and teamwork is presented in this
training film which can be easily adapted for use with commercial pilots.
The Crew of a C-141 Starlifter is confronted with a partially retracted
landing gear problem upon takeoff for a trip to New Zealand. At several
points during the flight the aviators must confront and solve problems
associated with the broken gear ... and the viewer is asked what he would do
as well. Because of the complexity of the problem there are numerous
alternatives that must be considered, along with the need for acquiring
additional information and keeping mindful of fuel-burn in relation to the
targeted airport destination. There are natural breaks in the film that
allow the CRM coordinator to discuss with seminar participants what they
would do if they were the crew aboard the C-141. The results of those
discussions can then be compared with the actual decisions reached (and
results achieved) by the Starlifter aviators as they attempt to complete
their mission successfully.
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14. The Public Mind. Image and Reality in America (with Bill Moyers) #4: The
Truth About Lies
[Originally aired on PBS, 11/29/1989. To order write: Films for the
Humanities & Sciences, 12 Perrine Road, Monmouth Junction, NJ 08852.]
This thoughtful examination of truth and deception in American life contains
a 12 minute, 30 second segment concerning the Challenger tragedy which is a
must-see item for advocates of CRM. The presentation focuses on the
pressures faced by Morton Thiokol and NASA, pressures which played a crucial
role in pushing ahead with the iII-fated and ill-advised launch. The
desperate efforts of Morton Thiokol engineer Roger Buisjoly to halt the
countdown ... the fateful conference call between Morton Thiokol, the
Kennedy Space Center, and the Marshall Space Flight Center ... the
investigative hearings into the tragic affair ... all are powerfully and
succinctly presented for the viewer's sobering consideration.
This Challenger segment serves as a wake-up call to those individuals who
allow non-flight factors to unduly influence appropriate flight decisions.
Perhaps this needless and catastrophic accident will not have been in vain
if it serves to remind us that, even in the competitive environment of
commercial aviation, operational pressures must never be allowed to
compromise the integrity of flight safety.
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15. Groupthink
(revised edition)
[CRM Films, 2215 Faraday Avenue, Carlsbad, CA 92008.] 1995. Running time: 25
minutes.
This training film has two things in common with #14 above: (1) both films
focus on the Challenger disaster; (2) both films examine the pressures that
led to the inappropriate decision to launch. But, whereas The Truth About
Lies focused on pressures impacting the organization, Groupthink targets
group pressures impacting the individual group member. When such a condition
exists, it can lead to a flawed decision-making process whereby "...the
members' striving for unanimity [within the group] overrides their
motivation to realistically appraise alternative courses of action (Janis,
1995)." In a flight deck context, where "teamwork" and "crew involvement in
problem-solving" is encouraged, the Groupthink phenomenon can present a
potential decision-making hazard that pilots need to know about. This film
provides them with that awareness.
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16. Fall From Grace: Patterns of Human Error
[BBC Videos for Education and Training (1987). Address: Woodlands, 80 Wood
Lane, London W12 OTT, England.] Running time: 30 minutes.
The distributors of this film ask a provocative question: "We all make
mistakes now and again, but what would happen if we suffered the same kind
of lapse when flying a jumbo jet?" The answer is not pleasant, as a powerful
re-enactment of the Tenerife tragedy amply demonstrates (minutes 9:00
through 13:05). This documentary suggests that everyday inconsequential
errors (trivial mistakes) can lead to major accidents ... it all depends on
where and when they occur (in the kitchen they might result in an improperly
brewed cup of tea, in the cockpit they might lead to an improperly
configured aircraft). It seems that one danger of learning a skill too well
is the individual's tendency to perform that routine on "autopilot"-without
proper monitoring--leading to errors that can pop up when certain kinds of
distractions occur.
This is a good film for emphasizing the importance of situational awareness
and monitoring for effective flight deck management, particularly in the
glass cockpit environment.
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17.
(Not available to the public)
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18. The Mystery of Flight 163
[Granada Productions, World in Action. Address: BRITE, London Television
Centre, Upper Ground, London SE1-9LT, England.]
On August 19, 1980 the pilots aboard Saudi Flight 163 reported "smoke in the
cabin" and made an emergency landing. The touchdown was accomplished without
incident, but all 301 passengers and crew aboard the L-1011 were killed by
fire and fumes that swept the length of the aircraft before they could
escape. The documentary explores two aspects of the tragedy, (a) what caused
the catastrophic fire; and (b) crew performance in responding to the crisis.
For CRM purposes, the crew performance segment (the first 12 minutes of the
film) provides the most relevant material. The reconstruction of the
ill-fated flight, detailing how the tech crew handled the emergency, reveals
several serious break-downs in crew communication, coordination and
decision-making. For that reason, the film segment provides an effective
introduction to the CRM seminar; where it can be used to illustrate and/or
stimulate discussion of human factor errors on the flight deck.
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19. Fatal Error
[BBC Videos for Education and Training (1991). Address: Woodlands, 80 Wood
Lane, London W12 OTT, England.] Running time: 30 minutes.
On January 8, 1989, a British Midland B737-400 crashed with the loss of 47
lives. The film begins with a recreation of the accident sequence in which
the pilots, faced with an engine malfunction, mistakenly shut down the wrong
(good) one. It appears to be an open and shut case of pilot error. But is
it? The film's commentator goes on to suggest that "pilot error" might be
too simplistic an explanation and points to other factors that played a role
in the accident: (1) poor ergonomic design of cockpit instrumentation which
made it difficult to detect which engine was malfunctioning; (2) no
B-737-400 simulator available for pilots to train on and a very abbreviated
conversion course in preparation to fly the aircraft; (3) a flaw in the
engine design, which went undetected, in part, because the engine wasn't
tested in the air; and (4) failure to mount a camera in the rear of the
plane so the pilots could see which engine was malfunctioning.
Fatal Error is a useful film for showing how a chain of events can lead to
an accident. It also provides a useful and interesting lead-in for a
discussion of decision-making. CRM participants find it stimulating to
examine whether the British Midlands pilots could have made a better
decision ... and if so, how? Was the decision reached too quickly? Was there
adequate information gathering and assessment to determine if the course of
action was the correct one? Once the decision was reached, should it have
been evaluated further? In examining these questions, the CRM coordinator
might want to incorporate a KLM training film that discusses the Midlands
crash in a problem-solving context. [Information Management (1995). Address:
KLM Flight Crew Training Department (SPL/NT), P 0 Box 7700, 1117ZL Schiphol
Airport, The Netherlands.]
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20. Moment of Crisis: There's A Hole in the Plane
[ABC News, 20-20, September 22, 1989. Address: Film & Tape Practices, ABC
News, 47 West 66th Street, New York NY 10023-6290.]
What better way to end a CRM seminar--or an article on CRM films--than with
a heart-warming example of how pilots can "get it right" and save lives and
airplanes in the process! CRM presenters, in their admirable attempt to
enhance flight safety by pointing out pilot errors ("learning from our
mistakes"), sometimes fail to emphasize the positive side of the cockpit
performance equation: the thousands of examples where skilled, dedicated
aviators have saved the day. Moment of Crisis presents the saga of United
Airlines Flight 811, a B-747 that experienced an explosive decompression and
loss of two engines when, at 22,000 feet, the forward cargo door and part of
the passenger cabin blew out, sending nine passengers to their death. The
crew was able to turn the plane around and safely land in Hawaii where
engineers, astounded by the massive hole in the 747's fuselage, claimed that
"... based on the structural damage there was no way the aircraft could have
gotten back."
Moment of Crisis ends with moments of joy. Captain David Cronin, the
commander who had piloted Flight 811 to safety, flew one last flight before
reaching the mandatory retirement age of 60. As he left the cockpit for the
final time there was a celebration to honor him. Grateful passengers and
crew embraced him and placed garlands of flowers around his neck. It is a
fitting tribute to a remarkable man and, in the final analysis, a salute to
all the commercial pilots who share in his triumph of making the skies a
safer place to be.
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Some final observations:
Films will never take the place of the CRM presenter any more than automated
cockpits will take the place of the airline pilot. Rather, these video
productions are meant to provide additional learning tools for use in the
aviational training environment. To maximize their effectiveness, a few
final recommendations are offered:
(1) when ordering videos, be sure to specify the tape format used in your
country (e.g., the United States utilizes the NTSC format; many Asian
countries have PAL).
(2) Through-out this article the authors have used time designations
(expressed in minutes) to pinpoint a specific topic/scene in a film. Please
be aware that these times can vary up to two minutes (although usually much
less) for readers using the films due to: (a) playback variations in
different video systems; and (b) viewer variations in defining where the
film "begins."
(3) Some films go out of print or are assigned to new distributors. If a
reader should encounter difficulty obtaining any film listed in this
article, please contact the senior author for assistance (by phone:
813-974-1746; by fax: 813-684-2224).
(4) The NTSB maintains a large library of aviation videotapes and accident
reports. Written accident reports are available from the National Technical
Information Service (NTIS), 5285 Port Royal Road, Springfield, VA 22161.
Videotapes can be ordered for $20 each from: General Microfilm, P 0 Box
2360, Wheaton, MD 20915.
(5) Transcripts (and sometimes videos) of various television and radio
programs are also available. For programs appearing on ABC, PBS, CNN and NPR
contact: JournalGraphics, Inc., 1535 Grant Street, Denver, CO 80203 (phone:
800-825-5746 or 800-255-6397). For programs airing on CBS, NBC and CNBC
contact: Burrelle's, 75 East Northfield Road, Livingston, NJ 07039 (phone:
800-631-1160).
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ACKNOWLEDGMENTS
Several individuals provided encouragement and assistance in the preparation
of this manuscript. The authors gratefully acknowledge them here:
Patricia Antersijn, KLM Flight Crew Training Department;
Captain Graham Beaumont, CRM Coordinator, Qantas Airways Ltd;
Captain John L. Bedker II, President, AnCam Inc;
Benjamin A. Berman, Aviation Safety Investigator, Operational Factors
Division, NTSB;
Jeffrey M. Betz, Z-Axis Corporation;
Captain John D. Crawley, Supervisor, General Operational Subjects, Flight
Crew Training, America West Airlines;
Roland P. Desjardins, Director - Commercial Flight Operations, American
Airlines Flight Academy;
Claire Dinan, BBC Videos for Education and Training;
Dr. Eleana Edens, Office of the Chief Scientfic and Technical Advisor for
Human Factors, Federal Aviation Administration;
Dr. Robert L. Helmreich, Professor of Psychology, University of Texas-Austin;
Captain Calvin L. Hutchings, C/L/R Coordinator, United Airlines;
Dr. Richard S. Jensen, Professor of Aviation & Director of Aviation
Psychology Laboratory, Ohio State University;
Amy Klene, Journal Graphics, Inc;
Captain Louis G. Nemeth, Supervisor, AQP Training Development and
Validation,. USAir;
Dr. Maureen Pettitt, School of Aviation Sciences, Western Michigan University;
Captain Kurt Shular, Delta Airlines;
Felicia D. Stoler, ,ABC News; and
George Sweeney, Manager- Human Factors Development, Northwest Airlines.
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Karlins, M., Koh, F., McCully, L., & Chan, C.T. Expanding teamwork beyond
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