The Wombat's Take-Off
and
The 'Third Wave'
in
Cockpit1 Resource Management
by
Doug Edwards
There is, on the Internet, a 'CRM Industry Developers Group'2. Amongst the people I regard as the more active and professional members of the group, there is widespread acknowledgement that CRM training has not 'worked'. The most recent Aviation Week report (it's a bit dated, to be sure) on the effectiveness of CRM programs concludes in the same way. (See FtF-CTP3, p 144.) I know from my own contact with airline pilots both how they evade the intent of CRM exercises and the persistence of dangerous behaviour on flight decks.4
Safety in airline operations is characterised by exceptional attainment. The record is plain, air travel is almost wholly without risk. However, accidents still occur. And when they do, 60 to 80% are attributable to human failure on the part of flight crew. The motivation to eliminate that factor is that it will render air travel many times safer yet. In the case of single pilot flight operations, the accident record is far worse, with the pilot error factor being about the same, or slightly higher (85%).
Analysis of accidents (and incidents5) involving crew and individual performance breakdown invariably reveals forces at work associated with the psychological phenomenon known as 'denial'.6 Its most common manifestion is the failure to resolve confusion. FtF-CTP offers pilots the opportunity both to assay their innate denial levels and potential, and to perform excercises that will enable them to control autonomous denial responses in flight. In short, FtF-CTP shows how pilots can make themselves safer by becoming 'cognitively fit'.
Cognitive exercise has not been a runaway success as a concept. The offer to make them safer is being turned down in a big way by pilots everywhere. Of the 400 training schools in Australia, 200 received a brochure advertising the book and its safety training value. There was one inquiry. The book was most favourably reviewed by the two major aviation periodicals in this country, triggering barely a trickle of orders (from an aviation community of over 20,000 pilots.) Approaches to airlines have been ignored. (Correspondence is not even answered!) 500 copies of the brochure were left in the crew room of a major airline, for a month, resulting in one order. The major Australian aviation insurance underwriter also reviewed FtF-CTP, in a newsletter, to a client audience of several thousand. One asked to see it. Attempts to interest pilots and aviation authorities and operators overseas have met with similar results.
One (there are many others) remarkable aspect of the response within the aviation community is that the training regime advocated by FtF-CTP can be cost-free. It will not be without discomfort, but it does not have to cost money or duty time.
Fellow CRM developers agree that the single biggest obstacle to making progress in our endeavours (be they aimed at military, airline or single-pilot-operator pilots) is the want of motivation - the lack of a force that will not only induce pilots to take CRM training seriously, but to get them to make it an on-going part of their life, exercising themselves to ensure they are as fit for their flying as they can be.
That powerful motivating force is no longer absent.
Starting on p115 of FtF-CTP, I outline the arguments concerning the 'duty of care' in professional aviation. It begins on page 115, climaxes on p117 - second para -- 'She elaborates . . .' -- and goes on a bit beyond there. I point out, inter alia, that pilots who decline fully to prepare themselves for their flight duties will, after an accident, be found guilty of 'wilful misconduct'. This section of argument precisely anticipated the finding recently handed down in the Miami District Court, by Judge Stanley Marcus, concerning the American Airlines 757 crash north of Cali in Colombia, South America.7
As I say to my fellow CRM developers, we have a professional duty (more on which, later) to pilots who are our clients to ensure they are aware of the baleful implications of this case.
Which are, in short, that pilots found to have engaged in wilful misconduct are personally liable for damages claims. (If the action is posthumous, the estate is liable.) To be realistic, no-one is going to sue an airline pilot when there is a big fat airline bank account sitting there. However, say it was a small charter operation, or that the pilot had taken a friend up for sight-seeing, things would be different.
But that's not the end of the legal fallout. When you read a report on the Miami Court decision, you'll find that it is the airline appealling the decision, not the insurer. That tells us who is expecting to pay the bills for damages. More important, the airline is also suing Jeppesen and Honeywell over 'development and manufacture of navigation equipment and software'. That, too, says that they know that the wilful misconduct finding invalidates the airline's insurance - American is thus exposed - and needs to spread the exposure. (You can insure against negligence, but not wilful misconduct.)
I expect the litigation will go on for years - with the contestants eventually settling out of Court. I also predict the airline will cop most of the costs - and that a team of airline lawyers will very closely look at recovering some of that from the pilots' estates. It may not be worth their while, but they'll check it out.8
Acknowledgement of the legal position pilots place themselves in through failure adequately to prepare for flight, may well provide the motivation for them to put a little more effort into attaining and maintaining top levels of 'flight fitness'. However, the picture is not sufficiently clear for that noble goal to be realised. To bring the necessary clarity, what 'flight fitness' comprises needs to be clearly stated.
One component is physical fitness. There is no doubt that a pilot who is physically fit, will, at the end of an 18 hour day, be in better shape to deal with normal or abnormal arisings in flight. How fit must he or she be? is a question the lawyer will assist define, by citing the legal principle of the 'reasonable man'. Courts will accept that level of physical fitness, as being sufficient for professional pilot duties, that the hypothetical average citizen would regard as being the product of a 'reasonable' amount of exertion.
Of course, fitness levels will have to be established through objective, scientifically-valid, testing (say, bi-annually). Assessing physical fitness is easy enough. How to measure the second major factor in 'flight fitness' - cognitive fitness - is a different challenge altogether. Sadly, humans are not equipped with annunciator panels in their foreheads that display the current 'state of mind'. But, all is not lost.
Enter the Wombat.
Though designed primarily to test pilot ability, the Wombat will permit a precise reading of a pilot's cognitive fitness at any time. If the aim of cognitive fitness is for the pilot, 'to be able to perform complex functions (ie, fly a plane, direct a crew in the control of a plane) under stress', then the Wombat can measure the current state of an individual's ability to do that.9
Again, review of accidents so often shows the immediate cause of pilot dysfunction to have been failure to deal with fear or uncertainty - want of cognitive fitness.10
Indeed, it may be better put as ' lack of cognitive toughness'. The hypothetical 'man in the street' the lawyer will cite in court as the 'reasonable man', expects pilots to be cognitively tough, able to withstand high anxiety states. Pilots can exercise - as shown in FtF-CTP, to attain cognitive resilience. And they can prove their high state of mental fitness by sitting for a Wombat test.11 To do neither, to fail to do these things that enhance professional capacity, things that are eminently 'doable', is to engage in wilful misconduct - and to become personally liable for the consequences.
Stating the proposition baldly may be accurate, but it is negative motivation. It relies on postulation of a threat to get a person to do something. Trainers know that this is less effective than the obverse, positive inducement, best achieved by activating self-motivation.
The self-interest argument is clear. While the conclusion is indisputably valid, it is a view of the future. The full attainment of such a regime will evolve over years. There is time to get ahead of the game, to do something about it, time to get stuck into exercising so that when the tests come along, you'll know you will pass with ease. Proof yourself and your estate against the depredations of the airline or passengers' lawyers. Show you have done all that could have been done, according to the 'reasonable man' test. It can be done in your own time, and at little or no cost. Better yet, by sitting a Wombat test12 occasionally, you can demonstrate your attainment, the level of your cognitive resilience.
I have used legal arguments to define certain aspects of aviation's professional13 structure. To most pilots, the arguments will be new and strange - and undoubtedly confronting. Yet, to other professionals - say, doctors and engineers14 - they would be commonplace - as is the concept of Professional Indemnity (PI) insurance15 (against negligence, not malpractice).
In professional terms, aviation can only be seen as immature. That the other professions have been around for much longer is one reason. More important, they have been subject to the main force which introduces maturity into a profession - litigation.
Recent experience in the sporting field assists analysis of the 'professional maturing' phenomenon. Until recently, the Australian Rugby League had an image of itself as a loose confederation of clubs with common interests, sort of an 'old boys network' which, having evolved out of amateur competition, still bore many of the hallmarks of amateurism. The advent of the competing Super League shattered the illusion, with challenge to many of the old management arrangements in Court.
The idea of clubs-as-they-had-always-been was rudely thrown out, with a Judge making plain that the clubs were not suburban amateur social affairs, but commercial corporations, trading in sport-as-a-commodity, and subject to the extensive and highly technical dictates of legislation. Who owned what? for example, like club regalia and insignias, was called into question, again and again, so as to be ruthlessly defined by teams of lawyers and accountants. Even the notion of who owned the game itself came up for grabs. With patient precision, the Judge peeled away layer after layer of camouflage from the reality, leaving exposed what many found hideous - sport-as-business, operating in a highly sophisticated marketplace with no trace remaining of the cosy practices of club management of yesterday.
If the overall national economy can be seen, collectively, as a series of discrete sub- and sub-sub-markets, then the Rugby League is a sub-set of the sports-in-general sub-market. Thanks to the litigation - and all of the attendant pain and cost - it is now a very sophisticated sub-sub-market, indeed. It has thus matured. One newly acquired characteristic, as a result, is far clearer understanding of the term 'professionalism'.
By comparison, the aviation market is extremely immature, amateurish. To establish this proposition, with absolute certainty - as must be done, the reality cannot be evaded - other aspects of professionalism need to be examined.
Take, as an example, the Chieftain accident at Launceston, in which the pilot survived, and several passengers perished.
The pilot seems to have been in a hurry to get the plane on the ground, no doubt owing to passengers, who had been drinking for some hours before take-off, wanting to urinate. The BASI's16 findings in the case, as presented in their report, appear to support the pilot's being charged with causing the passenger deaths. No such charge has eventuated. Indeed, in this milieu, the aviation community, charges against errant pilots are rarely laid, and even more rarely taken to conviction when they are.17
By way of comparison, an anaesthetist recently was found to have been responsible for the death of a patient on the operating table, in circumstances such that manslaughter charges will be laid as a result.18 Such accidents are rare. However, when that particular level of human failure is found in the practice of medicine, criminal charges are invariably laid. The medical profession can thus be seen to be measurably more 'mature', in this area, than its aviation counterpart.19
The 'professionalism' message does need to be rammed home to pilots and aviation executives and proprietors. (As in, don't wait for litigation to sort things out for you.) They really must be aware of their very real (for sure, it's only potential) exposure to civil and criminal action, and the clear definition of the duty of care they owe their clients - the passengers. At present, they do not - not in Australia, as I know from first-hand experience, nor in any other nation, as far as I can determine.
The extent and authority of society's imposed code of conduct for professionals is not understood nor its ramifications appreciated by pilots. It should be. The Launceston accident provides further answer to the question, 'Why?'.
Before undertaking the fatal flight, the pilot (himself an instructor) had been checked out in the Chieftain by a fellow instructor at the same school. Passengers arrived mid-afternoon, but the aircraft was delayed. While waiting, the pax had a few drinks. The instructor who had performed the earlier flight check observed this, and formed the opinion, from their boisterous behaviour, that some who were to board the fated flight were in a state of insobriety that, under Australian law, prohibited their being carried in a plane. He did not intervene.
The flight pilot was clearly in a position to have reached the same conclusion. His going on with the flight, and other aspects of his lack of preparedness for it, places him in a legal position that has already been defined. However, the implications for the other instructor, who had checked him out in the Chieftain, will not be as plain.
In fact, he too is culpable, liable to criminal sanctions should the authorities choose to lay charges, and to civil damages should a passenger's family seek compensation.
As this will come as a surprise to most pilots, they might want to check it out with their legal adviser. He or she will confirm the concept wherein a professional, who sees or has knowledge that a fellow professional is about to trangress the rules of professional practice, has a duty to attempt to persuade them not to, and, failing in that, to notify the authorities. The fellow instructor who noted the intention to contravene flight regulations, should have intervened. To not do so is to assume a share of the legal liability consequent on the wrongful act. As it was clearly not something done in error, but a deliberate decision to not do something, it comprises wilful misconduct.
As I argue in the above-cited sections of FtF-CTP, the principal relationship for the professional is with his or her client. This is the focus of interest, the responsibility for another person's life or livelihood, vicariously assumed, the basis for the hallowed code of proper conduct. Those within the aviation industry, who have pilots as clients - Chief Pilots, CRM developers, check captains, safety promoters, instructors - need to pay greater heed to the concept of professionalism. They have a duty to pass on essential facts, for example, such as are laid out in this paper. They have a duty to encourage 'flight fitness', by deed and example as well as through advocacy. They must, inter alia, see Wombat testing as simply a part of their own maintenance of self-awareness-of-fitness-levels, and be overt in their testing themselves on it.
The time will come when precise measures of flight fitness are mandated, along with the necessity to demonstrate their presence through testing. The pressure to adopt such rules may come from the regulators, it may emerge as a result of the growing 'passengers rights' movement, or because airframe insurance underwriters insist on it, or because airline executives dictate it. By far the most preferable is that it be adopted as a voluntary code by the pilots themselves, as a demonstration that they are prepared to lead the aviation industry towards maturity and its acceptance by the community at large as a fully-fledged profession. Pilots. knowing they are fully fit, in every way, for their duties, will stand tall within their community, as respected professionals. To have assisted them to get there will be cause for pride.
1 I use the older term 'Cockpit Resource Management', vice 'Crew R . . . M . . .' so as to include single pilot operations that equally need to benefit from CRM prescriptions, training and practices.
2 http://www.caar.db.erau.edu/crm/
3 'Fit to Fly - Cognitive Training for Pilots', by Doug Edwards, ISBN 1 875401 61 X, published by CopyRight Publishing, phone orders to 07 (Int +617) 3229 6366, or email to John McRobert <mcrobert@bit.net.au>.
4 The principal weaknesses seem to be inadequate application of pedagogic training design principles - as in, absence of clear training objectives and no or little training-effect assessment - and inappropriate delivery technique - typically, lectures are over-used. That said, where CRM training has been effective, it is in the better organised and funded areas of the industry - airlines and military units. The ideas that CRM practices should begin being taught before first flight and integrated into all future pilot development, are just beginning to take hold.
5 Incidents are, typically, misinterpretation of ATC instructions, levelling off at the wrong altitude, turning to the wrong heading, adopting the wrong SID or arrival pattern.
6 Indeed, the Swedish academic studies that led to development of the Defence Mechanism Test (apologies, can't cite, references in storage) came right to the point in saying, 'High Ego Defence (Denial) and poor performance under stressd are strongly correlated.'
7 See, for example, 'News Break', Aviation Week and Space Technology, 15 Sep 97, p19.
8 Yes, I know most airlines have 'hold harmless' clauses in employment agreements, undertaking not to sue pilots, not even for negligence. These clauses are of doubtful legitimacy. More, they are worthless if the suit is originated by a third party - say, a passenger's family member. The cause of action is then not with the airline, but between the pilot(s) and the claimant.
9 Find out about the Wombat at Aero Innovation's home page - http://www.aero.ca/
10 The Pittsburgh 737 is an example of total 'cognitive collapse'. ALPA's defence of the flight crew is understandable, but listen to the CVR tapes. The crew panicked. They had a recoverable situation, but stalled the wing with excessive backstick.
11 After the first encounter, which includes 60 minutes of introduction, the test only takes 30 minutes.
12 There are other 'BATs'. The ones I know all differ from Wombat in utilising, at least for much of the testing, an aircraft instrument panel. Depending on the individual's flight experience, this may or may not confer an advantage. The Wombat is purely 'generic'. The test challenge-cues hardly resemble flight demands or instruments at all. The concept that skills that support flight can be learned and 'hardened' in non-flight activities - eg, abseilling toughens anxiety control - is thus re-inforced.
13 For a more detailed exposition of aviation-as-a-profession, see pages 107 - 119 in FtF-CTP, and the 'Afterword' beginning on p 150.
14 Note the common grounds - public safety, lives potentially at risk.
15 That PI insurance is not available to pilots supports the (following) observation that aviation has not yet matured to fully-fledged status as a profession. Pilots, especially instructors, should be able to secure PI insurance cover. No underwriter is going to offer such a product until there is clear evidence of effective control over all aspects of aviation. In turn, only self-regulation can deliver that, as it has for the other professions.
16 Bureau of Air Safety Investigation.
17 A classic case in point is the crash in Western Queensland, where the BASI report shows clear evidence that the pilot had been drinking with his passengers before take-off. The pilot became lost in the dark, and the wreck was not found for several days. The Coroner at Mt Isa was persuaded that it was impossible to distinguish between the alcohol to be found in a body as the by-product of decomposition and that which might have been ingested. No blame was thus attributed to the pilot.
18 Care must be taken in discussing this difficult topic to not pre-judge. A charge is not a conviction. It simply means a legal threshold has been stepped over. The point being made is that this threshold lies in different places in different professions.
19 In Australia, but not everywhere. Lest there be any doubt as to the direction of progress, in New Zealand recently, two pilots were charged with manslaughter following an acccident in which passengers died. Just as the market-place is becoming global, so too will this aspect of professional liability spread, both in the criminal law (society's application of sanctions for wilful misconduct) and in the civil law (aggrieved families seeking larger compensation payouts than available under routine insurance provisions). The 'Cali' case will further define these boundaries, across national borders.
Copyright © 1996-2005 by Neil C. Krey unless otherwise indicated.
Non-commercial reproduction rights granted if the following notice is included:
"Source: Neil Krey's CRM Developers Forum, http://www.crm-devel.org"