Maritime Team Dynamics: 'Lessons from the Flight Deck'
As a new initiative from the UK Club loss prevention team and CAE, the world’s largest aviation training company, we published “Maritime Team Dynamics: Lessons from the Flight Deck” in September 2021.
It features 12 aviation incidents, introduces important and transferable ‘lessons from the flight deck’ and cross-refers to the maritime sector.
This time, we would like to introduce one of the 12 cases (Case Study-1).
Case Study 1 - Doing it right
Crew Resource Management (CRM) Works
Case studies traditionally reference things that have gone wrong and how humans have failed. However, humans are more often the creators of safety. When presented with a challenging set of circumstances outside the scope of their normal and emergency procedures, they can deliver an effective solution to the problem by applying the appropriate crew resource management (CRM) tools, as shown in this case study.
The Dash 8 aircraft was on the final flight of four that had commenced at Newcastle Airport at 07:05 that morning. The Commander (Captain, the most senior officer responsible for the aircraft) had performed the pre-flight inspection, including a visual examination of the right landing gear, and nothing unusual was noted.
During the take-off from Exeter Airport a single ‘ding’ audio signal activated.
The co-pilot checked for any indications on the relevant instruments but there were none and he reported: “spurious, continue”. The take-off continued and retraction of the landing gear was initiated once a positive rate of climb was established.
Several passengers seated on the right side of the aircraft noticed sparks emanating from the right inboard wheel area during take-off and saw the right inboard wheel fall from the aircraft as the landing gear retracted. They did not inform the cabin crew at this point.
The flight crew were advised by the Tower, shortly after take-off, that the aircraft may have lost a wheel. The climb was continued to 3,000 ft and a right turn was made to join the holding pattern at Exeter. The Flight Management System was programmed to fly the holding pattern and the autopilot was engaged.
The Commander contacted the senior cabin crew member to inform her of the situation and asked her to inspect the right landing gear area. The passengers informed the senior cabin crew member of the loss of the wheel. She could see that the gear was retracted and the landing gear doors were closed, but parts of the landing gear mechanism were protruding. She reported this to the Commander. The co-pilot then spoke with a company engineer who was a passenger on the flight and confirmed for himself the senior cabin crew member’s observations.
The flight crew reviewed the ‘Landing Gear Malfunction’ and ‘Emergency Landing’ sections of the ‘Abnormal and Emergency’ checklist and agreed that the landing gear should be extended using the ‘Alternate Landing Gear Extension’ procedure. On actioning this, the left main and nose landing gear indicated down and locked, but the right landing gear did not indicate any movement. The company engineer advised the flight crew that the right landing gear had not lowered. Following a discussion with the engineer, the pilots prepared to use the ‘Landing Gear Manual Lowering’ procedure. The right landing gear then lowered and indicated it was down and locked. This was visually confirmed from the cabin by the engineer and the co-pilot.
The Commander transmitted a Mayday that was acknowledged by the Tower. The pilots reviewed the ‘Emergency Landing’ procedure and discussed their options. They agreed that although the landing gear had lowered and indicated it was locked down, there was a possibility that the right outboard wheel may detach in the air or on landing and that they should also be prepared for the right landing gear to collapse on touchdown.
They considered shutting down the right engine for the approach and landing but agreed to keep it operating to reduce the asymmetric effects. The Commander gave a ‘Nature, Intentions, Timings and Special Instructions’ briefing to the senior cabin crew member, who then briefed the other cabin crew member. The passengers were then individually briefed. Following the Commander’s instructions, they moved passengers on the right side away from the propeller area, distributing them evenly forward and aft.
The co-pilot contacted the operator’s chief pilot by radio to discuss the most appropriate landing procedure.
The approach was flown manually and at 1,000 ft on the radio altimeter, the passengers were instructed to adopt the brace position. The aircraft touched down on the left main wheels and the right main wheel was lowered onto the runway.
The Commander had to apply significant amounts of right rudder to regain the centreline. In their pre-landing briefing, the pilots agreed not to use the brakes during the landing roll and as the aircraft slowed to a walking pace, the Commander made a gentle application of the emergency brake, bringing the aircraft to a stop. The parking brake was set. The co-pilot and the senior cabin crew member used the public address system to make announcements before the aircraft’s electrical systems were isolated.
Once the Airport Rescue Service was in position, the Commander instructed the senior cabin crew member to disembark the passengers; this was carried out through the front left door. Following the disembarkation, the passengers were taken to the terminal in buses.
The Commander, when performing the pre-flight inspection of the right main landing gear, had not noticed any abnormalities and given the nature of the bearing failure, it is unlikely that any would have been visible.
After the Tower had notified them of the loss of the wheel, the crew took up a holding pattern, which gave them a safe environment in which to analyse the problem. Having an engineer on board, licensed on the aircraft type, was beneficial and his knowledge was used to good advantage.
The flight crew’s incremental approach to solving the problem and effective CRM contributed to a safe outcome.
How might this apply in maritime operations?
When presented with an unexpected and unplanned situation, make time to use all the available and appropriate resources.
- Use CRM effectively
- avoid time pressures in decision making
- communicate effectively to all concerned parties, including passengers, if applicable
- use all the resources available on board the ship
- use the available procedures and, when these do not cover the situation, use a ‘short-term strategy’ methodology to develop solutions.
The bulk carrier ‘Cape Leonidas’ was on a fully laden pilotage voyage towards Hamburg on the river Elbe. In the early hours of the morning, the ship began to experience problems with its main engines, which eventually failed. The pilot notified the VTS and requested tug assistance. The Captain ordered the forecastle to be manned and the starboard anchor to be made ready to let go. As the ship reduced speed, some slight steerage remained for it to be manoeuvred. As the speed reduced to 4 knots, the decision was made to conduct an emergency anchoring manoeuvre.
The incident report concluded that the decision to anchor the ship prevented any damage to it and protected the local marine environment. The actions taken by the entire bridge team were prudent and technically sound. This is a clear example of how CRM is used effectively between pilots and the bridge team. It also shows how communicating effectively to all parties, including VTS, tugs and onboard crew, can result in a safe outcome.
Maritime Team Dynamics “Lessons from the Flight Deck”
UK P&I, CAE (Witherby Publishing Group Ltd)
Captain Hiroshi Sekine
Senior Loss Prevention Executive
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