Warren Le Grice
The long road from “The Captain is always right” to Safety Management Systems
The concept in the transportation industry, that the captain is always right, very likely dates back to the 17th century when sailing ships provided the fastest mode of world travel. Sailors would question the wisdom of the Commanders decision making, at their own peril. Changes to safety standards were introduced very slowly, and over an extended period time. More often than not, major tragic events were the catalyst for change, and in that respect, not a whole lot has changed over the centuries.
The Scilly Naval disaster in 1707 involving the loss of four ships, onto the rocks west of Scilly, on the night of Oct 22, and the loss of over 1300 mariners in stormy weather, would eventually lead to a major change in navigation. At that point in history, mariners were able to calculate their latitude but not longitude. In 1714 the British government passed the Longitude Act, which offered up a prize of 20,000 British pounds ( about 1.5 million pounds today) for a practical and useful method to determine longitude to an accuracy of one half a degree.
Longitude at that time was calculated by “dead reckoning”. John Harrison’s marine chronometer in 1735 would finally solve the problem of calculating longitude while at sea. His solution would revolutionize navigation and increase the safety of sea travel.
The sinking of RMS Titanic in the early hours of April 15, 1912 resulted in major changes to maritime regulations, and leading to the establishment of the International Convention for the Safety of Life at Sea in 1914. In spite of six warnings of icebergs in the area, the Captain was travelling at a speed that was only 3 knots below the maximum design speed, attempting it is believed, to set a speed record on the trip to New York. The glancing blow to an iceberg sliced open six of the sixteen compartments. The ship had been designed to withstand being able to stay afloat after four compartments being breached. As the ship only carried 20 lifeboats, over one thousand passengers perished. Captain Edward Smith went down with his ship.
On June 18, 1972 BEA Flight 548 a VC10 Trident, crashed 3 mins after taking off from runway 28R at Heathrow on a flight to Brussels. There were 118 persons on board and there were no survivors. Investigation revealed that the flaps and leading edge devices were retracted prematurely and the aircraft entered a deep stall from which there was no recovery. The pilot in command was a senior captain with the airline, the first and second officers were junior pilots.
There had been a strong argument between Captain Key and another pilot in the crew briefing room, immediately prior to the flight involving another pilot regarding impending strike action at the airline. There was some evidence in the autopsy that the captain had previous heart damage. Investigators determined what had happened to the VC10, but not why it had happened.
This accident would result in the installation of CVRs, (cockpit voice recorders), which are now standard equipment on airliners around the world.
Tenerife / Portland Oregon
On March 27, 1977 two Boeing 747s were both heading for Las Palmas. On Gran Canary Island in the Canary Islands to take their passengers to meet cruise ships. A terrorist bomb being set off in the Las Palmas terminal building, resulted in both aircraft being re-routed to Tenerife airport. Tenerife airport is located on another island about 30 miles west of Las Palmas.
Tenerife is a secondary airport and it would soon become over whelmed by the number of aircraft that were diverted there from Las Palmas. The airport had no surface detection radar and had but a single runway, 12/30. Both 747s, KLM4805 and PAA1736 were both delayed several hours on the ground at Tenerife, and when Las Palmas airport did finally open, there was a rush to depart, as the crew duty times were almost up, which meant the aircraft and several hundred passengers would have to wait until the next day to depart.
As the parallel taxiway was blocked by parked aircraft, the two 747s would have to back track on runway 12 for their departures on runway 30. As the two aircraft began their taxi with KLM4805 in the lead followed by PAA1736 low cloud moved down and covered the airport to the point that the airport went IMC. KLM was piloted by Capt. Jacob van Zanten a very senior captain and training captain with the airline. Two first and second officers were former students of van Zanten who was very anxious to get on his way.
The KLM aircraft went to the far end and turned around and was waiting for Clipper 1736 to back track and take the last taxi way, in order to clear the runway and be number two for departure. The thick cloud prevented either aircraft from seeing the other, and the visibility was likely below take-off limits.
van Zanten who was the pilot flying, was very anxious to be on his way and started to advance the power levers. The co-pilot stopped him by reminding him that they did not yet have their IFR clearance. After obtaining their IFR clearance they still needed a take-off clearance from the tower, which they would not receive until Pan American had reported clear of the runway.
Radio communications were disrupted, but PAA did state they were still on the runway but that message was distorted by another radio transmission. The Captain again advanced the power levers and then the second officer questioned “is he not clear then” van Zanten replied yes he was clear, and commenced the take off run, with out a take-off clearance. The first officer had the nerve to intervene once, but probably didn’t think he could get away with it a second time.
PAA saw the lights of KLM shaking and the Bob Bragg the first officer said to Captain Grubb, I think he is taking off, get off, get off. KLM saw the Clipper as they came out of the low cloud and struck the PAA1736 well behind the cockpit. Of the KLM crew of 14 and 234 passengers, there were no survivors.
Of the PAA crew of 16, 9 were fatally injured and of the 380 passengers, 326 were fatally injured. Because a pilot was in a hurry, and would not listen to his crew, there were 583 fatalities, and Tenerife remains the world’s worst aviation accident. KLM airlines after initially blaming the accident on ATC, did finally admit that their crew was responsible for the accident, and provided financial compensation to the families of all the victims.
UAL173 Portland Oregon- Dec 28- 1978
The DC8 was inbound from Denver and when the landing gear was lowered for landing, there was an unusual noise when the gear was extended. The aircraft was put into a hold at low altitude while the crew went through check lists, and prepared for a possible gear failure on landing. The first and second officers were aware that they were rapidly burning through their fuel at low altitude, with gear and flaps extended.
The captain did not grasp their situation until engines started to fail and the crew members failed to effectively communicate their concerns about the fuel situation. Captain McBroom was able to perform an engine out landing in a wooded area east of the airport. There were 10 fatalities. Family members and passenger who spoke to McBroom at reunion of crash survivors in 1998, reported that he was a broken man who was plagued by guilt over his role in the accident.
The above two accidents lead to CRM -Cockpit Resource Management being introduced by United Airlines and that training has now world wide acceptance, now called Crew Resource Management.
A reactive approach to safety has been the norm for the last 400 years.
It has been the practice to wait for an accident to happen, investigate it and then implement changes to prevent it from reoccurring.
Lytton B.C – June 2021
The latest example of waiting until an accident occurs is demonstrated in the Lytton fire on June 30, after days of record braking heat. Transport Canada has ordered new safety measures for rail operators across Canada aimed at reducing the risk of wildfires after speculation that a passing train sparked the blaze that destroyed the village of Lytton and killed two people.
A pro-active approach works to identify possible safety failures before they lead to an accident and that approach is applied in a Safety Management System. SMS is achieving world wide acceptance in the aviation community.
The block diagram below represents a concept that would work for the Abbotsford Flying Club. SMS entails a “cultural change” where safety is the focus and a culture of continuous learning is encouraged and supported.
A Safety Management System includes several components, which work towards the simple goal of having everyone go home safely, at the end of the day.