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Who failed in Crash of Flight IX-812? Part 2

Various factors defining the success or failure in a multi-crew operations depend on communication, situational awareness, problem solving, decision making, judgement, leadership – followership, stress management, critique and interpersonal skills [2, 3]. In this tragic accident flawed decision making affected good judgement, leading to deliberately compromised situational awareness, aggravated by self-imposed stress and perceived workload with failed teamwork, broken down communication and poor leadership.

 

Failed CRM

The accident report [1] mentions that some first officers who had flown with the captain found him to be “assertive in his actions” and being”always right”. The first officer was a meticulous pilot but a man of few words, who had recently complained about a foreign captain not following the company SOP and correct CRM technique. The captain had 10,215:50 hours as PIC and 2844:50 hours on Boeing 737-800. The first Officer had 3620 Hours of total flying, and 3319:40 hours on type.

There was a contrast in personalities – an assertive (rather imposing) captain and submissive first officer. This resulted in a steep trans-cockpit authority gradient. This was evident where as per procedures, if first officer calls for go around due to unstabilised conditions, captain invariably performs a go around; unlike in this accident where the captain persisted with approach despite of not being stabilied (stabilised approach is when aircraft is stabilised on approach by 1000 feet alitude in IFR or 500 feet in VFR), ignoring the wise counsel of his co-pilot. Moreover, as per Air India Express SOP, first officer can perform a ‘go around’ after two intercom calls to that effect, but the ‘follower’ first officer of IX-812 did not, surrendering to the ill-fated decision of the captain! Was there an underlying element of ‘get-over-with it’ or ‘get homitis’? This cannot be commented upon in absence of any evidence, but may have played a role.

Cultural differences too could have contributed to the accident. The Serb captain, on contract as PIC, was flying with an Indian first officer, a company employee. Differences in language, specifically accent of spoken English could have been a factor, but did not emerge as a contributory factor about communication in cockpit. But what emerged was break down in communication – due to prolonged nap in the cockpit by the Captain, and his apparent disinterest in briefing about the approach, or being forceful enough to make first officer give an ‘affirmative’ radio call to ATC on a pointed query about establishing on ILS [1]. The first officer, though persisting with his cautionary calls of warning during approach and landing was ignored, with disastrous consequences.

CRM trained multi-crew operations aim at crew members not having excessive workload, while effectively engaging in communication to arrive at safe and optimal decision making, without stress deteriorating performance while maintaining situational awareness [4]. But XI-812 revealed that workload increased significantly due to the flight altitude being higher than required for the conventional approach, spurring the captain to follow unconventional means to achieve the desired altitude, including a descent rate of about 4000 feet per minute. This was a display of risk taking attitude, and sign of poor airmanship. When he could not establish on the ILS approach, he chose to ignore both the first officer as well as EGPWS warning. He made a poor choice by attempting to take off realising his folly that the aircraft may overshoot beyond the available runway. This was decision making at its worst, contravening the manufacturer’s operating procedures too!

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Reference

Acknowledgement  Image courtesy Wikipedia

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