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San Juan, Puerto Rico

On 9 May 2004, an ATR 72 bounced twice and then crashed on landing at San Juan. Puerto Rico (NTSB, 2005). At 1849:46. the cockpit voice recorder (CVR) captured the sound of a thump as the aircraft landed heavily followed by one of the pilots whispering the single word - ‘God’. The aircraft had struck the runway 1600ft beyond the runway threshold after a challenging approach flown by the first officer (FO). The aircraft skipped to a height of 4ft. At this point, the captain seems to have taken control. Six seconds later, there was a second, very loud, bang. The aircraft touched down for the second time 2200ft beyond the threshold, bounced, and climbed to 37 ft with a nose-up attitude of 9°. The engine torque increased from 10% to 43%. The aircraft then pitched down to -3°, and the torque was reduced to 20%. The aircraft pitched further down to -10° and struck the runway about 3300 ft beyond the threshold with a bank angle of 7° left-wing down. A vertical load of 5g was recorded. The aircraft bounced to an altitude of 24 ft before, 5 seconds later, making its final contact with the runway 4000ft beyond the threshold. The aircraft ran off the side of the runway. Both engine mountings had broken and, among other damage, the captain’s seat had broken free from the flight deck floor.

The crew had departed from Mayagiiez, Puerto Rico, climbing to a cruising altitude of 7000ft for the short 25-minute sector. The crew were handed over to San Juan approach controller about 15 minutes out from the airfield. They were told to expect an instrument landing system (ILS) to Runway 10, the anticipated approach and the one that was briefed before departure, and to descend to 6000 ft. They were further cleared dowm to 5000 ft and then given vectors to the ILS. At this stage, the aircraft was directed around bad weather. The crew were instructed to reduce speed to 210 kts and, about 8 minutes from touchdowm, were told to reduce speed further to 180 kts and to intercept the localiser. Just before handover to tower, the crew were informed of a Boeing 727 that was 4 miles ahead of them and warned of possible wake turbulence. The crew were then told to reduce speed to 160 kts and to contact the tower controller.

At this point, the captain instructed the FO to reduce speed further, to 120 knots, to maintain separation between themselves and the Boeing 727. He described the effects of being caught in wake turbulence in an ATR 72. The FO questioned the fact that this was contrary to the АТС instruction. The captain’s next radio call was to tower during which he requested a change to the visual approach to Runway 08. With 3 minutes of the flight remaining this was approved by АТС. At this point, the aircraft was approaching 1000 ft and was flying too fast. The FO suggested slowing down, but the captain commented that there was an aircraft behind them and they had already been going slower than the other traffic, having arbitrarily reduced the speed from the instructed 160 knots. The FO confirmed his approach profile using the VASIs but, at this stage, the configuration of the aircraft, its speed, power setting and attitude became confused. The aircraft drifted low on the glideslope, and the FO pulled the nose up to compensate with the effect that the aircraft ballooned and floated for some distance before making its first impact with the runway.

The bare bones of the event would indicate poor aircraft handling. However, the short duration of the flight means that all of the conversations between the two pilots, from just after starting the engines on the ground at Mayagiiez to the moment when power is shut off after the crash, was captured on the CVR. It is very rare to have access to the crew’s conversation for almost an entire flight, and this is the evidence we will use in our examination of communication.

What Is ‘Communication’?

Traditional models of communication portray a closed-loop process. On one side, we find the sender of a signal or transmitter. The sender encodes a message and transmits using a variety of communication media. The media available include written and spoken words, formal hand signals, the whole gamut of non-verbal signals and so on. Communication often comprises assemblages of media combining to transmit the message. On the other side, there is the receiver, the intended target for the communication. The receiver has to receive, decode and understand the message for communication to occur. The loop is closed when the receiver provides feedback to the sender to establish that communication has been successful. Failure can occur at each stage of the encode-decode cycle. Unfortunately, the apparent simplicity of the closed-loop model does not necessarily fully capture what happens in the real world. According to one view, ‘communication is one of those sprawling, complex topics that has many facets and many uses because it is fundamental to all social processes’ (Kanki & Palmer, 1993). In fact, so pervasive is the topic that, when developing a set of behavioural markers to assess crew resource management, one group of researchers decided not to include a specific marker for communication. They argued that communication underpinned other observable crew behaviours and general performance was predicated on effective communication (Flin & Martin, 1998). While these two positions may reflect the fuzziness of the topic, it is generally accepted that communication has identifiable properties and structure, fulfils specific functions in social settings and is exercised with varying degrees of effectiveness. These are the aspects that we will explore.

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