There are three things most of us don't realize about the history of Cockpit/Crew Resource Management:
- The "captain is always right" culture in aviation was pretty much invented by one airline: Pan American World Airways.
- The solution to the "captain is always right" culture came from an industry that realized that things had to change and the best demonstration of how such a change can turn things around came from that very same airline: Pan American World Airways.
- There is a tendency in young and old aviators to return to that problematic culture. And therein lies the reason for this article.
A History Lesson: Why pilots are called "captains" and "first officers"
Photo: Pan American Airways Boeing 314 "Yankee Clipper," 1939, (Library of Congress)
Click photo for a larger image
The following narrative is from the excellent book, Skygods, by Robert Gandt. It may be one of the best books on Crew Resource Management ever written. Of course it is thought more of a history of the airline than anything else. But the very concept of aircraft pilots in crew aircraft comes from the days Pan American Airways flew the majestic flying boats, just a few decades after the birth of powered flight itself.
[Gandt, p. 19]
Back in the boat days . . .
The new hires heard a lot of that during their training. Whenever someone talked about an event that happened in the first half of Pan Am's existence, his voice took a reverential tone: "Things were different in the boat days, you know. Back in the boat days we used to ... "
Everything of consequence happened then. Those were the days when Pan American took to the skies, and oceans, in its great flying boats-lumbering, deep-hulled leviathans that took off and alighted on water. To the old-timers, everything that happened after the boat days was anticlimactic. Then came the coldly efficient, unromantic land planes like the Douglas DC-4 and DC-6 and the Boeing Stratocruiser and then the antiseptic, kerosene-belching jets.
The flying boat was a hybrid-neither fish nor fowl-born of the notion that because two-thirds of the planet happened to be covered with water, it made sense to use the stuff for taking off and landing airplanes. And for a while that was the only option. Conventional land planes required long runways of thick concrete in order to take off with a heavy load. Until the late thirties, no such hard-surfaced runways existed anywhere in the world. Only the flying boat, using miles of sheltered harbor and lagoon, was able to lift the vast store of fuel required to carry a payload across an ocean.
There was also a psychological factor. Passengers took comfort in the knowledge that should calamity strike and the flying boat be no longer able to fly, it could become, in fact, a boat.
Juan Trippe, it was said, had a nautical fetish. On the walls of his home hung paintings of clipper ships, the fast full-rigged merchant vessels of the nineteenth century. It was Trippe's dream that his airline, Pan American, would become America's airborne maritime service. Pan Am flying boats would be the clipper ships of the twentieth century.
So he called his flying boats Clippers. Aircraft speed was measured in knots. The pilots who commanded the clippers were given the rank of captain. Copilots became first officers.
It wouldn't do for a Pan American pilot to look like the scruffy, leather-jacketed, silk-scarved airmail haulers of the domestic airlines. Instead, they wore naval-style double-breasted uniforms with officer's caps. When they boarded their flying boats, they marched up the ramp, two abreast, led, of course, by the captain.
Trippe understood pilots, having been one himself. He knew they were prima donnas who loved the pomp and perquisites of command. The captains of the great oceangoing, four-motored behemoths like the China Clipper needed a suitable grand title. So he gave them one: Master of Ocean Flying Boats.
Like commanders of ships at sea, the Masters of Ocean Flying Boats were a law unto themselves. While under way they exercised absolute authority over their aircraft and all its occupants. And with such authority went, inevitably, arrogance.
A CRM History Lesson: Pan American World Airways and the Boeing 707
Juan Trippe was a visionary in many ways; he foresaw profitable international airline service before anyone else thought it even possible. He pushed aircraft manufacturers into bigger, faster, longer. You can argue that he was the driving force behind the Boeing 707 and 747 programs. Pan American World Airways and the Boeing 707 have a linked history, and that history shows just how important Crew Resource Management is in an airplane with more than one pilot.
Photo: The first three Pan Am Boeing 707s (N709PA, N710PA, N711PA), Seattle, Washington, 1958, (Public Domain)
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During its lifespan, nobody crashed more Boeing 707s than Pan American World Airways. In fact, the accident rate in their first real transoceanic jet was going up while the rate for the rest of the industry was going down. There are lessons here.
Note: this list does not include aircraft involved with hijackings (24 Nov 1968, 22 Jun 1970, 29 May 1971, 17 Dec 1973).
- 3 Feb 1959 — Pan Am 115 — An inept copilot made several mistakes that plunged the aircraft into a spiraling dive. While the captain was able to recover, the question that should have been asked but wasn't is this: what about the Pan Am culture allowed such a pilot into the seat of their flagship aircraft? PILOT ERROR
- 8 Dec 1963 — Pan Am 214 — A lightning strike ignited fuel in a wing tank, causing that portion of the wing to separate; the pilots were unable to recover.
- 7 Apr 1964 — Pan Am 212 — The captain deviated from the ILS glide slope and ended up landing too long to stop on the runway. While nobody was killed, the aircraft was damaged beyond repair. PILOT ERROR
- 28 Jun 1965 — Pan Am 843 — An engine turbine disintegration caused a fire, the crew made a successful emergency landing.
- 17 Sep 1965 — Pan Am 292 — After the captain deviated from weather visually, the crew lost position awareness and descended too early into the terrain. PILOT ERROR
- 12 Jun 1968 — Pan Am 001 — The crew misset their altimeters on approach (millibars versus inches) and flew too low on approach. PILOT ERROR
- 12 Dec 1968 — Pan Am 217 — The crew flew into the ocean during approach, perhaps because of the visual illusion of the dark ocean against a dark sky. PILOT ERROR
- 26 Dec 1968 — Pan Am 799 — The crew attempted to takeoff without the flaps set. PILOT ERROR
- 25 Jul 1971 — Pan Am 6005 — The captain misflew the approach and impacted a mountain short of the runway. PILOT ERROR
- 22 Jul 1973 — Pan Am 816 — An instrument failure might have distracted the crew after takeoff; they flew a descending turn into the ocean. PILOT ERROR
- 3 Nov 1973 — Pan Am 160 — Uncontrollable smoke in the cockpit contributed to a number of CRM errors that left the aircraft unflyable. PILOT ERROR
- 30 Jan 1974 — Pan Am 806 — The crew failed to recognize an excessive descent rate caused by a recoverable windshear. PILOT ERROR
- 22 Apr 1974 — Pan Am 812 — The crew turned and descended 30 nautical miles early, opting to bet their lives on one ADF needle that had swung (indicating station passage) while the other remained steady, pointing ahead. PILOT ERROR
By the close of 1973, Pan American World Airways had lost ten Boeing 707s, not including one lost in a hijacking. (The 3 Feb 1959 aircraft was repaired and returned to service.) As Robert Gandt put it, "Pan Am was littering the islands of the Pacific with the hulks of Boeing jetliners." Pan Am initiated a study to figure out what was wrong.
As the study was being conducted, Pan Am crashed two more.
After the crash of Pan 812 the FAA had had enough. The corrective action was necessarily severe. Pan American World Airways fully embraced the fixes and it is telling that for the remainder of their existence, they had a stellar safety record. The demise of the airline, I think, had more to do with their bet on larger and larger aircraft when fuel economy was becoming the driving force in the industry. Lockerbie and Tenerife sealed their fate. (Neither incident was due to Pan Am or its pilots.)
[Gandt, p. 115]
The Bali calamity brought Pan Am's 707 losses to eleven. Pan Am had crashed more Boeing jets than any other carrier in the world. And not just 707s. A three-engine 727 was lost during a night approach to Berlin. One of the new 747s struck the approach lights and incurred heavy damage during a miscalculated takeoff in San Francisco. Another 747 was lost to a new and still unrecognized threat. Terrorists hijacked the jumbo jet in Amsterdam, then had it flown to Cairo where they blew it up.
Something had to be done. Before the smoke subsided from the burning wreckage on Mount Patas in Bali, the probe of Pan American's flight operations had begun.
Inspectors from the Federal Aviation Administration climbed aboard Pan Am Clippers all over the world. FAA men rode in cockpits, pored through maintenance records, asked questions, observed check rides and training flights.
The inspection went on for six weeks. The FAA's findings confirmed the dismal facts that the internal Operations Review Group had already determined: Pan Am was crashing airplanes at three times the average rate of the United States airlines. Worse, Pan Am's accident rate was on the rise, a reverse of the steadily decreasing industry-wide accident experience with jet airliners.
The report was scathing. Pan Am's accidents in the Pacific, declared the FAA, involved "substandard airmen." Training was inadequate, and there was a lack of standardization among crews. The FAA's list went on to cover a host of operational items, matters of training manuals, route qualification, radio communications, and availability of spare parts.
But at the heart of Pan Am's troubles, according to the FAA, were human factors. That was the trendy new term psychologists were using in accident reports. It meant people who screwed up. When applied to airline cockpits, it had the same taint as pilot error.
With the exception of a crash caused by a cargo fire, and excluding the unknown circumstances of the Tahiti crash, every recent Pan Am accident could be attributed to some form of pilot error.
The indictment landed in Skygod country like a canister of tear gas.
Substandard airmen? Wait a minute, you bureaucratic piss ants . .. this is Pan American, the world's most experienced airline. . . we were the first to fly jets, the first to . . .
That was then, said the Feds. This is now. Clean up your act, or you will be the world's most grounded airline.
Heads, of course, would have to roll. And so they did, particularly in the San Francisco base, where the Skygod umbrella had long ago been raised over the heads of the venerable Masters of Ocean Flying Boats.
[Gandt, pp. 117-119]
But the most profound change was still coming. It was an invisible transformation and it had more to do with philosophy than with procedure. Pan Am was forced to peer into its own soul and answer previously unasked questions. Instead of What's wrong with the way we fly airplanes? the question became What's wrong with the way we manage our cockpits?
A new term was coming into play: crew concept. The idea was that crews were supposed to function as management teams, not autocracies with a supreme captain and two or three minions. It meant the captain was still the captain, but he no longer had the divine license to crash his airplane without the consent of his crew. Copilots and flight engineers-lowly new hires-were now empowered to speak up. Their opinions actually counted for something.
Disagree? With the captain? In the sanctums of the Skygods, it amounted to anarchy. Hadn't the Masters of Ocean Flying Boats labored for thirty years to preserve the cult of the Skygod? The barbarians were storming the gates.
But history was running against the ancient Skygods. Though Pan American technology had led the world into the jet age, Pan Am's cockpits had not emerged from the flying boat days. A new era, like it or not, was upon them. The Skygods were about to become as extinct as pterodactyls.
The cockpit transformation came down to two separate problems. The first was to de-autocratize the cockpit-to dismantle the Skygod ethic. Pan Am captains must master the subtle distinction between commanding and managing. Junior pilots must learn to participate in the decision-making process.
This was revolutionary. Pan Am copilots actually having an opinion . . .
The other problem was standardization. There wasn't any. Pilots from the unregulated, make-the-rules-as-you-go-along flying boat days were inherently nonstandard. They were, by God, supposed to be different. Flying was a game for individuals-chest-thumping, throttle pushing, flint-eyed Masters of-Ocean-Flying Boats-not compliant drones.
The newer breed of airmen had come from a different environment. High-tech airplanes demanded a collaborative effort from their crews. Uniqueness in a pilot was okay, but it ought to be manifested by excellence, by a mastery of technical skill, rather than by eccentricity.
The magic word standardization brought eventual relief. It meant that everybody operated the airplane the same way. Total strangers captains, first officers, flight engineers-could check in for a flight, enter the cockpit, and work in total harmony. They could fly the airplane around the world-and each would know what the other would do. Gone were the surprises.
It would take time to change an ethic so deeply embedded in the airline's skin, but there was no choice. It had to work.
And it did. The nightmare was over. From 1974, following the Bali crash, not another Pan Am 707 was lost in a crash.
The 747, which was emerging as the new flagship, established itself as the safest airliner ever operated by Pan Am. Not a single life would ever be lost in a flying accident with a Pan Am 747*.
Pan American went on to establish a safety record that was the envy of the industry.
* In neither of two fatal 747 disasters-the bombing of PA 103 in 1988 and the runway collision with a KLM 747 at Tenerife in 1977-was the 747 or the Pan Am crew held to blame.
It is all too tempting to take a look at the Pan American World Airways Boeing 707 era and say, "that's ancient history." It predates the 1979 NASA study which is supposed to have given birth the Crew Resource Management (CRM), after all! But here we are, almost forty years later, and we can still see old vestiges of the those crusty old Pan Am Captains — the ones the CEO called "Master of Ocean Flying Boats" — in cockpits today, as well as the occasional first officer too afraid to speak up.
So there are lessons aplenty. First, lessons on how to avoid falling into the culture that gave rise to these problems in the first place. And, secondly, lessons on how to fix those who have somehow become broken.
Of course these are just my thoughts. Am I wrong? Or can these be improved upon? Hit the "contact" button on the bottom or top if this page, and let me know.
How to avoid the "Master of Ocean Flying Boats" Trap
- An honest captain is honest about his or her own shortcomings — Nobody (not even you) can fly without making mistakes. We often excuse these mistakes on mechanical failures, misunderstandings, weather, or even acts of God. But for most of these, we must realize there could have been something we could have done to do better. The best way to learn is to seek critique from formal means (check rides, observations, and audits), from the crew ("how could we have done better?" debriefs), and from self-critiques ("how could I have done better?").
- A strong captain wants a strong crew, a weak captain wants a weak crew; both types get what they want — A crew that fears retribution (everything from a "cold shoulder" to a formal and written rebuke) may be reluctant to act as a crew and may even start to disengage from their roles as active participants of the crew. If, for example, a first officer is reprimanded for making glide slope deviation callout, the first officer may stop paying attention to the glide slope needle.
- Organizations can promote strong crews by preventing organizational complacency — Pan American World Airways started the jet age with a well deserved reputation for being the best international airline in the world. They invented the entire genre. But one of the problems with a large group of pilots beholden to the seniority system is the higher up the food chain you are, the more comfortable you become. This comfort breeds complacency. But even a very small flight department can give into the same forces. If you are one of two pilots doing the same job without outside oversight for years and years, you are at risk. So how do you introduce a little humility? Don't let anyone get comfortable. Here are some techniques:
- Buying a new airplane can force everyone to become experts at new things, but only if you structure it correctly. Rather than hand them the keys to the new bird with an airline ticket to school, get them involved in the selection process. Give them a say on who does the training, and make some of that training in house. (The best way to learn is to teach.)
- Take some (or all) management duties in house. A bored pilot who has never had to apply for an FAA Letter of Authorization has a lot to learn about the FAA as well as the specific authorization. Your pilots will have a better appreciation for RVSM, for example, after having to get the LOA.
- Shuffle job responsibilities. If you have a "go to" guy in your flight department that you keep going to, because you want things done right, you are stunting the career development potential of your second stringers. In the end, everyone gets bored.
- Introduce new blood. Find another flight department with similar equipment and offer an inter-fly agreement to help out to cover the load when manning is short. Once you've done this, try to "cross pollinate" your safety and standards departments.
Recognizing a "Master of Ocean Flying Boats"
We in aviation are not alone with these Masters of Flying Boats. Perhaps the best way to learn how to spot one is to examine one in another profession. Here's a report from Surgeon Atul Gawande:
[Gawande, p. 103] The most common obstacle to effective teams, it turns out, is not the occasional fire-breathing, scalpel-flinging, terror-inducing surgeon, though some do exist. (One favorite example: Several years ago, when I was in training, a senior surgeon grew incensed with one of my fellow residents for questioning the operative plan and commanded him to leave the table and stand in the corner until he was sorry. When he refused, the surgeon threw him out of the room and tried to get him suspended for insubordination.) No, the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. "That's not my problem" is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper. But in medicine, we see it all the time.
How to turn a "Master of Ocean Flying Boats" into a real Crewmember
- Safety Stand Downs — The best way to show a "Master of Ocean Flying Boats" that he or she isn't so special is to put him or her in an auditorium filled with other pilots who have longer resumes, flown more airplanes, and have higher "Master of . . ." credentials but are humble enough to worry about their own complacency. But if you are going to send your prima donna to an all expenses paid trip, ask for something in return. Look at the agenda and ask for a detailed report about the subjects you think more important.
- Personal Case Studies — The next time the industry has a high profile crash, ask your "Master of . . ." to investigate and give you his or her perspective. Ask for follow ups as the official investigation unfolds. There is nothing more humbling than to get into the weeds about a crash and realize, "it could happen to me."
- Hire an intern — Ask your "Master of . . ." to mentor a younger pilot that you know or can find through local flight schools. Let him or her know this is important to you. You want to "give back" and this is one way to do that. Having to show an outsider what goes on behind the curtain may force the "Master of . . ." to rethink the reason there is a curtain there in the first place.
Gandt, Robert, Skygods: The Fall of Pan Am, 2012, Wm. Morrow Company, Inc., New York
Gawande, Atul., The Checklist Manifesto: How to Get Things Right, 2009, Metropolitan Boos, Henry Holt and Company, LLC, New York.