Crew Resource Management in Korean Air - Essay Example

Crew Resource Management in Korean Air Introduction Korean Air Flight 801 a Boeing 747-300 crashed and caused a catastrophic accident at Nimitz Hill a high terrain just a few miles on the southwest of the Guam International Airport in the early morning hours of August 6, 1997. The flight had departed from Kimpo International Airport in Seoul, South Korea operated by two pilots, one flight engineer, fourteen flight attendants and two hundred and thirty seven passengers on board. Out of the about two hundred and fifty four persons on board the plane, two hundred and twenty eight were killed in the crash with only about only twenty-six surviving amongst them the passengers and a few flight attendants. The plane was licensed by the Federal Aviation Authority (FAA) to fly in and out international passengers in America through the requisite domestic regulations and the relevant convention that governs international aircraft movements. The investigations by the NTSB found that the likely cause of the crash of the Korean Air Flight 801 could have been the failure by the captain to have a briefing and execution of the approach towards the airport, as well as the inability of the assisting crew to monitor how the captain was conducting the approach (Korovin, 2010). Contributing to these is the fatigue experienced by the captain and the inadequacy of Korean Air in the training of the crew and the deliberate act of the FAA in disabling the instruments and devices that would have warned the crew of the aircraft the safest altitude to make a landing at the airport. Therefore, it can be concluded that the safety issues majored on the performance of the flight crew, the procedures of approach, pilot training, air traffic control including the performance of the controllers and the intentional inhibition of the MSAW at Guam International System. Other factors that could be blamed for the crash include how the airport reacted to the emergency, the technical and safety inadequacy standards in training by the South Korean body in-charge of the aviation industry and the role played by the FAA in its oversight role as well as the documentation got from the flight data recorder. Human Factor (Pilot Error) Korean Air cockpit procedures call for approach briefing before a descent and it includes a briefing about the weather conditions, a proper review of the instrument approach procedure, the actions and callouts of the crew and any abnormal conditions or configurations (Krause, 2003). It also includes the details of the execution of the approach that denotes the minimum safe altitude, the approach frequency and course and the runway touchdown zone elevation as well as the missed approach procedure. From the CVR information, the investigation team concluded that the plane’s captain failed to do the usual briefing of the information about the localizer-only approach, including the step-down fixes and the FAF as well as their associated restrictions on the crossing altitude with the effective dates of approach charts as used. NTSB also noted that the captain failed to brief the first officer and the flight engineer on how he would carry out the descent including the planned autopilot the angle of descent or the step-down fixes. The captain also failed to note the need for special caution in the UN VOR area of Guam airport, which would have been necessary, as it was their first flight together with the first officer (United States, 1994). The importance of this is usually to develop a shared mental model that ensures that all the crewmembers solve the same problem and have an understanding of the priorities, urgency of operations and the significance of cue in flight operations. From the foregoing observations and evidence, it is possible to conclude that the captain was not prepared neither were his crew on how to approach the airport for landing and this impeded them from monitoring all the aspects of a safe approach (Kanki, Helmreich and Anka, 2010). Fatigue Fatigue is an important factor when it comes to flight operations and that is the reason why the NTSB examine factors related on fatigue such as the time of the day, the sleeping patterns including the number of hours since awakening and how it affected the performance of the captain as well as other crewmembers (Caldwell and Caldwell, 2003). However, the NTSB was unable to get information on the most up to date sleeping patterns of the first officer and the flight engineer of Korean Air Flight 801. The air crash occurred at around 0042 Hrs just after midnight in the hometown of the flight crew, which is just one hour behind the time line of Guam, and research has shown that around this time, there is reduced alertness as well as performance thus a higher probability of causing an error or an accident. Korean Air Flight 801 would also arrive after several hours far from the usual or normal sleeping time of the captain, which is 2200 to 2300 according to the local time in Seoul, a time that the body would usually be in place for sound sleep (Gander et al, 1998). According to the evidence on the CVR, the captain was tired, as he had made spontaneous comments related to fatigue showing that he underestimated his level of fatigue and had a degraded performance susceptible to errors or an accident. The fact that the captain had been awake for 11 hours prior to the flight and had not had quality sleep in line with his sleep needs made him susceptible to make an error. The fatigue degraded all the aspects of performance and alertness of the captain as displayed by his behavior, which includes his anxiety and confusion with the status of the glidescope while excluding important information, his incomplete briefing, as well as failed to react to the alerts made by the GPWS. The NTSB therefore concluded that the captain was fatigued which led to a degradation of performance thus contributing to his failure to properly carry out the approach to the airport safely. Hierarchy Culture and Crew Management of Korean Air Crew resource management requires that culture and flying come together in a type of training, the cockpit crew must communicate clearly in times of emergency, and the co-pilots and the flight engineers must speak with force when a problem arises and the captains are bound to listen. The question that was raised in the Korean Air Flight 801 investigations is whether cultural factors may have contributed to the deference to command authority that led to the crash. This is so because from the information recorded, no person in the cockpit spoke forcefully to the captain on the right procedures. Studies have found different variations of pilots depending on their countries of origins and the approach relationships with colleagues within the cockpit and therefore airlines must adjust their training regimens to account for the differences especially with regard to automation and hierarchy culture. It has been confirmed that Korean pilots report feel shameful about themselves when they make a mistakes in front of other crewmembers especially the juniors and are obedient to authority even when flying which may give a clue on the actions of the crew in the cockpit (Phillips, 1998). The organizational culture of Korean Air, which is over-reliant on the use of cockpit information due to its ability to follow an approach path and perform better landing, was also debated to have been one of the causes of the crash. Other studies have shown automation to be a leading killer, as pilots get reluctant to turn it off even when things get wrong as shown by the captain’s failure to turn off the automation until moments before the crash. Confusion of Altitude (Familiarity to Guam International Airport) The National Transport Safety Board noted that when the captain of the ill-fated plane had made a familiarization flight at the airport a moth before the accident, he had used an instrument landing system approach to land on runway 6L as it was well visible apart from the scattered build up of cumulous. However, the video that the crew of the aircraft had watched one month earlier as a means of familiarization of the airport had indicated that the weather at the airport was favorable for landing through just seeing most times within the year but with minimal visibility during the rainy season from June to November (United States, 2000). The captain and the first officer therefore would have assumed that the conditions for Korean Air Flight 801 approach would be similar to those they had seen a month earlier in the familiarization video and that they would easily make a safe landing. He also assumed that the visual slope indicator (VASI) would be in sight after the flight was vectored into the final approach by the CERAP controller and would have provided a visual guidance for a constant angle of descent that can velar obstacles safely. Therefore, the NTSB concluded that the expectations of the captain of a visual approach contributed to his incomplete briefing of the localizer approach, which is common among pilots operating passenger flights whereby they abbreviate the briefing on the instruments when they expect to approach an airport simply by sighting it. The NTSB therefore concluded that the Korean Air crew viewed the familiarization video that gave only the generalized description of the topography of Guam Island but did not indicate but did not disclose any impediments that may be on the course of approach. This familiarization video however failed to show that the radio navigation station for aircraft was on a hill and the Distance Measuring Equipment was not in the same location as the localizer. It also failed to show that the last bit in approaching the airport was over a hilly terrain as well as the non-precision approaches such as the many step-down fixes and the use of two separate navigation facilities. The NTSB therefore concluded that the Korean Airport familiarization video for Guam airport by putting an emphasis of the visual aspects of the approach cultivated the expectation by flight crews of a visual approach while not putting keen interest of the hazards posed by the terrain and the DME factors. Contributing Factor; DME and the Weather According to the information on the weather around the time of the crash, there was an indication that there were variable clouds and scattered rain showers that can be associated with a weak low-pressure trough that is moving eastwards (Cramoisi, 2011). This pressure around Guam was also made worse by increasing intensity of showers, which moved over the higher terrain of the island where the airport was situated. According to interviews conducted by the National Transport Safety Board, the lights of the island could still be seen as far away as 150 nm. The information recorded by the CVR also indicated that the crew who were flying the plane at the time of the accident made visual contact with the island 16 minutes before the accident as indicated by the flight engineer’s recorded statement of "its Guam, Guam." In addition, from the data recordings of the weather and witness statements, Korean Air Flight 801 may have encountered scattered cloud layers at levels below 5000 feel msl as it approached Guam. The flights on the ground were likely to be intermittently visible along the Guam coastline and there is a possibility that there were scattered clouds beneath the plane in the vicinity of the intersection of FLAKE that is located DME from the NIMITZ VOR (UNZ). Further, the radar data from the Doppler indicated that there was heavy or very heavy rain shower at the southwest part of the airport that is the usual approach corridor at the time of the air accident. Though the Apra Harbor area which is 5 DME on the approach would have been visible to the pilots as the plane made a descent through the 2000 msl, the plane would have still gone through the scattered clouds as well as the light precipitation after passing it. The data from the radar also indicated that the flight was likely to have met rain that increased in intensity continuously as it proceeded towards the airport. The indication is that at the time the aircraft reached the outer marker, there was already heady precipitation and the aircraft wiper had already been activated because of the watery drops. Therefore, based on the Doppler radar data, there was slight rain shower activity around the Nimitz Hill as well as the Guam International Airport, which makes the Safety Board conclude that the crew of Korean Air Flight 801 met instrument meteorological conditions (IMCs). The conclusion is that although the flight made it through the heavy precipitation a few seconds before the crash occurred, the captain and his first officer could still not sight the airport as another shower was already ongoing in the areas around Nimitz Hill. Confusion about Location of DME At around 0140:37 when Korean Air Flight 801 was about 2400 feet msl and making a descent of 1000 feet per minute, the captain argued that since on that day the glideslope condition was not good, there is need to maintain 1400 feet. The implication of that argument is that the pilot was convinced he was complying with the restrictions put in place by the localizer-only approach and wrongly assumed he had gone through the outer marker. The question left for the NTSB at this point is whether the crew of the Korean Air Flight 801 had confused on the configuration of runway 6L localizer and the one in which the Distance Measuring Equipment is located. From their training, the flight crew was found to have trained and undertaken check rides that had the DME located within the airport while a countdown DME procedure rarely found in a localizer procedure was not in any of the training on the part of Korean Air at their flight simulation sessions. (Walters and Sumwalts, 2000). Therefore, if the crew misconceived that DME refers to the distance from the airport, they might have had a perception that the plane was a few distance from the airport than it actually was as the Distance Measuring Equipment was located about three miles from the airport to the south. The plane was also at the right altitude that would enable it conduct the step-down fixes and come down to the MDA according to the training that that the Korean Air crew had got in flying the plane. If at all the captain and such a misconception, it could give a concrete explanation as to why he flew the plane commanding altitude selections as though he had a belief that he was at or above the altitude constrains for any navigational fix along the approach. The implication of this is that if at all the flight crewmembers equally misconceived this important aspect; it explains why neither of them challenged the premature descent made by the captain at levels below 2000 and the recommended 1440 feet. The concrete conclusion of the cause of this accident is that the captain as well as the first officer may have wrongly conceived that the aircraft was nearer the airport than it was actually, and descended in total disregard of the Distance Measuring Equipment fix definitions that they had seen and understood previously from the approach chart. References Caldwell, J. A., & Caldwell, J. L. (2003). Fatigue in aviation: A guide to staying awake at the stick. Burlington, VT: Ashgate. Cramoisi, G. (2011). Air crash investigations: The end of the Concorde era: the crash of Air France Flight 4590. Manila, Philippines: Mabuhay Publishing. Gander, P. H., Gregory, K. B., Miller, D. L., Graeber, R. C., Connell, L. J., & Rosekind, M. R. (January 01, 1998). Flight crew fatigue V: long-haul air transport operations. Aviation, Space, and Environmental Medicine, 69, 9, 37-48. Kanki, B. G., Helmreich, R. L., & Anca, J. M. (2010). Crew resource management. Amsterdam: Academic Press/Elsevier. Korovin, I. (2010). Air crash investigations: Horror in Guam : the crash of Korean Air Flight 801. United States?: Mabuhay Pub. Krause, S. S. (2003). Aircraft safety: Accident investigations, analyses, and applications. New York: McGraw-Hill. Phillips, D. (March 19, 1998). Do Cultural Factors Play A Role In Air Crashes? -- Flight Safety May Be Hurt By Deference To Authority, The Seattle Times. Retrieved from United States. (1994). A review of flightcrew-involved major accidents of U.S. air carriers, 1978 through 1990. Washington, D.C: The Board. United States. (2000). Controlled flight into terrain, Korean Air flight 801, Boeing 747-300, HL7468, Nimitz Hill, Guam, August 6, 1997. Washington, D.C: The Board. Walters, J. M., & Sumwalt, R. L. (2000). Aircraft accident analysis: Final reports. New York: McGraw-Hill. Read More