reducing "Crew-caused"
approach and landing

Pilot-in-charge Monitored Approach

If, with the benefit of hindsight, we query the Captain’s judgement, we have in turn to answer this question. What was the appropriate point for the Captain to have decided that the situation justified departing from the airline’s basic SOP, (which required him as Pilot-in-Charge to act as pilot flying), and ask his First Officer to act as pilot flying while he resolved more significant problems - a decision which in itself would signal to the First Officer that a major problem had arisen?   Was it

  1. When he himself realised that “something wasn’t right” and initiated the go-around - by which time disaster was unavoidable?
  2. When the F/O commented that “something wasn’t right” at 1000 ft. radio - by which time the aircraft was already well established on the wrong profile?
  3. When they established that the glide-slope was not available - but is glide-slope failure a “major problem”?
  4. When the autopilot failed to capture the ILS localiser - but is hand-flying so difficult?
  5. When the “flap motor” alert occurred - but is that a "major aircraft defect"?
  6. When it was decided to switch from runway 35 to 17 - but is changing runways such a big deal?
  7. When the aircraft departed 90 minutes off schedule from its previous station - but is just being late so unusual? 

Or was it the First Officer's fault for not switching from assisting his Captain to calling for a go-around?   If so, when should he have done so? 

It can be seen that in fact each of these events (perhaps as well as others) contributed to the situation, but no single one can be clearly identified as THE point where every pilot would agree it would have been desirable for the Captain to give himself a bit more opportunity to assess the situation.  Moreover, at most of these points the workload rose as a direct result of decisions made by the crew themselves - requiring a paradoxical recognition that a decision which was believed to be sound had made the flight less safe.

In fact it is only by revising the basic allocation of duties so that delegation is the normal procedure, that the Captain would not have been faced with this problem. If that had been the case then the risk would have been significantly lower.

It would be easy to construct a parallel, fictional tale using the alternative procedure and which (obviously) did not terminate in disaster - but futile, as it would hardly be convincing. Instead, one must just ask whether it is more or less likely that events would have worked out differently. For example,

  • If the First Officer had been asked to conduct the entire descent and approach (on instruments, and without the need to acquire visual cues), and his workload started to increase due to the need to hand-fly the aircraft, is it more or less likely that he would have used misleading external cues instead of instrument information?
  • If the Captain had been the first one to become concerned that they were not actually in the right place, is it more or less likely that the crew would have initiated an earlier go-around?
  • If the Captain had been the one to be concerned (rightly or wrongly) that there was no longer enough landing distance, is it more or less likely that the crew would have taken some delaying action (such as a hold) whilst establishing the correct data?

This author’s view is that any individual’s ability to evaluate the overall situation is enhanced by offloading short-term manipulative tasks. However if those tasks have been retained, it becomes increasingly harder to assess one’s own workload level.

The ability to conform to the advice to “delegate for better CRM in high workload situations” may also be severely constrained by a natural reluctance to admit that a difficult situation has developed, particularly where these may be partially self-induced - as in this case, with the decision to change the planned arrival runway.  The “strong individual” culture of many pilots gives a powerful psychological incentive to continue acting as though everything is absolutely under control, even when a more objective evaluation would suggest that an individual’s limits are being reached.

Equally, all pilot training engrains a need to stick to SOPs, especially when things go wrong.  A captain who follows the advice given - “in situations generating high workload, such as serious aircraft deficiencies, Captains should give consideration to delegating the flying to the co-pilot, in order to give maximum attention to the effect of such situations on the safety of the flight” is saying, in effect, “we have such a serious problem that we have to deviate from our normal SOPs, because they can’t cope with the situation” - and an unspoken subtext to that would be “and we’re on our own from here on”.  

Making such a statement both requires a major intellectual and emotional effort on the part of the Captain, and has a consequent and significant intellectual and emotional effect on the First Officer; indeed, it may induce undesirable additional stress in the latter in particular. It recognizes in fact that the flight is now outside the normal range of safe operation, so the normal procedures can no longer apply.

For this crew, their basic SOP was not fault-tolerant, because it did not assume that entirely normal imperfections - time pressure, technical problems, incorrect weather reporting and unreliable facilities - would sometimes combine into a predictable high risk situation. When they did coincide, it took relatively little by way of human failure to let the situation to get out of control.

The only way to maximise the probability that all resources will be used when needed is to ensure that it is built into the basic procedures to which all pilots are expected to conform. This removes the conflict between good CRM for abnormal situations, and normal duty allocations for normal operations.