“If I speak, I am condemned. If I stay silent, I am damned!”

“If I speak, I am condemned.
If I stay silent, I am damned!”

― victor hugos, Les Misérables

Is this the fate of the pilot monitoring in the modern flight deck?

The flight of Eastern Airlines 212, 1974 in the USA highlighted poor cockpit discipline as one of the reasons for the accident wherein the DC-9 with 78 passengers and crew perished while carrying out an approach to land at Charlotte, North Carolina.

Investigation report extract:NTSB
Investigation report extract:NTSB

Following is an extract of the conversation.

CVR extract of Eastern Airlines 212
CVR extract of Eastern Airlines 212

In 1981, after a series of accidents, the FAA enacted regulations which prohibit crew members from performing non-essential duties while the aircraft is in a “critical phase of flight.” In aviation, it is also known as “sterile cockpit rule”.

On July 6, Asiana Airlines Flight 214 crashed while attempting a landing at San Francisco International Airport (SFO). Two people were killed in the Boeing 777 accident, and more than 180 of the 307 people on the flight were injured.

The flight began deviating from the intended profile during the final approach. In addition to the co-pilot, there was a third crew member in the cockpit. The NTSB report concludes “A third pilot riding in the jump seat noticed the plane was descending too fast but didn’t speak up right away.”

Bienefeld and Grote (2012)
Bienefeld and Grote (2012)

Bienefeld and Grote (2012) conducted a study to determine the reasons why aircraft crew members sometimes choose to stay silent and not speak up to each other about safety critical information during flight. Another objective of their study was to understand whether there are specific group differences as to why crew members aren’t speaking up, for example whether the barriers to speaking up are different between Captains and First Officers. The crew groups analysed were Captain’s, Flight Attendant’s, Purser’s (Chief Flight Attendant) and Flight Attendant’s. In their study, Bienefeld and Grote define speaking up as “as an upward voice directed from lower to higher status individuals within and across teams, that challenges the status quo, to avert or mitigate errors” 

Reasons for silence
Reasons for silence

Fear of damaging the relationship featured as the main reason for not speaking up amongst the Captain and First Officer.

The full research report can be accessed here.

Selective mutism

Some people have a condition that means in most situations, they can’t speak. There’s nothing wrong with their tongue or vocal chords , and they don’t have “aphasia” which is when brain damage affects speech. Yet most of them time, they feel completely unable to speak.

In 1934, the term “elective mutism” was coined to describe this condition based on the idea that people fitting the diagnosis were choosing to remain silent. But the favoured term, at least in the UK, has since changed to “selective mutism” to reflect the fact that for many, their inability to talk in some situations does not feel like a choice. For instance, someone with selective mutism might talk perfectly normally when home alone with their parents or other close family, but find themselves totally incapable of speech in public or at school or work.

mindFly analysis

Accident investigation reports gives us information on what happened but the why is not fully researched and disclosed. While we know that the role of the pilot monitoring is important, especially during critical phases of the flight, this is not very often investigated. Why did the pilot monitoring not speak up?

The Air Canada overflight of the taxiway with 4 aircraft below missed an accident by almost 60 feet. The role of the pilot monitoring was not investigated in detail. If the pilot was approaching the taxiway instead of the runway and there were 4 aircrafts in front, what was the co-pilot doing?

The regulators and airlines have issued numerous circulars and instruction for the pilot monitoring to speak up and be assertive but the ‘why’ has not been understood. It is not a technical issue, it is a human factor issue which could transgress into multiple disciplines. Psychology, Sociology, Anthropology, Biology etc. are some of the disciplines that can tell us why it happened.

Until we seek to find out why the event took place, the issue will keep on occurring the aviation industry. This applies to all other safety issues like runway overruns, unstabalised approaches, aircraft upset.

 

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