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Cockpit culture change

The public image of the Asia-Pacific airlines has been shattered by 12 major crashes, raising safety issues which are providing fertile ground for experts in crew resources management.

In the months after a Korean Airlines Boeing 747 hit a mountain in Guam last August, killing 228 people, KAL pilots entering their main training base were confronted with a shrine to the dead, pictures of each passenger killed and even with grieving relatives visiting the memorial with gifts and candles.

It wasn't a spontaneous gesture, but a deliberate act of policy, 'a mind-blowing reality check', as one industry source puts it. All airlines know that, human nature being what it is, passengers who desert a carrier in the months after a disaster will eventually return and, in some cases, cheap fares are offered as an incentive.

But KAL, according to insiders, has decided it is time to seriously begin overhauling what the industry calls 'cockpit culture' or, more correctly, crew resources management.

For KAL, it is not just a matter of pride or image that it be seen by its customers - Koreans, Asians, Americans and Europeans alike - as a safe operator. As one of the largest Asian carriers, with a fleet of more than 110 aircraft from 100 to 400 seats, Korean operates from one of the world's best-positioned hubs at Seoul's Kimpo airport. Its future potential in linking Asia with the USand Europe is as great as that of any operator at Singapore's Changi, London/Heathrow or Chicago/O'Hare and KAL now is acting to protect its investment.

Asia's recession was only one side of a 'double whammy' for the region's airline business. As a currency crisis set back some economies by two decades, confidence in the region's airlines was shattered by 12 major crashes that killed more than 1,000 people in the year to February - more than 70 per cent of the worldwide toll.

A coincidence that they all happened here or just bad luck, some analysts said at first. But, as investigations progressed, the probability grew that most of the aircraft involved were functioning normally when disastrous crew errors slammed them into the ground. The industry calls this CFIT: controlled flight into terrain.

Alarm about regional safety standards came to a head in February this year when a China Airlines Airbus A300 crashed while approaching Taipei's Chiang Kai Shek airport, killing all 196 passengers and crew and six people on the ground. It was Taiwan's worst air accident and, although the investigation drags on, it was probably CFIT. But it was eerily similar to another China Airlines A300 crash at Nagoya, Japan, that killed 264 passengers and crew in 1994.

On top of the Korean Airlines Guam crash, there were two 1997 disasters in Indonesia. A Garuda A300 hit the ground in poor visibility at Medan, killing 234 people (possibly as a result of an air traffic control error), and a Silk Air Boeing 737 nosedived into a Sumatran river, killing 104 (possibly as a result of pilot suicide). Earlier in February, what was probably a CFIT crash in the Philippines killed 99. Suddenly there was clamour for reform.

Salomon Brothers senior aviation analyst in Hong Kong, Peter Negline, railed against the region's 'horrendous' safety record in the Australian Financial Review, calling on national regulatory authorities to lift their game.

'There has to be a cessation of this desire to have market share ahead of anything else,' he said. 'The fact is that to provide all the appropriate safety standards does cost money and, therefore, fares cannot fall below a certain level.

'Are you going to have planes falling out of the sky on a regular basis or a higher level of confidence in the industry at higher prices? That is the question that needs to be answered.'

However, behind the scenes, safety experts were aware of long-standing problems in crew training that many viewed literally as an accident waiting to happen.

The relatively new human science of crew resources management has become, in the past few years, virtually a compulsory programme for the world's leading airlines. But it is rarely, if ever, spoken of publicly.

Airlines sell their programmes to other airlines, while major aircraft manufacturers provide them for their customers and a small industry of consultants has grown up around the science. But, because crew resources management is about pilots making mistakes and, in some cases, changing ingrained commercial and even national culture, the doors are typically closed to outsiders when the briefings begin.

Explained simply, crew resources management is designed to foster trust and create accountability between pilots on a flight deck. This helps ensure that errors are detected and acted upon before they can combine with another abnormality - such as the weather or equipment failure - to create a disaster. It is commonly accepted that accidents are almost never the result of one factor alone.

In its broader application, crew resources management also creates teamwork between pilots and cabin staff and, equally importantly, between air crews and management. In a landmark finding, the Australian Civil Aviation Safety Authority partly blamed commercial pressure from management for a non-fatal near-disaster in 1996, when an Ansett 747-300 crash-landed at Sydney with its nose gear retracted.

Modern aircraft are designed to be flown by teams of two, crosschecking each other's actions and interacting with complex flight management systems, say experts. But the system breaks down if the cross-checking between pilots does not happen.

This system of accountability is well entrenched in countries with the longest involvement in aviation. However, in Asia, the most spectacular growth has been only in the past two decades and there has been a heavy reliance on national air forces to supply commercial pilots. This means there is often a command-and-control culture that discourages subordinates from questioning superiors.

And, as a dynamic consequence of relentlessly high annual growth over the past decade in particular, there is concern that the pool of experienced senior pilots is being drained.

In at least two Asian accidents over the past few years, there is evidence that serious, even violent, disagreement occurred between pilots in the moments before impact. In many others, there is evidence that effective questioning and crosschecking could have changed settings that led to disaster.

However, CFIT and crew resources management are both worldwide problems and certainly not confined to Asia. International industry organisations, such as Iata, are alarmed by the growth in the proportion of crashes each year caused by pilot error. These amounted to just 1 per cent in 1967, but had grown to 58 per cent by 1996. Yet, after the collapse of its own national currency and a recession in its key foreign markets, it would be tempting for an airline like Korean Airlines, reeling from its worst-ever loss - US$246 million in the first half - to put safety issues in budget priorities for next year or the year after.

Korean Airlines, and South Korean aviation in general, should be used to disaster by now. The country has a painful history stretching back to 1958, the year of the country's first hijacking. According to a report by Reuters, no less than six of the 12 serious accidents, incidents and aircraft losses suffered by Korean carriers between 1958 and 1993 were the result of piracy, terrorism or military aggression

But some key factors (although not all of them) that led to the Guam crash were within KAL's control and the airline will almost certainly bear some of the blame when the findings of the accident investigation by the US National Transportation Safety Board are eventually brought down.

As part of its response to the Guam crash, KAL announced a multi-pronged assault on safety problems, commissioning the US Flight Safety Foundation to examine all the safety divisions of the airline. KAL is also understood to have commissioned an extensive crew resources management programme from alliance partners Delta Air Lines.

Industry sources emphasise that Delta isn't simply importing a ready-made product for the use of Korean Airlines' pilot educators, but is working closely with the pilot community. At the time of writing, the programme was believed to be close to completion and major internal recommendations were to be made.

Similarly, in Taiwan, China Airlines has turned to Germany's Lufthansa for input on pilot training, although, in the wake of the February crash and a series of fatal commuter airline accidents, the island is also busy with consultants, Boeing and Airbus crew resource management experts, General Electric representatives and foreign government agencies, such as the US Federal Aviation Administration.

Taiwan's Civil Aviation Authority is stressing that, in place of periodic inspections, there is now daily surveillance of all airlines. More safety inspectors are being hired to boost their numbers to over 40 and there has been a turnover of executives in the air safety division.

The CAA says that, while its brief is to conduct a thorough, ongoing safety audit of the airlines, it is up to them to improve internal training procedures. The airlines, says a CAA spokesman, already had crew resource management programmes in place prior to the latest CAL accident, but he adds that they were 'too basic.' However there has been cynicism in the industry that the CAA's new broom will have much impact on the way in which inspections are carried out.

Equally, there is criticism of CAL's public response to the February crash. It started a price war to boost flagging load factors, cutting regular fares by up to 60 per cent.

In fact, the entire Taiwanese foreign travel market - not just CAL's share - shrank by up to 15 per cent following the February crash. On top of Taiwan's own mild economic recession and the more severe turbulence around it, CAL's decision to cut yield to get load factors up, and the loss of load factor by competitors that didn't match CAL's discounts, may yet prove a calamity when full annual results are posted later this year. 'Everyone's just crossing their fingers,' says an executive at one of CAL's regional competitors. 'What CAL's doing is damaging the whole market.'

In contrast, the abandonment by Indonesian airlines of some US dollar-denominated aircraft leases following the collapse of the rupiah, although forced upon them, may be a long-term blessing.

Even at depressed yields, load factors are on the rise as the carrier has disposed of capacity of nearly 2,000 seats in the shape of the six MD-11s which have been returned to lessors.

But the future will still hold a bleak fight for survival as Garuda and the remaining domestic airlines, Merpati Nusantara Airlines, Bouraq Indonesia, Mandala Airlines and Sempati Air, which ceased trading in June, officially pool their resources as the Indonesian Airline System.

Despite recent crashes, issues such as crew resources management appear to be taking a back seat to engineering in Indonesia, as its carriers rely more on older aircraft, some of which had been grounded and were ready for sale when the rupiah crashed. If there is any upside, says one source, it is that a number of these aircraft had undergone heavy D-check maintenance and are ready for service in good condition.

And, perhaps in a sign of shifting priorities, the man who has overseen a culture change in Garuda's engineering function in the past year, senior vice president engineering and maintenance Bambang Wahyudi, has been moved up the ladder to senior vice president commercial, the only senior executive to survive the corruption purge by new chief executive Robby Djohan.

Despite the current economic turmoil, Asian carriers are undoubtedly coming to terms with the need to address their flight safety procedures and adopt more sophisticated crew resource management techniques. In so doing many are finding their alliance partners to be willing sources of expertise.

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