Crashes that resulted from co-pilots failing to speak up.

[avro1]

Greetings,

I'm trying to help a friend with a class project. He's trying to find examples of aircraft accidents where the crash would have been preventable if it weren't for a cultural barrier that prohibits co-pilots from questioning their highly experienced captains. In particular he's looking for an example from a country where this "superior vs. subordinate" culture exists in general (outside aviation as well).

Can anyone come up with a clear shinning example that matches this description?

Many thanks to all who reply.

[corroded_camshaft]

http://en.wikipedia.org/wiki/Flash_Airlines_Flight_604

[Gannet167]

http://en.wikipedia.org/wiki/Tenerife_airport_disaster

The worst and probably one of the most famous.

[Heliian]

http://en.wikipedia.org/wiki/Flash_Airlines_Flight_604

Was that the one where they said it could have possibly been hari kari by the captain?

[AUGER9]

Birgenair Flight 301 was a good one that fits exactly what you're looking for.

[mike123]

Polish president's plane crash may not be exactly what your friend is looking for, but is a good example of "superior vs. subordinate" culture that resulted in a tragedy.

[200hr Wonder]

Flying Tiger Line Flight 66 into Kuala Lumpur

http://en.wikipedia.org/wiki/Flying_Tig ... _Flight_66

There is a great video with CVR recording on it. The FO on several occasions says he does not like what is going on. At one point he even says lets just go around and do the ILS. No one in the cockpit has any situational awareness and it is a complete cluster. I am pretty sure there was no approach briefing done even. As for the cultural aspect, most of these pilots where ex-military and that is how the airline was run.

The video: http://www.patricksaviation.com/videos/acobra123/3766/

[200hr Wonder]

Here is some video on the KLM Tenerife flight:

http://www.pakistan.tv/videos-tenerife- ... MMM%5D.cfm

[Stinky]

What about Swiss Air, didn't the co-pilot want to lad overweight and the captain insisted on dumping fuel.

[parm]

There's a chapter in Malcolm Gladwell's book "Outliers" that deals with Korean Air Flight 801, and how the power dynamic in that cockpit, shaped by the rigid Korean social structure, may have to led to crew members not contesting the captain's poor PDM. Your friend would also do well to read some of the various rebuttals to this book, and in particular to this chapter, that are available online.

[Elliot Moose]

Brit Air pranged an RJ several years ago in Brest. The FO let the Capt drive them into the ground 2km short of the runway with the EGPWS blaring for 22 seconds that they were below glideslope. He tried to take over about 2 seconds to impact, but didn't do enough even then.
http://www.1001crash.com/index-page-des ... sh-70.html

[Canoehead]

RE: Flying Tiger 66

I almost launched my beer through my nose when I read this line on Wikipedia:

The second officer was 70 years old and used a magnifying glass to see with.

Then I realized that we are on our way to this here in Canada...

[grimey]

There's a chapter in Malcolm Gladwell's book "Outliers" that deals with Korean Air Flight 801, and how the power dynamic in that cockpit, shaped by the rigid Korean social structure, may have to led to crew members not contesting the captain's poor PDM. Your friend would also do well to read some of the various rebuttals to this book, and in particular to this chapter, that are available online.

It's also the subject of an episode of Mayday. Season 4 episode 4.

http://en.wikipedia.org/wiki/List_of_Mayday_episodes

Outliers has a good writeup on it though, along with the aftermath. Korean Air brought in an American to run their training, to attempt to get rid of the cultural problems. Their safety record improved dramatically

[StudentPilot]

If they're looking for a Captain > Co-pilot attitude, the Garuda crash a few years back could work as well. I haven't read the CVR transcript, but I'm pretty sure the co-pilot got as far as begging the captain to go around before he "landed" at something like 220 kts and shortly thereafter killed a hundred and some people.

[ahramin]

In a lot of these examples the first officer did speak up, but was ignored.

There is a problem here in that if the first officer didn't speak up, how do we know that he was aware of the impending crash?

[Liquid Charlie]

I almost launched my beer through my nose when I read this line on Wikipedia:
Quote:

I met a guy in Europe who was an F/E on the L188 and he was 78 years old -- sharp as a tack and very few could keep up to him -- He had been a career F/E and was with one of the legacy carriers In the USA until they phased out F/E's -- Austin airways had Archie -- flew until he was 80 and was originally a CP captain -- got to face it -- some guys just got the genes - in reality we are a narrow minded bunch of buggers -- we really don't care about a guys age just that he is taking up a seat you figure you should have -- it's about money and ego -- -- take a deep breath -- your turn will come too soon to have all the younguns drooling over your position -- haha

It's been my experience that guys who support CRM don't need it -- it's the people who thumb their nose at which sets off my alarms -- I have witnessed a few guys in my time that feel they don't make mistakes and if they do it's not their fault but blame it on anyone - anything but themselves -- usually when they did @#$! up and bent an airplane -

[iflyforpie]

15:59:32 CAM-1 Okay, your throttles.
15:59:35 [SOUND OF ENGINE SPOOLUP]
15:59:49 CAM-1 Holler if you need the wipers.
15:59:51 CAM-1 It's spooled. Real cold, real cold.
15:59:58 CAM-2 God, look at that thing. That don't seem right, does it? Uh, that's not right.
16:00:09 CAM-1 Yes it is, there's eighty.
16:00:10 CAM-2 Naw, I don't think that's right. Ah, maybe it is.
16:00:21 CAM-1 Hundred and twenty.
16:00:23 CAM-2 I don't know.
16:00:31 CAM-1 Vee-one. Easy, vee-two.
16:00:39 [SOUND OF STICKSHAKER STARTS AND CONTINUES UNTIL IMPACT]
16:00:41 TWR Palm 90 contact departure control.
16:00:45 CAM-1 Forward, forward, easy. We only want five hundred.
16:00:48 CAM-1 Come on forward....forward, just barely climb.
16:00:59 CAM-1 Stalling, we're falling!
16:01:00 CAM-2 Larry, we're going down, Larry....
16:01:01 CAM-1 I know it!
16:01:01 [SOUND OF IMPACT]

http://en.wikipedia.org/wiki/Air_Florida_Flight_90

As far as 'cultural' goes, yes it was an American crew but in a much different era than today...

[SunWuKong]

A whole thread "avwikipedia" for the first time...

A crash because the F/O didn't speak up? Hard to speak up when you are not sure, and you are just as puzzled as your captain is by the situation.

Modern CRM seemed to have identified why we crashed, and they tell us that the more you understand and apply CRM, the less you will crash... In fact the engines became extremely more reliable since the 80s, explaining the good safety records recently. And when some airlines show a very bad safety history, well the maintenance (or lack of) often explains why.
Other than that, hard to prove in 2010 that a cutural problem would explain some crash. Observe the safety record of China, Korea, Japan (speaking about culture issue, if this is where you want to come?) the 10 last year, they are extremely good. What happened, did they change their culture, not really, at least not in China (Korea is a bit different see Korean Air history). They just change their rules: all airplane that are bought should be either brand new, either still in production. So exit all the old Russian airplanes. And Changed ATC rules. That how they only had 1 fatal crash in 5 years.

CRM became a religion with some guru teaching their ideology, a religion to pray because we all unconsciously understood that sometimes crash just happens, whatever the crew says during the crash. You are going down? Well all the call out (escpecially the unsure one's...) and all the F/O in the world won't save the day. I mean if I hear a "REJECT!!!!!!!!!!" from my F/O and disregard it, well yes I would crash because I didn't listen to him. But wait! My SOP/CRM says only the Captain can call out REJECT

[x15]

This accident is resulting in a change of regulations here in Canada. CRM is a requirement for 703 operators now.

Excellent report. Long. But well worth the read. Check all the others on TSB. I learned a lot from reading all the reports.

http://www.tsb.gc.ca/eng/rapports-repor ... 7c0001.asp

[Sidebar]

This accident is resulting in a change of regulations here in Canada. CRM is a requirement for 703 operators now.
http://www.tsb.gc.ca/eng/rapports-repor ... 7c0001.asp

This investigation made a recommendation in October 2009 to require 703 operators to provide CRM training. While many operators do so, there is still no requirement.

[SunWuKong]

I read the report, that is completely off topic.
That is nothing like a F/O too impressed to speak up because his captain is experienced. It is more like the captain being unclear and an F/O unaware about the situation. And personnaly I don't need any CRM to teach me that I have to tell my colleague I take or release the controls, it's just plain common sense. Any way any pilot on earth learn to give or take the controls at the very beginning of their PPL and ever after. And because I read all the report I know it is written that both pilot knew how to give/take control.

I don't see how a bullcrap 2 hours CRM seminar could have changed anything about those 2 pilot who didn't like each other. The F/O had a college aviation diploma, don't worry he had enough theory and blabla about CRM. Anyway the best crew coordination ever reported (three pilot effectively on control for the ones who remember...) occured when the "CRM" term didn't even exist.

We are so arrogant with our so called CRM seminar. I even had a class will smileys emoticon on the entry door in my first "CRM seminar" 's airline. What a joke.
Let's come back in time and teach our "CRM seminar" to the 60s and 70s crew flying their not so safe aircraft, I guess we would get real and fast.

In Europe they do their CRM actually in a simulator, but I guess we will never know what makes a difference, getting some experience praticing emergencies in that sim (couldn't hurt right?), or calling it "CRM".

[x15]

This accident is resulting in a change of regulations here in Canada. CRM is a requirement for 703 operators now.
http://www.tsb.gc.ca/eng/rapports-repor ... 7c0001.asp

This investigation made a recommendation in October 2009 to require 703 operators to provide CRM training. While many operators do so, there is still no requirement.

Good to know. Thanks for clearing that up. Kudos to the company I work for. They have embraced it and taking steps to implement it using in class and sim based training.

[Panama Jack]

There are many. Here are a few that I could think of:

http://www.airdisaster.com/reports/ntsb/AAR80-01.pdf

http://www.airdisaster.com/reports/ntsb/AAR94-05.pdf

[xsbank]

We have a saying in our cockpit, if the copilot has something to say and the captain will not listen for whatever reason, the PNF says "Captain, you must listen to this."
This is a red flag that something needs addressing and has now achieved priority.

CRM works. Proven by improvements in accident statistics.

What you will need to understand now is that CRM has been absorbed by "standardization" and "facilitation." These are new buzzwords you will be hearing more and more of, CRM becomes just 2 boxes out of a matrix of 9. In fact it is called the "Pilot's Skills List" and is composed of:
Briefings
Teamwork (CRM)
Communication (CRM)
Situational Awareness
Workload
Decisions
Professional Style
Aircraft Handling
Applied Knowledge

This is all brought to you by EASA and will be part of your training soon. If TC is only mandating CRM for 703s, it is completely in the stone age and will likely not catch up for years. Be proactive.

By the way, if you do not embrace CRM, it means your mind is firmly shut and you should probably be thinking seriously of a career change. CRM has come a long way from the old "Charm School For Pilots" label and you ain't seen nothing yet...

[x15]

We have a saying in our cockpit, if the copilot has something to say and the captain will not listen for whatever reason, the PNF says "Captain, you must listen to this."
This is a red flag that something needs addressing and has now achieved priority.

CRM works. Proven by improvements in accident statistics.

What you will need to understand now is that CRM has been absorbed by "standardization" and "facilitation." These are new buzzwords you will be hearing more and more of, CRM becomes just 2 boxes out of a matrix of 9. In fact it is called the "Pilot's Skills List" and is composed of:
Briefings
Teamwork (CRM)
Communication (CRM)
Situational Awareness
Workload
Decisions
Professional Style
Aircraft Handling
Applied Knowledge

This is all brought to you by EASA and will be part of your training soon. If TC is only mandating CRM for 703s, it is completely in the stone age and will likely not catch up for years. Be proactive.

By the way, if you do not embrace CRM, it means your mind is firmly shut and you should probably be thinking seriously of a career change. CRM has come a long way from the old "Charm School For Pilots" label and you ain't seen nothing yet...

+1

Can you point to some materials that one might reference for their own self study? Ive been reading the Tony Kern books (Redefining Airmanship and Flight Discipline) and they refer to many of the above topics. I also had several courses that I took while taking my degree that led a professional down the aforementioned path. But since graduation 18 months ago I have been looking for materials to study on my own.

x15