"You know that for the last 10 years or so there has been lots of human error involvement in accidents," United Airlines Capt. Rod Gilstrap tells his audience of pilots.
That remark, an admission from a member of one of the world's most defensive fraternities that his fellow pilots make mistakes, is revolutionary. "Human error involvement" is a polite way of saying that the pilot or someone else in the cockpit fouled up.
For years, to listen to the pilots' union, the Air Line Pilots Association, accidents were caused by the Federal Aviation Administration, air traffic controllers, airline training, a mechanical defect or that favorite excuse, lack of information, but never, ever, by pilots.
"You can't say that the cause of the accident was because the pilot did thus and so," ALPA President John J. O'Donnell has often said, "unless you answer the question of why the pilot did thus and so."
From 1970 through 1980, according to a National Transportation Safety Board computer, U.S. commercial airliners were involved in 380 accidents, 56 of which were fatal and resulted in more than 2,500 deaths. In 33 of those, the board listed the pilot as the primary cause of the crash.
United's closed-circuit television lecture, part of a new recurrent training program for pilots, is creating excitement in the aviation industry because it requires crew members to look at themselves, how they perform and how they work with each other.
That is substantially different from the checklist and flight- time training given most airline crew members. The program comes as public attention is focused sharply on whether pilots are doing their jobs properly.
That question, and the related one of why pilots choose to fly in bad weather, will be major themes for the National Transportation Safety Board when it starts a public hearing Tuesday in the New Orleans suburb of Kenner, La., to examine the Pan American World Airways crash there that killed 153 people July 9.
In that crash and the nation's other major airline disaster this year, the Air Florida accident here Jan. 13, it is possible -- with the benefit of hindsight -- to point to the cockpit and ask, why?
"We've spent 30 to 40 years teaching people how to use systems," said Robert S. Crump, United's vice president for flight standards and training, "but we've never gotten into the part that's just as important," the people who fly the planes.
Part of the answer in the Pan Am and Air Florida accidents lies with timely weather forecasting and intimately involves the FAA's air traffic control system and its somewhat strained relations with the National Weater Service, which provides the forecasts. (That issue is the subject of the next article in this series.)
United, taking a cue from some pilot performance research done by NASA, seems to be the leader in attempting to address problems of how well pilots do their jobs, particularly under stress.
Many competitors are asking United about its pilot training program, and United is attempting to market part of it as a commercial venture. Some other airlines, notably Northwest and Eastern, are also given high marks by industry insiders for burnishing their pilot training techniques.
Gilstrap's TV Chalk- talk is remarkably blunt. He recites a litany of plane crashes that every honest pilot knows were partially or wholly the fault of someone in the cockpit.
These include accidents as famous and horrible as the jumbo jet collision on the Tenerife runway in March, 1977, that killed 583 persons, and as strange as the National Airlines flight into Escambia Bay, a mile short of the Pensacola, Fla., runway in May, 1978. All but three persons survived that crash.
Three accidents cited by Gilstrap in volved United flights, including one in Portland, Ore., in December, 1978, when a McDonnell Douglas DC8 flight from New York and Denver crashed several miles short of the runway because it ran out of fuel.
Ten of the 189 on board were killed, so the accident received only brief national attention, but among pilots it is much discussed. The plane ran out of fuel while crew members were preoccupied with a landing-gear problem that had forced them to circle Portland.
Excerpts from the safety board's report tell of a copilot and flight engineer who knew the fuel situation was becoming critical but didn't do enough to warn the captain.
The copilot "did, in fact, make several subtle comments questioning or discussing the aircraft's fuel state," the board said, but did not express undisguised alarm until the first of the four engines quit.
The flight engineer, the only cockpit crew member to die in the crash, made several warnings about the developing fuel problem, but they seemed to fall on deaf ears. As the board said, "although he informed the captain . . . that an 'additional 15 minutes is really gonna run us low on fuel here,' there is no indication that he took affirmative action to insure that the captain was fully aware" that time was running out.
"The safety board believes," it said, "that this accident exemplifies a recurring problem -- a break down in cockpit management and teamwork during a situation involving malfunctions. . . "
United's top managers have reached the same conclusion. W.H. Traub, director of flight standards and training at United's Flight Training Center in Denver said, "If any one of the other two guys had said, "Hey, let's get this damn thing on the ground,' it would have been different." But, he said, "it's life, too."
There is no question: a study of a transcript of the cockpit conversation confirms that warnings were made but were subtle, gentle and d-ferential to the senior captain . They went unheard or unrespected.
The same types of communication problems can be seen in the two major accidents this year:
The snow and cold weather were abundantly obvious to crew members of Air Florida Flight 90 here Jan. 13. There were even clues that the Boeing 737 was not performing properly as it bounced along a slushy runway toward takeoff.
The copilot, presumably staring at the instrument panel, asks, "That don't seem right, does it?" and " I don't think that's right," But neither he nor the captain translated the clues into a danger signal serious enough to stop the flight before it lurched into the air, struck the 14th Street Bridge and killed 78 people.
Crew members of Pan Am Flight 759 discussed the New Orleans weather at length, talked about operational procedures and listened to tower warnings of potentially dangerous low- level winds. Then they took off.
The warnings, other pilots have pointed out, were given by the air traffic controller in a way that did not precisely follow the book. But no one in the cockpit bothered to ask the tower or seek a clarification, and the cockpit recorder suggests that no thought was given to delaying the takeoff for a few minutes and waiting for the weather to clear.
As both accidents occured, other planes were taking off and landing at the same airports on the same runways without difficulty.
William W. Melvin, one of a panel of pilots provided by ALPA for an interview, was asked about that cockpit decision process.
"Guys are not, contrary to what FAA would have you believe, flying around with their white scarves hanging out their windows and would not fly under the Golden Gate bridge if they could . . .," he said.
"Guys are not deliberately taking airplanes off and risking passengers' lives and their own lives. They may make a bad judgment; they may be wrong, and later they may say, "I'll never do that again,' largely because they didn't have the information or the proper risk assessment at the time."
Further, he said and other pilots agreed, if only one pilot in a departure line declines to take off, suddenly everybody thinks that is a good idea. "you see a guy take off and really have trouble with the airplane," Melvin said, "The next guy says, 'I'm sorry, cancel my clearance, I'm not going.' And the tower says to the guy behind him, 'You ready to go?' and he says, 'No, I'm going to stay here, too,' and all of a sudden everybody's in Lockstep and saying, 'Hell no, if it's not good enough for him I'm not going either.' "
All of the pilots on the panel, and several others interviewed independently of ALPA over the years, said they knew of no instances where they felt pressure from their companies to fly regardless of the weather. The decision on taking off, they said, was theirs alone.
Shortly after United established a task force to study crew performance and how it could be improved, researchers at NASA's Ames Research Center in California delved into the same issue.
Eighteen fully qualified three-member crews were placed in a simulator, where mistakes would not be fatal, and given material and information needed to fly a four-engine jet transport from Dulles Airport to London with a stop in New York.
Shortly after the simulated flight left New York and climbed to cruising altitude, difficulties were introduced that required the captain to shut down one engine and return to New York. The variations in quality of per formance by the 18 crews, all from the same unnamed airline, were remarkable.
For example, it took one captain three seconds to notice the warning light indicating the start of engine trouble, while another needed 96 seconds. Mistakes of all kinds were made in piloting technique, fuel management and use and interpretation of navigational aids.
NASA's John Lauber worked on that study and became an advocate for using such simulated situations as crew training exercises, not just to sharpen an individual's skills.
ALPA became an advocate and United, which had set up a task force to study crew performance and devise training programs, jumped aboard after Lauber and his associates presented their results at a June seminar in San Franciso in 1979.
United's new training program Looks much like the NASA simulation studies. Crews are placed in the simulator for a flight from Chicago to Cleveland, and things go wrong, ultimately necessitating an emergency landing at an alternate airport. A television camera in the cockpit records everything the crew does during the flight, and the videotape becomes a key training tool.
"When we replay the tape, the guys can see and analyze their own errors," said United's Dave Shroyer, coordinator for the training program. Crew members who have difficulties with their peers can see the problems. "We were running a tape recently," Shroyer said, "and the first officer told me to stop it. He turned to the other crew members and said, 'My God, do I come across like that?' They told him he sure did." The tape is destroyed after the training session, part of United's agreement with ALPA, and thus cannot be used for disciplinary purposes.
Lauber, who helped run the NASA studies, said that, as an informal observation, he does not think age is a significant factor crew members' willingness to listen and learn from each other.
"Most of the guys who grew up in the very different aviation environment, with a single-pilot operation where the copilot was an apprentice, have retired," he said.
United's program is much more than a complicated simulator flight, a technique used by several airlines. It starts with a home-study course entitled Command/Leadership/Resource Management, which presents several cockpit situations in a written narrative, and describes how various crews handle them.
It also presents a concept developed by Scientific Methods Inc. and called the Grid, a system in which crew members evaluate their own leadership styles to see if they are more oriented toward people (fellow crew members), the product (getting the flight safely from Point A to Point B) or equally to both.
United's program stresses that two or three heads working on a problem in the cockpit are likely to arrive at a better answer than one head resisting or not hearing suggestions from the others.
"We can't change personalities, but we can change the ways" crew members operate with each other, Crump said. "Our final goal is to get crews to evaluate their ow- performance on a flight-by-flight basis, to get used to critiquing them, selves. . .
The program has been used for slightly more than a year; it is too early, Crump said, to claim definitive improvement. However, United crew members have had much lower mistake rates on flights with FAA inspectors than they did before the program was started a year ago, he said.
United's program lasts three days in Denver and has been approved by the FAA as meeting its annual recurrent training requirement for airline crews. Because of the length of the training program, with lectures, seminars, Grid drills and simulator and flight time, United sought an exemption from an FAA rule requiring retraining at shorter semiannual sessions.
"We spent a week at United looking at that program," said Kenneth S. Hunt, FAA's director of flight operations. He said the FAA saw no deterioration of standards and granted the exemption, which only United holds.
Pilot Gilstrap's videotaped lecture, the introduction to the training sessions in Denver, ends with this admonition:
"The most inefficient thing we can do is have a fatal accident."