Air Safety – Lessons from Kegworth

The captain’s first action on taking over was to disengage the autopilot. Why? A substantial part of his mental processing capacity was now taken up in pure handling, leaving him much less able to think clearly about what was wrong and what to do about it. There is an innate tendency in all of us, when confronted with a crisis, to do something – no matter how inappropriate, Physical control of the aircraft is the simplest thing to do. The first officer was left with the task of diagnosing – a task which, for whatever reason, he did not accomplish correctly. Most airlines have a very clear routine for dealing with emergencies. Usually, one pilot identifies the problem and the other confirms it. The question, “Which one is it?”·suggests that the captain was so busy handling that he relied on the F/O’s assessment without any at confirmation. Had he brought his greater experience to bear on studying the symptoms, surely he would have been able to arrive at a more accurate assessment.

Mac Job mentioned the fact that the cabin crew did not contribute, and the probable reason why. It can be further argued, as it was by the investigating board, that the captain’s failure to consult the cabin crew virtually sealed their fate. It is worth remembering that there are times when cabin crew can provide valuable information about the state of the aeroplane. Looking at an engine used to be one way of confirming one’s worst suspicions. Where the engine or other component is out of sight from the cockpit, cabin crew knowledge may be a useful resource. By comparison, Kendell Airlines, in their Crew Management course, emphasises this point, and include cabin crew in the training so that better teamwork may result.

The question arises here ofwhen to notify Air Traffic Control of a problem. The old maxim, ”. Aviate, navigate, communicate” is indeed pertinent. When the first officer called ATC, he started a chain of interruptions to their thought processes that plagued them to the very end. ATC is of marvelous assistance to a pilot in distress, but the pilot must first assess his or her priorities, attending to the most important first. Only when the problem is correctly identified and dealt with can attention be turned to supplementary issues, such as where to go and to whom to talk. The workload intensity in this case was extremely high from this point, not because of any real urgency, but because of the numerous radio calls to Control and the company, the carrying out of checklists and the reprogramming of navaids. In most (though not all) emergencies, it is possible to take enough time, if necessary by holding, to ensure that procedures are carried out carefully and fully. The accident carries a message also for company managements.

It has been said more than once that any accident is traceable ultimately to management, since that is where the responsibility for training lies. Thorough training ensures that crews can handle any foreseen emergency with a minimum of fuss.

Tony Wilson is a CRM specialist with the Australian firm Crew Dynamics.

Have you an air safety story to tell? Particularly one with a lesson that might save other pilots from making a similar error of judgement? If you have, write to Macarthur Job, cl- Australian Aviation, PO Box 3105, Weston Creek, ACT 2611. Contributors to this series are assured their anonymity will be fully respected!