RE: The C in CRM

Breen, John (BreenJo_at_NAVCANADA.CA)
Thu, 14 May 1998 17:28:51 -0400


A note from another guy lurking in the tall grass...

Two events spring to mind from Joel's post here.
1) I had one of my more interesting rides in the jump seat of a 757 a
few years ago. Early morning, cold (-35C) and the number one engine on
start, ignites a puddle of fuel that had pooled by seeping through seals
during the night. While the two in the "good" seats were setting up to
start #2, the lead FA bursts into the flight deck (we could hear her
bounding up the aisle) yelling that #1 is on fire. No indication on the
panel, no fire alarm, nothing. Crew tells FA it can't be. Then there is
over wing emergency exit light (passengers want to jump ship) and an
eerie red glow from aft of the left cockpit window. Tower tells us fire
trucks are on the way. Now the crew believes what the FA had to say.
As the pooled fuel burned out, everybody calmed down. The left side of
the aircraft was scorched, some wing root fairings buckled from the
heat. The airplane was ferried to home base for maintenance. I don't
know what might have been accomplished if the crew had immediately
responded in a positive way to the FA's rush to the cockpit (strong
message there). All I know is that the FA was the FIRST source of info
about the fire.

2) Some years back a 737 burned to the ground in Calgary, AB. Please
excuse any stray from exacting details. As I recall, the first
indication of fire was from an observent crew of another aircraft. The
transcript shows interventions by the FA, but the crew in the front end
chose to disregard the intervention of the FA, even tho' smoke was
reported in the cabin. Confusing signals, like the 757 story above: no
info on the instrument panel - no fire alarm, nothing, because, as I
recall, fan blades has severed some wiring. Long story short: perhaps
they should have listened more closely to the FA. A wonderful case
study for a CRM course, which is where I came across the report.
Thanks, Air Canada.

Now, back to the tall grass...

John G Breen
ATS Team Resource Management Project
NAV CANADA
Edmonton, AB

>----------
>From: Joel Morley[SMTP:jmorley_at_ranaprocess.com]
>Sent: May 14, 1998 12:51 PM
>To: crm-devel_at_db.erau.edu
>Subject: The C in CRM
>
>
>Greetings,
>
>Gordon Breault's comments jolted me out of my normal place as an observer
>of these discussions...
>
>>When was the last time a
>>flight attendant crashed a jet? Sure, there may be that odd spilled cup of
>>McDonalds hot coffee in the aircrews lap, but that's like saying we
>>shouldn't wear seatbelts because one jammed while stalled on the railroad
>>tracks. It's the folks up front, folks, who gave rise to CRM, and all the
>>reasons for focusing on the aircrew are just as valid today as they were
>>when the program was birthed.
>
>While I cannot think of an example where a flight attendant caused an
>aircraft to crash, I can think of numerous examples where intervention by a
>member of the cabin crew might have averted an accident or an incident:
>
>1) The Dryden F28 accident: if the cabin crew had communicated passenger
>concerns regarding icing to the cockpit crew, the decision to take off
>might have been averted.
>
>2) The 737 crash at Kegworth: Although the captain had announced to the
>passengers that they were having trouble with the (wrong) engine, the
>passengers and cabin crew could see smoke coming from what the flight crew
>thought was the good engine. Again, communication of this fact to the
>cockpit crew might have led to a different outcome.
>
>3) The Northwest Airlines DC10 which landed at Brussels: Although the
>flight deck crew had lost situational awareness (and did not realize that
>they were headed to the wrong airport), the moving map display in the cabin
>had raised questions among the passengers. A question posed in the cockpit
>might have resolved the situation.
>
>The point is that the comment above minimizes the contribution that people
>in the system other than pilots make to safety. Cabin crew are privy to
>information that the flight deck crew do not have (e.g. they can SEE the
>wings and engines). Including them within CREW Resource Management serves
>to communicate the importance of their contribution to safety and may
>provide the impetus for cabin crew to ask questions and communicate safety
>concerns.
>
>Regards,
>
>Joel Morley
>
>Joel Morley, Senior Consultant
>RANA International Inc.
>PO Box 527, Merrickville ON K0G 1N0 Canada
>Tel: 613-284-0776 Fax: 613-283-6992
>Website: www.ranaprocess.com
>
>Home Office: Tel: (613) 567-0535
>
>