March 1, 2002
MARC K. HENEGAR
We hear a lot about CRM (crew resource management) and about the value it can bring to the safe operation of an aircraft. However, there is a flip side to CRM that is worth considering. Let's call this reverse CRM. Or, how two people can talk themselves into doing something that neither one would have signed up for on his own.
A "friend" of mine is flying in a high-performance jet in the busy Northeast corridor. As is the custom in New York airspace, the flight has been instructed to descend to about 10 feet above the ground about 8 million miles from the destination airport. The crew is going into Teterboro, New Jersey, a place where on-time flights go to die.
The crew is happily buzzing along at 250 KIAS, talking about their day, when they are advised that Teterboro is IFR, now encountering delays, and they can expect to hold for 45 minutes. Both pilots exchange knowing looks. They've been in situations like this before.
About five seconds later, just about at the end of the knowing look, New York Center gives holding instructions. "Hold north of Somewhere on Victor 123; expect further clearance later." This has put the crew in a high-workload environment — fast.
A quick glance at the FMS (flight management system) indicates that "Somewhere" and "V123" are not in the current flight plan. One pilot starts scrambling for the low-altitude charts; the other takes his best guess at spelling Sumware and tries to input it into the FMS. (This particular FMS can't accept V123 without knowing a point on the airway first.) Turns out Sumware is in Africa somewhere. Various combinations are tried until Somewhere is correctly input into the FMS. At this point, the crew deduces that they are 14 seconds from Somewhere and need a plan in a hurry. As they cross Somewhere they realize they are basically on V123 and to hold north is behind them. The only thing left to figure out is which way to turn.
Did you remember which way he said? He didn't say, so it's a standard holding pattern. Uh, which way is a standard holding pattern? "Left turns," says one pilot, with absolutely no confidence. The other, who was leaning toward right turns but was hoping to use a 50/50, Phone-a-Friend, or Ask the Audience to get a little more confidence, says, "Yeah, that's it, left turns, final answer." And one pilot starts to turn the airplane left.
About 30 degrees into the left turn, the other pilot sees his Career Dissipation Light going off and comes up with a way to ask Center which direction a standard hold is without coming across like a complete idiot. "Center, Challenger One-Two-Three, did you want right turns or left turns for the hold at Somewhere?" Center responds with "right turns."
Both pilots utter a universal "uh-oh" as the airplane is deftly turned right to enter the hold using the now-famous dinosaur-head entry (draw it). The rest of the conversation on the way home consists mostly of where the NASA forms are kept at the hangar.
There are a couple of obvious things that we can learn from this. First, always have the appropriate charts available for the current phase of flight. My friends were cleared direct to a point and there was no mention of airways in the original clearance. However, ATC thinks nothing of giving an obscure airways clearance at the drop of a hat. Many controllers assume that we have the charts open and are tracing our route with a pencil down the airway every time they call.
Second, if you cannot execute a clearance, don't accept it. ATC should realistically give you three minutes prior to the holding fix to set up for a hold. This is implied by AIM 5-3-7d, which states that you should begin slowing down for the hold at least three minutes from the holding fix. When my friends looked down at the FMS and saw that they literally had seconds to go to the fix, they simply should have refused the clearance. It doesn't have to be simply, "We refuse." It can be, "Center, Challenger One-Two-Three needs a little more time to set up the hold, can you give us a vector, Victor?"
Take the crew out of the airplane, and they both will say that right turns are standard for holding patterns. However, put them in the airplane faced with a very high workload and unexpected complications, and what seems simple when sitting on the ground is much more difficult.
Add to this the power of suggestion and you can have real trouble. One pilot is not sure and looks to his partner for help, saying, "I think it's left turns." The other pilot does not interpret this as a question, but as a statement. His original instinct was right turns, but with his partner now suggesting left turns he is not sure, thinks about it for a second, and says, "Yep, left turns." That's all it takes. We see this chain of events happen in everyday life and as a contributor to many serious aircraft accidents.
Try this on for size. Different friends are at the edge of the south ramp in Santa Barbara, California. They are cleared to taxi to Runway 15L. This is expected and involves departing the ramp and turning right on Taxiway Bravo.
At one point, many years ago, Runway 15L was actually a taxiway. It was lengthened, widened, and turned into a runway. At the same time, a narrow strip of ramp was turned into Taxiway Bravo, which is very easy to miss. Because of this, my friends were given taxi instructions that were fairly specific. "Aztec One-Two-Three-Four-Five, make your first right on Bravo, taxi to Runway 15L, hold short of Runway 25 on Bravo." My friends acknowledged these instructions.
The pilot and his passenger, who also happened to be a pilot, both missed the turn for Bravo and took what they perceived to be the first right turn, which, unfortunately for them, was on Runway 15L.
Ordinarily this would be a minor annoyance, except for two problems: First, the Aztec had competition for the runway in the form of a Baron that had just landed on 15L. The Baron pilot, suddenly realizing that operating in VFR conditions meant see and avoid in the air and on the ground, managed to stop short of the Aztec. The Aztec pilots were left wondering why the Baron was landing on their taxiway.
The second reason it's not a minor annoyance? Well, which person in the Aztec would you most like to be in this situation? The person taking his ATP checkride in the left seat or the FAA inspector giving the checkride in the right seat? There is not a pink slip big enough for that one. In addition, if you're the FAA in this situation, do you violate yourself? (OK, we'll just let that one go.)
The controller, having seen similar situations before, caught the mistake pretty fast. But by the time he could get the transmission out, the Aztec was already on the runway. The controller might have let it go with a phone call to the Tower, except for the aforementioned Baron rolling out on the runway. At that point, the controller had very few options but to pull the tapes, kill a tree, and start the paperwork.
This brings up another interesting point. When you are taking a checkride, what do you assume is the worst that can happen to you? A bust? Think again. Do you think the ATP applicant even remotely considered the possibility the night before his exam that there was something worse than a pink slip at the end of a checkride?
About the time my friends completed the turn and looked up, the Career Dissipation Light must have been going off like a strobe in a dark room. Unfortunately, unlike my New York friends, they had no time to undo what they had done. Game over, here's your pink slip. It boggles the mind. To get busted and violated and put lives in danger before you've even done your runup is pretty impressive. It usually takes hours to get all that accomplished.
I have no idea how the conversation in the cockpit went, but I imagine it went something like, "That big runway over there looks like Bravo," to which the other guy must have responded, "Yep." I am sure the conversation took a decided turn for the worse the moment the pair realized what was happening. I also have no idea how the debrief went, but I imagine it was long on paperwork and short on witty repartee.
The most disturbing thing that we can take away from these examples is that four fairly experienced pilots — with thousands of hours of flight time — can goof up something as simple as which way to turn to start a standard holding pattern or where to turn onto a taxiway.
CRM is a great thing, reverse CRM is not. We have to make sure that we don't allow CRM to talk us into something together that we would not do alone. Most of this is common sense. But we as pilots are reluctant to cry "uncle" and ask for help. If you are not sure, say so. Don't try to bluff your way through the situation with ATC, your flying partners, or yourself. If you are not sure, get sure and be safe. Ask for a vector, delay the approach, do whatever it takes to get home safely.
Marc K. Henegar flies a Boeing 737 for Alaska Airlines.
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