Lessons from the Staines Trident

A little after 4pm on the 18th June 1972 Trident G-ARPI started its takeoff roll at Heathrow. About three minutes later “Papa India” lay shattered in a small field between the A30 and a housing estate just outside the southwestern boundary of the airport. Everyone on board was either dead or dying.

http://en.wikipedia.org/wiki/British_European_Airways_Flight_548

http://www.aaib.gov.uk/publications/formal_reports/4_1973__g_arpi.cfm

The accident drew out the best and worst in people: a small boy ran to alert a nurse who was playing near to the site of the crash. She called the emergency services who later squabbled over whose territory the aircraft had crashed on. Policemen risked themselves to look for survivors. Cars stopped on the A30 so that their occupants could stand on the edge of the road and watch the broken remains and rescue effort in the field below.

The gloomy pallor of industrial unrest enveloped the disaster. Bitter disputes were commonplace in 1970's Britain. The nation was riven with post-austerity anger and division and BEA was no different. Lurching from one disagreement to another about pay, status, mergers, aircraft, conditions. You name it, there was disagreement about it and 19th June was planned to be a strike day. This ensured that 'Papa India' was full of passengers anxious to avoid the chaos of the next few days.

Airlines had ceased to be the preserve of the super-rich and super-famous. By '72 getting on an airliner was almost normal. Airlines responded to demand by adding flights, fleet size and destinations. Pilots were needed to feed this demand. The Trident was crewed by three pilots and BEA were actively recruiting young men to train at the colleges in either Oxford or Hamble to fill these seats.

In the cockpit were three operating pilots: Captain Stanley Key. A veteran, a Route Check Captain and – according to the report – an extremely accomplished pilot. He was assisted by two young Hamble graduates: S/O Jeremy Keighley was seated next to Key performing copilot duties, behind them Simon Ticehurst performed third pilot duties.

Popularised reports and documentaries over decades have singled out Captain Stanley Key as the main protagonist in the accident. I remember the accident being discussed during CRM courses. Key bore the brunt: Books, articles, internet posts all rounded on Key's personality coupled with his latent heart condition. The outburst in the crew room, the puerile slogans scrawled by others on parts of the flight deck, his reputation as a 'stickler' for procedures and his brusque manner all pointed in the direction of Key as the root cause.

On the 18th June this year I drove down the A30 on my way to work at our training centre. The lights turned to red and I pulled to a halt at the traffic lights by the Staines junction. I glanced, into the field and decided to read the accident report with twenty-first century eyes. I needed to know whether Key really was an ogre. Was it his domineering personality which caused the 'droops' to be retracted too early? Did both Copilots remain silent, aware of their fate but paralysed by fear?

A few things are certain: the event marked a sea change in aircraft accident investigation and the understanding of human emotions in aircraft events. One section entitled “Human Factors” probably started that concept the instant it was published.

One frustrating element was missing for the investigation: the cockpit voice recorder. Eyed suspiciously by pilots who were already nervous about flight data analysis, recorders were available on other types but not on the Trident. The question of professional privacy kept them away from some flight decks but Papa India changed all that. Flight Data for the accident was available but it told a confusing story. A litany of extraordinary error spewed out amongst the electronic confusion. There were more questions than answers. The public demanded to know what was going on in the flight decks of their airliners. Eavesdropping on the pilots' conversations was the only way to know for certain.

The report

I thumbed through the report. The tone is fatherly, patrician, complex with more than a whiff of the judiciary about it. I was transported back to that era. I read it front to back a few times, sketching down notes and questions before being drawn back to the 'argument'. In my memory there was an arc drawn between the moment in the crew room and the crash itself. I was surprised that the whole thing is described in just two paragraphs. Key was challenged about his efforts to garner support against the upcoming strike. He was against the strike (I had assumed he supported it) and the outburst ended with him apologising to his inquisitor and leading him away by the arm: Not really the actions of a monster with no recognition of his own behaviour. Could a couple of seconds of disagreement really be the true root cause?

The more I read the more I realised the subtext of the investigation; it was a defence of the then-new system for training 'cadet pilots'. The report was a guarded defence of both of the copilots and with it the whole cadet scheme. There was clearly contemporary criticism directed at a programme which could place pilots on board a complex jet airliner with just 225 hours inked into the pages of their logbook. This criticism presumably came from pilots who had been sent off to war decades previously with far less experience and nothing like the structured training or focused understanding of their role.

Poor design

I was interested in the balance of the report. It occasionally made sweeping generalisations to close down elements of an argument. Hawker-Siddley's design was quickly exonerated by virtue of their response to a number of similar events and their actions. The report chooses to avoid questioning how other manufacturers design their flap and slat systems. I found this absolutely extraordinary. At the root of this accident was an error of selection and the design of the aircraft made such an error possible. A cursory study of contemporary designs reveals that Boeing combined trailing edge and leading edge selections into a single lever. The 707 – designed in the 50s – had this feature as did all of the subsequent 7-series models.

Ergonomically this design was poor: Look how close the levers are in my picture above. Modern analysis would look at the likelihood of an error occurring and the severity of it happening. Such an appalling design simply wouldn't get off the drawing board today. Frankly, this design is the most tragic part of the crash. Contemporary designers had foreseen an issue such as this and engineered it out. No amount of weepy-eyed sentimentality or patriotic duty would cause me to make excuses for this awful oversight. Complex aircraft are not made better by being made more dangerous and trickier. The 767 that I fly is a great aircraft precisely because it is so faithful in its flying qualities. The A320, the 737, the 777: they didn't become market leaders because they were like taking a tiger for a visit to a primary school.

Training signals

Keighley's training record leapt off the page at me: He was “slow to learn” and would “require careful watching”. Perhaps most significantly he was “slow to react in an emergency” and “lacked initiative”. To my modern, training manager brain this told me two things: That it was doubtful that Keighley had met the required standard on the course, and it was probable that the course and its instructors did not meet his needs as a trainee.

Did this mean he was not suitable to fly the Trident? Absolutely not. Trainees learn at different rates. Trainees like different styles. The system back then was something of a monotheism: it was trainer-centric too. My boss (Chief Pilot!) went through Hamble in 1972 – he proudly described his instructor report from that time which angrily states that he would “…never be an airline pilot…”. Today we have a different philosophy. Start from where the trainee is, give them a reason to progress, adapt your instructional style to get them there. It's a contract, a partnership between trainee, instructor and training organisation. We don't send people to the line with a flea in their ear about “needing careful watching”. The trainee can do absolutely nothing with that information. It gives him neither purpose, nor direction. If you wanted to send someone into a job feeling underconfident and adrift, that was the way to do it.

Loss of control

Severe Loss of control accidents are usually characterised by a lack of recognition of the problem. By their nature, loss of control events are usually a surprise to the crew. Often the pilots continue to force their perception of what should be happening in front of what actually is occurring. When I am teaching, I describe the process of fixing the issue as a mental “gear change”. The brain needs to neatly slot from “flying to Brussels” mode to “Save the aircraft” mode.

Not easy: for starters you have to convince yourself that a massive error or mistake has occurred. You might even be responsible for it. Pilots are not good with admitting fault. Initial training is all about success. It is all about correctness, rectitude, getting it spot on. The accident ends up being just a tragic comment on human nature – hoping for success despite the evidence.

Air France 447 was precisely the same: if you are an airline pilot back stick usually means 'up'. Forward stick usually means 'down'. It doesn't really matter if you are flying an Airbus, a Boeing or a Beechcraft. For your whole career that has been true. With the wing stalling forward stick is sanctuary; it helps turn the wing back into a beautiful and artful shape for teasing lift from air instead of a lump of draggy metal.

The report describes how stalling is taught: clean, approach configuration with some flap out and then again with some thrust on. Crucially the exercise was – and usually still is – conducted as a theoretical exercise. If you really stall an airliner nobody ever says to you “…ok, shortly we will explore the stalling characteristics…”. So, if the difference between success and failure is recognition, we really need to put the manoeuvre into some sort of context.

The cadet pilot programme

This is still topical. In the wake of the Colgan Air crash in 2009 the FAA now mandate that an airline First Officer has 1500 hours. This was an emotional response and an oversimplification of the issue at stake: Colgan had rest, employment and social issues at its heart. The same recognition issues that put Papa India into the ground put Air France and Colgan down too. Experience alone is no guarantee of competence.

The Hamble 225 hour route was the first of its kind. Highly structured, this programme assessed suitability and trained in competence from early on. The product, however, was – and still is – a green and limited individual. Competent and ripe for development but lacking outright experience. The theory is sound: aviation is diverse and complex. Why spend time flying around gaining skills in an aircraft type which is not relevant when you can pass on core skills and consolidate on an airliner?

The report stops short of discussing organisational themes: what about the extra skills and demands placed on your captains? Was a robust system in place for identifying the need for further support and monitoring progress? The debate will rage on: Multi-crew licences are here and the same old arguments rattle around. The key is that today's aircraft commander needs to understand that the capability and limitations of his crew change daily and with the environment.

Organisations need to refocus on providing the skills for commanders to coach, for first officers to accept feedback and for the whole culture to incorporate personal responsibility for development an learning. A 1500 hour pilot will suffer skills atrophy – if he ever even had them. A 225 hour pilot may have the skills and the aptitude but find himself in an organisation which does not provide support for development. A 10,000 hour pilot may find himself unable to intervene because he lacks the culutral skills or organisational support to act decisively when needed.

What I really learned…

…was that we are still learning the same lessons. We are even having the same arguments. Was Key's behaviour or heart problem to blame? I suspect that it was little more than a media sideshow; a great opportunity to dramatise a complex and convoluted event. More positively, the Papa India report assured me that I am on the right track: my vision for training systems, support, investigation and pilot management are sound. But it also reminded me that if I ever stop learning or enquiring then I should give it all up

 

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4 thoughts on “Lessons from the Staines Trident

  1. Pingback: The automation paradox | Making training relevant | mmsba

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