passengers take flying for granted but sometimes something goes wrong our
planes are getting safer but the accident rate is no longer going down
the reasons may surprise you tonight on Nova why planes crash
major funding for Nova is provided by this station and other public television
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engineered materials
I've been lucky in that I have not been involved in accidents or anything to
cause me to be scared or be feeling unsafe the natural concern for any
airline passenger is mostly fearing mechanical failure and I think that's
where we worry the most I worry more about like terrorist bombings and this
type of thing than I do actual mechanical accidents I rarely think of
the pilot and the crew as being at fault I feel like my odds are real good I
won't be one of the people that crash I think if it's my time my time it's the
pilots time it's my time also aviation is amazingly safe each year in the United
States several hundred million people fly the chances of them being involved
in an accident are miniscule when we start talking about statistics in terms
of the number of people killed in the airline industry in a given year we're
playing a very dastardly game because what we're really saying is how many
people can we kill a year and still say it's a safe enough system around 900
million people fly on airplanes worldwide every year almost all of them
reach their destinations without incident in an average year only 800
people die in plane accidents it's a safe system but a growing number of
industry observers are starting to ask tough questions about the margins of
this safety author and airline pilot John Nance is one for whom the issue is
not whether flying is safe but whether it's as safe as it could be in raw
numbers the fatality rate has been steadily dropping since 1950 and as a
percentage of the total hours flown there are fewer accidents now than
there used to be since 1975 the overall rate of decline has leveled off now it is
no longer improving and US analysts including some airline pilots are
worried about forces which could actually set it back Bill Raynard runs
the 10 year old national aviation safety reporting system the aviation system is
probably in one of its more challenging periods right now because you have
essentially three things happening all at once you've got the recovery from the
air traffic controller strike you've got the experience factor because as as the
system accommodates new air traffic controllers and new pilots you're going
to have new people in the system and you've got the deregulation environment
you've got more airlines safety is a very difficult thing to define the lack
of accidents does not in itself mean that something is safe we have a
potential that we're having to deal with here also and I do believe that the
margins are being reduced that the operating philosophy of the airlines has
changed based upon their increased competitive pressures early in 1982 a
disaster occurred which suggested that all these influences had converged to
strain the system to breaking point even more shocking to an industry normally
preoccupied with nuts and bolts was the attention this accident focused on human
beings here Florida was indeed a crucible of human factors it was a
quintessential example of what happens in an airline crash a crash of any sort
when there's nothing wrong with the airplane it's all a chain of human
failures that led to that accident January 13th 1982 at 401 on that snowy
afternoon Air Florida flight 90 was at the bottom of the Washington DC Potomac
River the rescue drama was about to be played out in real time on live
television the Boeing 737 had collided with the 14th Street Bridge shortly after
takeoff from National Airport on its way to Fort Lauderdale four people lay dead
on the bridge and America watched in disbelief as helicopters hovered over
the river searching for survivors
only five people were pulled out of the water alive
safety board accident investigator Rudy Kapustin was on his way home when the
news broke just as we got ready to go in the elevator somebody came out and said
airplane just hit the 14th Street Bridge and and it took off and the plane was
just flying over the river and the plane was just flying over the river and the
plane was just flying over the river and the plane was just flying over the river
said airplane just hit the 14th Street Bridge and and it just didn't sink in for
some reason to none of us that this was a big airplane my response was what the
hell's little airplane doing flying on a day like this a major snowstorm had
closed National Airport and the Air Florida 737 was held at the gate for two
hours waiting for snowplows to clear the way to the ramp at 3 58 p.m. the sound of
laughter was heard in the cockpit as flight 90 was being cleared for takeoff
less than three minutes later at 401 first officer Roger Pettit tells Captain
Larry Wheaton they are going down one second later the sound of impact ended
the transmission
seven days later the cockpit voice recorder was dredged up from the river
its grisly testimony helped explain the mystery of why the plane had been able
to leave the runway but without enough clearance to miss the bridge on the Air
Florida cockpit voice recorder we became aware that that something just wasn't
quite right with the engines Paul Turner is the safety board laboratory
technician responsible for analyzing the cockpit voice recorder we all had this
this funny feeling about it not having enough power on it so I brought the tape
into the into the laboratory in the other room and I ran a analysis on a
spectrum analyzer on the tape and was looking at the at the engine sounds and
it became apparent that when he ran his stand-up check with the throttles and he
pushed the throttles forward and he and he checked his engines out and then we
should have seen an increase in the engine power and the engine should have
gone up and they didn't they were they just barely rose of it all and then they
were stabilized at that particular EPR setting which is how you set this engine
engine pressure ratio the next test confirmed the idea that the crew had
tried to take off with only three-quarters of the necessary engine
power Boeing experts later confirmed Turner's hunch that this was due to an
ice-blocked pressure duct this in turn had created a misleadingly high
indication of the engine pressure ratio the first officer could see from the
other gauges that something was wrong but the captain paid no attention
determining why the duct was blocked raises the question of whether the
engine deice was on we went through the the portion of the checklist in which
the captain reads or the captain replies to the co-pilot as to whether the de-
icing system is on or off he said anti ice the answer would be on or off and
it's those two words are sometimes difficult to differentiate in the
cockpit with all the other noises on and the the group was actually divided in
this particular case and clearly the response was off and was everybody that
listened to it including the people that had no no reason to be partial towards
the investigation our own people couldn't believe it and of course the
Air Florida people didn't want to believe it pilot group didn't want to
believe it that this did the response was off failure to turn on the engine
deice in the middle of a freezing snowstorm was only one of the cold
weather protocols flouted by this crew they also ignored other deicing
procedures and knowingly took off with snow and ice on their wings Patricia
felch one of only five survivors later recalled her concern during testimony at
the accident hearings I remember the last deicing was about 315 and I
remember we took off about between five of and four o'clock I turned to my boss
and said they're gonna have to deice us again and when they came back to the
right side I turned and said see and he just laughed but they never came back to
the left side of the plane seven months later the National Transportation
Safety Board report implicated the controllers for the long delay between
deicing and departure clearance and the planes design for a winter performance
defect but chief blame for the accident was placed on the Air Florida crew for
three different counts of faulty judgment before and during takeoff there
were a lot of people at the time of the investigation and during the formulation
of the report that did say you know this is probably our first deregulation
accident but Air Florida had a pretty good screening process with this
particular pilot as captain I was picked up from another airline Air Sunshine and
he kind of fell through the crack he didn't go through the screening process
people have said that the the crew is inexperienced or that the crew didn't
know what they were doing or there's several several ideas along this line the
fact that they flew out of Florida and were not used to icing however they flew
into the north and and the co-pilot particularly was an old fighter pilot
who had plenty of experience with icing and so you would have to say in this
particular case that they were almost led into this thing by the circumstances
the first officer was described by his friends as jovial witty a good guy
we he was considered a fairly sharp pilot though skills-wise he was he was
fairly sharp and knowledge on the equipment nobody wants to believe that
pilots make mistakes including pilots themselves but they do for all its
complexity Air Florida is not an unusual accident between 60 and 80 percent of
all plane crashes are blamed on cockpit error certain US airlines like
Continental now make their crews attend classes designed to deal with this
problem in this seminar instructor Frank Tolo reviews the Air Florida case
emphasizing the breakdown in communication between the first officer
and his captain and what I want to make sure you understand is that any act of
assertiveness here would have prevented the accident and if the copilot had just
stopped nurturing this captain and said we better we got to do something we have
to either push the power up or abort because he obviously saw something five
separate times he made it a point ordinary human failings not paying
attention being afraid to speak up disrupt the teamwork so crucial to safe
flying aviation today is more than handling a machine it's handling people
and the accident rate suggests that pilots are ill-equipped for this
management role a study of all plane accidents occurring between 1959 and
1982 shows crew error as the most frequent cause followed by the aircraft
weather airport management or air traffic control miscellaneous and in
sixth place maintenance increasingly the planes themselves are not the chief
cause for concern 30 years ago the likelihood the equipment would fail was
ten times higher than it is now since the first turbo jets of the 50s each new
generation of aircraft has become more automated more reliable and safer to fly
but if the planes have improved the same cannot be said of the pilots captain Mel
volts is safety consultant and former head of training at United Airlines the
manufacturer has done such an outstanding job of providing us with
just a remarkable product the airplanes today are so far ahead of what they were
only a few years ago they're strong they're reliable the engines don't quit
they just they just run magnificently if we've done so well in attacking the
mechanical side of the equation that of course has left the human side over here
and that's the side we have to attack now dealing with the human side has meant
taking a close look at how pilots acquired the attitudes and cockpit
behavior that is getting them into trouble part of the answer lies in the
way many of them underwent their original training I remember let's look
around keep the speed up and you do get a bounce time off and driving in range
when you get in range shoot when you shoot shoot the kill okay let's go get
Korea was just one of the proving grounds for many of today's pilots
airlines have traditionally recruited military airmen those brave mavericks
who excelled in the single seater high-performance fighter aircraft by the
time author Tom Wolf had immortalized the combat flying ace in his book the
right stuff these men had found their way onto most of the flight decks of
America's passenger airlines that macho self-sufficiency that doesn't admit to
difficulties is now dangerously out of place in the team oriented peacetime
cockpit at NASA's aerospace human factors division psychologist dr. Clay
Fouchet is studying this legacy and the problems it has caused in the old days if
you're familiar with Tom Wolf Tom Wolf's treatment the right stuff pilots tended
to be very individual individualistic the the types of individuals who weren't
used to relying on other people to get something done and I think a lot of that
was bred from the the single-seat high-performance fighter aircraft school
flying an airplane something I've wanted to do since I was six years old the real
reason why I like flying I'm not sure I can tell you but I have to tell you that
flying an airplane is the best job in the world I've been flying for 30 years
and I wouldn't consider doing anything else it's a very dynamic business it's
filled with a great deal of challenge and a tremendous amount of reward where
else could you get this kind of satisfaction I take this gigantic
airplane and fly it through the sky and it's my sky it's my airplane the
responsibility of passengers is is not overwhelming it's a it's a the idea is
that you take excellent care of yourself and the passengers will be just great
most pilots that I know are confident in their own ability to solve problems they
feel that they are ultimate professionals that they know the job they
know the resources it's a feeling of exhilaration it's a feeling of
accomplishment and it's a feeling of mastery we're not completely sure what
today's right stuff is although if I were to venture a guess I would say that
you you would see a lot more emphasis on both instrumentality or concern with the
task that's clearly important since technical skills will always be
important in this job but you might also see an emphasis on on expressivity or
the ability to relate well to other people if stick-and-rutter skills are
no longer enough how will pilots with their technical orientation acquire the
necessary new abilities in search of a solution and after two bad accidents
United was the first of a handful of US carriers to embrace an idea called
cockpit resource management or CRM for short at their Denver facility captains
first officers and flight engineers all undergo three days of annual recurrency
training in the United program concern for personal relationships is valued as
highly as technical competence using ideas borrowed directly from business
management crews are taught to recognize how their individual styles can create
the communication blocks which cause accidents so we would move this guy Rob
would you have any problem with that you know I'm moving him up this way cockpit
resource management has two aims one is to a degree modified behavior it's not
sensitivity training and we would not get into that and the other is to also
get the crew to work together as a crew in all circumstances there are a number
of techniques that are utilized in CRM training but one of the most I think
useful techniques is where pilots fly a full mission simulation that full
mission simulation is videotaped and they sit down with an instructor
afterwards and go through exactly what occurred in the simulation they see
themselves very graphically these cockpit simulators so closely imitate
the real thing that pilots can be exposed to hazards far too dangerous for
an actual training flight a buzz off interconnect close system depressurized
instructor Tom branch observes how well the team handles pre-programmed
emergencies this crew is about to lose electrical power the kind of classic
problem which could divert attention from flying the plane in the debriefing
to follow the crew will be evaluated not only on how well they handled the
technical challenges but whether they did so in a coordinated effort
we've lost the cabin now
video replay requires the individuals to confront themselves as team players this
exposure is sensitive and the airline protects the pilots by erasing the tapes
right after the postmortem we had expected privileged access but a
computer malfunction made the flight problems more serious than necessary
causing amongst other things a dangerous loss of air pressure the crew had
performed well but by their standards not well enough to share much of their
analysis with us usually privacy ensures a more revealing discussion let's look
and see what happened to us you're at 35,000 feet and you lost all your
generators and first of all Frank what was your problem what was what was
different back there than you expected to see well the one of the things you
see in response to those situations are pilots turning around to the other crew
members and saying my god do I come across that way whereas the other crew
members will turn and say yeah you can be extremely overbearing in some cases
that type of feedback video feedback allows a person to see him or herself in
a way that that they're not used to doing this need to make the crews aware
of the impact of their behavior is underscored by the cockpit voice
recorders recovered from accidents conversations amongst the crew betray
patterns which are being acted out over and over again one of the most
straightforward examples is the tragedy of Eastern flight 401 so clearly
uncomplicated by any environmental factors that it has become a classic case
study on a dark December night in 1972 three able-bodied and experienced pilots
flew an L-1011 into the Florida Everglades after becoming distracted by
a burnt-out light bulb it sounds implausible but crew preoccupation with
minor mechanical hitches and an associated failure to monitor the
instruments is a common cause of accidents this disaster also illustrates
some other recurring problems like the failure of captains to act as leaders
make decisions set priorities and delegate responsibilities shortcomings
which are compounded by unassertive and complacent crew members a simulator
reenactment of the final eight minutes of this flight shows how all these
ordinary human failings led to a complete breakdown in teamwork and
ultimately to the deaths of 99 people
actual airline pilots play the parts of the ill-fated crew the dialogue is taken
from the cockpit voice recorder and altered only to remove or change
expletives and names certain omissions have been made to shorten the elapsed
time eastern flight 401 is on final approach to Miami International runway
nine left the nose landing gear indicator has failed to illuminate so
the crew cannot tell whether the gear is extended and locked you want me to test
the lights or not yeah check it which seat back
hey Dougie it could be the light could you jiggle the light it's got to come out
a little and then snap in I'll put them on up to 2000
you want me to fly Doug what frequency did he want us on 286 I'll talk to him
all right approach control eastern 401 we're right over the airport here and
climbing to 2,000 feet in fact we've just reached 2,000 feet and we've got to
get the green light on our nose gear eastern 401 Roger turn left heading 360
maintain 2,000 vectors to nine left final left to 360 I think it's above the
red one yeah I can't get it from here I can't make it pull out either we got
pressure yes sir all systems put the damn thing on all about all right see
if you can put that light out now you got to push the switch this a little bit
further forward I turn it to the right a little bit no I don't think it's gonna
fit hey get on there and see if that damn nose wheels down okay you got a
handkerchief or something so I can get a little better grip on this anything I
could do with this damn thing just won't come out Doug if I had a pair of pliers
like the cushion the captain has neglected to divide up flying
responsibilities everyone is absorbed by the crisis so they don't hear the audio
alert announcing a change in altitude
with this go down and see if that red line is lined up down there don't screw
around with that 20 cent piece of light equipment
Eastern 401 I'll go out West just a little further if we can here and see
if we can get this light to come on the autopilot has somehow become
disengaged the plane is slowly descending and nobody is paying any
attention to the altimeter it's always something we could have made
schedule we can tell if the damn gear is down by looking down at the indices an
emergency landing with a possible nose gear problem is neither very risky nor
all that unusual it's an option the captain could be preparing for now it's
got to be a faulty life like this damn thing just won't come out all right just
leave it there the controllers inquiry is too vague for the crew to realize
he's asking about 401 surprisingly low altitude okay 180
hey we did some of the altitude here what we're still at 2,000 right what's
happening here look at the time between when they first noticed that there was
something wrong with the altitude and when they hit the ground then that eight
seconds those two pilots both of them were so removed from their primary job
of flying the airplane that they couldn't do a thing they didn't reach up
and grab the yoke and change the pitch or the role of that aircraft one degree
that's how removed they were from their primary job of flying the airplane
you know we're we're sort of ingrained in what we've been taught over the years
and it's like the old story about our job description hours of sheer boredom
with moments of stark terror just what he was saying before we're focused on
one item at a time which is a very task-oriented we agree wholeheartedly
pilots are task-oriented they're they're used to having as a matter of fact
sometimes you'll see a pilot he's actually excited about the fact that
he's got a problem good let's get in here and solve this problem I would like to
prove to the world that I could solve this problem very difficult for a pilot
when he starts working a problem to leave that problem before it's resolved
well how do we prevent that how do we prevent that from happening in a cockpit
in your cockpit how do you prevent most of our pilots prior to coming in have a
very low opinion of what we're going to do they call it charm school but as
they leave the class I usually get a healthy handshake and the thank you for
a class they felt was very very worth their while we push sticky issues we
want the pilots to talk about the problems they've had in cockpits it
appears that just talking about them helps the situation our thinking is
still back too many years ago where where the captain was the god he was
Peter Pan and Mary Poppins all at the same time and the first offices didn't
have the input the first offices weren't allowed to have the input I'm flying
with captains right now that unless they get to a very dangerous point I'm not
gonna say a whole lot because they are really gonna jump I know one right now
that has been reported nothing done because he's a senior guy he's a check
airman but I he flies good boy you can't tell him anything I think if we learn
anything over past two days is the fact is us as first officers that we can't
speak up and question anything that we don't agree with it's my responsibility
as a first officer to say something and have the guts that if I get called in
we'll take it from there while pilots themselves may find this training
valuable the impact of CRM as an accident deterrent is hard to prove most
airlines have yet to climb on the bandwagon and it's not clear that
ingrained wrong stuff personalities are even amenable to change well changing
human behavior is a very difficult endeavor and clearly it's not something
that you can bring about within a couple of days within the classroom the program
has to contain some recurrent training now a member of the National
Transportation Safety Board psychologist dr. John Lauber pioneered much of NASA's
ongoing research into cockpit behavior does he believe that CRM training should
be mandatory if it were an idea and a concept that was fully developed that we
knew what techniques worked and worked effectively and we knew unequivocally
how effective they all were then it might be a good idea to consider making
the concept mandatory from my point of view and I think others agree it's still
a concept that's in development the airlines themselves are divided in their
enthusiasm for CRM pilots from 46 air carriers belong to the airline pilots
Association here in a Washington DC hotel for their annual safety forum but
only two members Pan Am and United and two other airlines continental and
people express run full-fledged CRM programs five others have partial
training even among the majors there are several who don't teach it at all
captain Joe Oliver on the left is a 28 year veteran of Delta Airlines our
philosophy is directed toward a captain oriented flight crew in such a
philosophy he is the director the leader of the band and by the time that the
individual reaches captain status he is either able to manage the resources that
are his or the four days or two days of training that you give him aren't going
to materially change that Charlie Finch is a Delta first officer the captain's
always the final authority you may be flying the aircraft but he'll always be
the one that maybe say let's put a little bit more power on or carry an
extra five knots of airspeed he reinforces your decisions in most
instances we have tremendous communication in with Delta because
everybody loves their job and that's really important but Delta doesn't have
any training per se not that not that I know of I mean I've never been told
how to get along with the captain you just assume that you get along with this
person make his job easier assertiveness training on Eastern Airlines as a
standalone unit as a specific objective we've not felt the need for it most
carriers have a corporate culture of their own and each carrier is a little
different one from the other at Eastern Airlines we have never had to the best
of my knowledge any need to teach our pilots how to be assertive as such
captain Burton Beach is in charge of training close to 5,000 pilots at Eastern
Airlines there is more evidence of the failure of the crew or the captain to
effectively manage the crew than there is positive evidence in my opinion that
it's a good thing you can always point to accidents and in this incidents that
have happened in the industry and say well if they had managed what they had
a little better that would not have happened accidents are terrible research
criteria for a couple of reasons first of all if you saw a reduction in
accidents it wouldn't mean very much because accidents are so infrequent if
you saw an increase in accidents you could argue it the same way so in short
accidents really make lousy research criteria if we haven't had an accident
for five years can we presume because we didn't have one for five years after the
program one end it was as a result of the program would we have had another
five years in the first place did we spend five million dollars for nothing
airlines may be skeptical about cockpit resource management but given the fact
of human error is there an alternative solution at the Boeing aircraft company
engineers are trying to enhance safety through improved design perhaps
automation can compensate for erratic behavior maybe the answer to pilot error
lies in doing away with the pilot it's interesting to consider removing the
pilot from the airplane however it's certainly not practical in the
foreseeable future because the pilot skill in cognitive decision-making just
can't be duplicated del fadden is manager of flight deck integration at
Boeing in Seattle Washington the cognitive process that the pilot goes
through is extremely complicated much of which is not consistent from person to
person and so we don't understand totally how everyone would do the
cognitive task the physical tasks are much more straightforward they're much
easier to replicate with the machine the autopilot's the most obvious piece of
automation in the airplane it allows the pilot to be freed from the continuous
flying task for major or minor portions of the flight and that has been
improving over the last 20 or 25 years the original autopilots were able to
maintain the airplane in straight and level flight but could do little else
subsequent auto flight systems could make approaches but couldn't land
autopilots on 757 and 767 and some of the other contemporary airplanes can do
very complex flight maneuvers in flight and do complete automatic landings so
the automatic ability there has been improved steadily with each airplane the
precision of autopilot saves fuel and is useful in crowded air corridors it
frees up the cruises scan for avoiding other planes and cuts fatigue on long
flights but the autopilot does little to relieve the pilots invisible workload
the 757 and its precursor the 767 ushered in the first generation of
Boeing planes to tackle this problem of mental workload the heart of the
innovation is a computer which augments decision-making especially during times
when pilots are liable to become overloaded and preoccupied the engine
hydraulic and electrical systems are now under computer surveillance all the data
is consolidated onto two screens for the first time the crew has the option of
calling up what they want to see and when they want to see it the information
presented is very accessible and more easily read than scanning an array of
instruments spread throughout the cockpit here the computer is flagging an
engine fire identifying which engine and recommending a shutdown additional help
can be had on demand on the screen now our instructions for restarting the
engine in mid-flight the information advance here allows us to put
information together in ways that the pilot could do previously but had to do
himself he can concentrate on the decisions what to do with the airplane
what to do with the relationships that he can see in the display rather than
how do these two pieces of information that are physically separated relate the
system saves mental effort by assembling the information needed for a decision
but is this so-called glass cockpit a radical safety breakthrough or just
another resource which the crew must manage Earl Weiner is professor of human
engineering at the University of Miami in collaboration with several airlines
including Eastern he is observing the impact of the 757 on pilots who are
making the transition from less automated planes
okay we're going to st. Thomas
have you been down there before I'll come down once on this trip
st. Thomas and I was kind of hoping we'd start flying that from New York instead
of just Miami because it's a perfect airplane for that route one of the
problems with any automatic device and certainly the highly development you
find in the cockpit of a 757 is that they are what I call the 2d is dumb and
dutiful dumb in the sense that if you set up a condition which is incorrect
or possibly even hazardous equipment won't necessarily recognize that dutiful
in the sense that it will carry out whatever its program to do in September
1983 Korean Airlines flight double-oh-seven was shot down when it
strayed into Soviet airspace how it got there is still a matter of conjecture
but Earl Weiner puts it down to a typing error I think that either the wrong
heading was programmed into the computer at Anchorage before takeoff or the wrong
initial position at Anchorage or perhaps it was put into a heading mode in flight
and just stayed on that heading rather than following the pre-programmed navigation
points I do not believe that it was a conspiracy on anybody's part at all it
was a simple navigational error when you go from manual flight to automatic
flight a new set of problems and conditions arise one of the problems is
the need to monitor which humans don't do very well automation needs constant
supervision but pilots are alienated by this machine-minding role they find it
difficult to stay vigilant the danger of this was dramatized by a 1985 Air China
incident dynasty flight six was at 41,000 feet over the Pacific when one of its
four engines failed the crew was not paying attention and didn't react in
time when the autopilot could no longer hold the nose straight the plane started
to yelp toward its dead engine by the time the crew regained control it had
already fallen six miles passengers were injured and the plane damaged in an
incident resulting directly from automation complacency the most
difficult part is the monitoring job or the watchkeeping job and when pilots
speak of complacency that's what they have in mind the tendency sometime to
set up the equipment and program it and then not keep track of it not watch
where it's going and that I think is a critical problem in the man's eye of the
pilot this is not the only source of concern for pilots who are trying to
adjust to automation some of the more negative things one hears in interviews
is a sense of powerlessness of loss of control they talk about being along for
the ride they refer to the new aircraft cockpits so Atari's and Pac-Man's and
some of the more specific complaints would be the problem of complacency that
they recognize that tendency to be complacent a concern about loss of skills
and that's a very realistic concern that is if they are spending most of their
time flying along under automatic control now do they have the skills to
take over manually and land the plane should the automation fail the heart of
the problem of flying into an airport like st. Thomas where the physical
characteristics of the airport create a situation that is trying you can't do
much with automation the Wizards with the drawing board would like us all to
believe that flying is an applied technology but flying is still an art
form and automation is not going to do some of the things that have to be done
pilots are error-prone but irreplaceable and even at their best entirely at the
mercy of a system over which they have no influence this system is currently
imposing some severe pressures from many different points of view yeah we've got
some problems going on in the industry right now based on lack of management
understanding of how close you can come to the line and and not decrease safety
when you start putting pressure on pilots to fly with fewer and fewer
amounts or lesser amounts of fuel you start cutting the margin into an area
that's subjective in other words you may be safe you may never get close to
crashing an airplane but what you are doing is reducing the margin of safety I
personally was involved in an incident which was frightening and there have
been several it involved a takeoff situation where an airplane was cleared
for landing at the same time that the airplane I was in was on takeoff well
the report seemed to indicate that we're seeing more runway transgressions that's
more than one aircraft or more than one vehicle on a runway when there should
only be one there we're seeing the automation issue certainly because we're
getting more automated aircraft there's a lot of another new airlines that are
coming in that aren't as quick on the radios that aren't as confident of or
experienced in the approaches that we've used over and over and it's you look out
a little bit more than you used to oh there are very strong pressures about
keeping integrity with the schedule and accepting airplanes that have mechanical
deficiencies and flying in weather that you certainly don't want to fly in but
it's not illegal for you to fly in
cockpit resource management theory meets reality out on the line
where crews must operate under all kinds of pressure and make judgments based on
insufficient and conflicting information nowhere was this made clearer than in a
disaster at Dallas Fort Worth Airport on August 2nd 1985 when treacherous winds
forced Delta flight 191 onto the ground a mile short of the runway wind shear
has caused 18 major US accidents since 1970 and in most cases the pilots were
held responsible this one killed a hundred and seventy three people and
involved a very experienced crew flying for an established airline is the kind
of accident that could well happen again how can pilots avoid danger which is
difficult to detect and can they be held responsible for the outcome of an entire
chain of human errors Jerry Chandler is an aviation journalist who happened to
be at the airport at the time of the crash he has since published a book
about the safety issues it raises on this road highway 114 we're heading west
toward Fort Worth Delta 191 first touch the ground off to the right dug a trench
about 260 270 feet long
curdled this lane airborne it's left engine the port engine headed
Toyota driven by a mechanic from Mississippi coming out here for a job
that slew the airplane about 10 degrees to the left and that put it directly in
line with the water towers tanks right over here to the left
are the tanks which the airplane finally impacted the nose hit the
southernmost tank pivoted the craft around and actually snapped off the tail
like a like a bullwhip as it was that tail was like an escape capsule for the
26 people who did survive we had a water tower
the wind shear see any lightning
Delta 191 had flown into a type of wind shear called a microburst a
thunderstorm produces a funnel of rapidly downward moving air which slams
into the ground causing violent wind eddies and swirling horizontal
tornadoes the plane was approaching to land when the first officer saw lightning
a minute later violent tailwinds and driving rain dropped airspeed and
altitude but 191 recovered another tailwind cut airspeed a downdraft forced
the nose down it continued to descend into a tailwind which slammed the plane
onto the road at 250 miles per hour dr. John McCarthy is investigating wind
shear for the National Center for atmospheric research
center field went 300 at Niner South Quadrant wind 17010 well from what we
know of the wind shear events particularly microburst that we've
studied approximately 25% of the microbursts we know about are no big
deal anybody can fly through them there's probably 25% on the other end of
the distribution which is probably fatal if you get into it you're not likely to
get out of it is this what happened to the crew of Delta 191 I'm acting
chairman of the National Transportation Safety Board we are here today to
consider the aircraft accident report of the Delta the wind shear that caused
this accident was the most violent ever recorded should they have been able to
escape and why did they fly into it in the first place these were the issues on
which the accident would be judged at the safety board hearing a year later
did the crew know the severity of the weather they were flying into the
controllers had informed them of the rain shower and the fact that the winds
were variable at the field that was the only additional information that
controllers had provided the flight crew which effectively was all that they were
in possession of the forecast was only for variable winds and rain showers so
the airport was not expecting wind shear conditions or thunderstorms that
afternoon this lack of accurate information was linked with the
operations of two different weather stations 72 miles apart the weather
radar specialist at Stephenville makes and disseminates weather radar
observations at least once an hour at about 30 minutes past the hour on the
evening of August 2nd the specialist left his radar position at 1735 for
dinner the other weather service is at Fort Worth on the evening of the
accident the meteorologist took a supper break at 525 p.m. meteorologist did not
return from supper until about 610 but approximately four minutes after the
accident the meteorologist testified that he would have issued a center
weather advisory for the level 4 thunderstorm north of the airport if he
had been at his position at 6 o'clock there were two weathermen monitoring
the gestation of the storm in the busiest time of day at the world's
third busiest airport both of them went to dinner at the same time leaving in
the fact the radar scopes unmanned the air traffic controllers saw lightning at
different times but did not advise incoming planes the controllers had also
stated during the interview that they had observed lightning on at least one
occasion and in the case of the local controller he had observed one flash
approximately one and a half miles east of runway 17 left at about the time he
observed the Delta aircraft emerged from the cloud mass and rain shower the the
controllers saw the tower controller he had an excellent view of that end of the
runway he saw that was pretty severe weather moving in and he didn't say
anything none of these things alone would have cost the accident then he put
them all together and then he got an accident and as I mentioned earlier we
felt that the traffic load in the tower was such particularly on the east side of
the airport that full attention was should have been focused on the traffic
situation and runway taxiway to runway 17 right right over here evening crash
crash occurred at 16 aircraft lined up waiting to take off on 17 right and your
runway 17 left both of these are being handled by one controller supervisory
controller handling right he had aircraft approaching 16 aircraft waiting to take
off moderate traffic I don't see how you can call it traffic
whether it falls into the category of additional services additional services
are required duties of controllers but are based on the time available to
control to provide those services had the controller found time to report
lightning it would probably not have changed the outcome because Delta 191
was already in the wind shear the next line of questioning concerned the airport
wind shear alert system and other potential sources of information about
the bad weather in this case here there were no alarms received in the tower
until 10 to 12 minutes after the accident therefore nothing was provided
to the flight crew the low-level wind shear alert system in its current form
at most airports has only six sensors and the spacing between the sensors is
like three kilometers or so and unfortunately many microbursts are like
only one or two kilometers across so that the problem is the net that we're
trying to catch these things in is so coarse that they slip right through
undetected when Delta 191 encountered the microburst it occurred outside of
the network and consequently the aircraft got in a big trouble once formed
the storm grew very rapidly but from the Delta 191 approach side it did not look
as ominous as it did from the control tower not once before the accident did
any arriving pilots complain about weather problems or request to
discontinue an approach several of these crews had noticed lightning but said
nothing at the time Delta 191 could see planes ahead landing safely so there was
no reason not to do the same or was there we played the tape through
obviously with the with the group around the table here in the cockpit voice
recorder lab and it was obvious to us that then obvious to them that they did
see a thunderstorm and they did comment on the fact that there was lightning
coming out of it the and they chose to proceed into the thunderstorm the pilots
were clearly flying into thunderstorm conditions they were flying into a known
rain shower with lightning dead ahead we've been training pilots for years to
stay out of thunderstorms at low altitude state in terms of the very
having determined how the plane flew into the storm the board moved on to
Delta policy on wind shear and thunderstorm avoidance whether the
pilots have been given sufficient guidance and training and how to detect
or how to fly through winch years became quite controversial and it took the board
five report drafts to agree on whether the crew had enough information to have
avoided this one and what are what is official company policy yes once the
pilot has been taught to recognize situations where wind shear might occur
company guidance company policy is to avoid such areas all conditions of
flight yes there were two basic positions being developed within the
board we could have split the vote and it would have stood as as the record on
that had we done so I'm afraid that that would have been the story that would
have been the message to the public and to the airlines and to the FAA a
confusing one a split message and by taking all three factors and making them
equal elements of the probable cause it was a it was an acceptable approach
under the circumstances and that's why the boat turned out the way it did in
effect the blame was spread three ways on the absence of wind shear hazard
information at the airport on the crews bad judgment and flying into a storm
and then continuing to land after the wind shear became apparent and on the
airline's ambiguous policy for managing situations like this we really don't
know what more we could have done in the area of training but what really
concerns us and where we have an enormous concern is the fact that no
warning was given any of our pilots by the National Weather Service about the
FAA controllers about the president storm even though both can see it it was
clear that we had to to to indicate to the public and to the airline community
and to the FAA and others that the we were very concerned about the action of
flying into that cell I guess we're very disappointed in those findings
because they they point back to the crew as the having the last chance at saving
the airplane they kind of like to point is that as the critical element near
end of the chain of events that happened there is a catch-22 involved here in
that we are expected by our airlines and by our passengers to fly in all weather
operations and we do so and just statistics prove that we do so very
skillfully but occasionally due to information you don't have or bad luck
or mechanical difficulty or something else it can result in a tragedy and then
we are blamed for doing what we are in effect and actually required to do on
daily basis 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 couldn't they improve the
odds on every flight for starting engines circuit breakers and switches
checking on voice recorder on tested oxygen on 100 speaker check on 100
speakers check and set indicating lights check left check right check the flight
control power switches all on and I skid test on stall warning tested speed
command tested altitude alert tested instrument transfer switches three no
longer reset on a break off emergency exit light arm alternate flap switches
real light recorder testing set seatbelt no smoke calls on transponder
standby window heat is on anti-ice is off little static heat is checking off
navigation lights position on fire warning switches in tested emergency
break and pressure handles wired off pressure is 1300 light instruments