British Aerospace Plc AVRO 146-RJ70A , VH-NJW

Investigation number

199803515

Occurrence date

08/07/1998

Location

9 km WNW Norfolk Island, Aero.

Report release date

01/10/1999

Report status

Final

Investigation type

Occurrence Investigation

Investigation status

Completed

Occurrence category

Incident

Highest injury level

None

Safety Action Significant Factors Analysis Summary

Local safety action

As a result of this investigation, the following safety actions
were initiated by the operator:

The operator advised that action would be taken to ensure a
uniform standard of crew resource management across the
company.
The pilot in command was provided with additional training to
address deficiencies in his knowledge of night visual
approaches.

BASI safety action

As a result of investigations into a number of previous
occurrences involving crew resource management issues, the Bureau
issued interim recommendation IR950101 on 17 July 1995 to the Civil
Aviation Safety Authority.

"IR950101

The Bureau of Air Safety Investigation recommends that the Civil
Aviation Safety Authority (CASA) require operators involved in
multi-crew air transport operations to ensure that pilots have
received effective training in crew resource management (CRM)
principles. To this end, the CASA should publish a timetable for
the phased introduction of CRM training to ensure that:

CRM principles are made an integral part of the operator's
recurrent check and training program and where practicable, such
training should be integrated with simulator LOFT exercises;
the CASA provides operators and/or CRM course providers with an
approved course syllabus based on international best practice;
such training integrates cabin crew into appropriate aspects of
the program; and
the effectiveness of each course is assessed to the
satisfaction of the CASA".

The following response was received from the Civil Aviation
Safety Authority on 8 September 1995:

"I refer to your Interim Recommendation No IR950101
concerning the B747-312 accident at Sydney on 19 October 1994.

CASA fully endorses the principles of and accepts the benefits
flowing from CRM and similar training as well as strongly
encouraging such training for flight crew, cabin crew and other
operating crew. However, CASA is not fully convinced that mandating
CRM or similar training, particularly for high and low capacity RPT
operations, will necessarily prevent or reduce the incidence of
such accidents in the future.

Nonetheless, CASA is willing to further investigate CRM training
including the position taken by leading overseas regulatory
authorities in this regard, particularly in relation to high and
low capacity RPT operations. To this end, CASA intends to consider
the issue as part of a major project to commence in the latter part
of 1995. This project is to review all aspects of RPT operations
conducted under CAR 217 in relation to Training and Checking
organisations and is the first major review of such operations to
be carried out for some time.

CASA undertakes to advise BASI of the outcome of that review in
relation to CRM and similar training".

The following response was received from the Civil Aviation
Safety Authority on 26 February 1997, and stated in part:

"I refer to BASI Interim Recommendation IR950101 and
the Civil Aviation Safety Authority responses of September 1995 and
January 1996.

My purpose in writing is to provide you with a formal update on
the CASA position on this recommendation. I understand that the
CASA General Manager Flying Operations informally conveyed this
position to Director BASI earlier this year and sought from him
copies of up to date material on crew resource management (CRM)
training acquired by BASI at a recent Orient Airlines Association
seminar. The CASA position for publication is shown in the quotes
below."

"After further review along the lines indicated in our
response of 8 September 1995, CASA agrees that regulations should
be introduced requiring operators engaged in multi-crew air
transport operations to have effective crew resource management
training programs.

This is one of the tasks being actioned by the Air Transport
Technical Committee of CASA's Regulatory Framework Program. The
crew training project team working under that committee, which
includes representatives from industry, is also considering
introduction of other best practice initiatives such as the
Advanced Qualification Program (AQP) introduced by the FAA and the
New Zealand CAA. Introduction of any new legislation on these
matters is of course subject to requirements for appropriate
consultation with industry. The RFP has a timetable to complete and
publish a new set of Civil Aviation Safety Regulations (CASRs) and
associated advisory material by the end of 1998. However, where
possible new CASRs will be introduced progressively before that
date."

"I would also like to take this opportunity to invite
BASI to provide a human factors qualified observer/adviser to
assist the project team developing the CRM/AQP regulations and
advisory material."

Response classification: CLOSED - ACCEPTED

CASA has since issued a Notice of Proposed Rulemaking
(NPRM9809RP) on regulations relating to passenger and crew-member
safety. Whilst all aircraft operators and crew members will be
affected to some degree by the NPRM, the principal thrust of the
proposed changes is to "upgrade safety with respect to the carriage
of fare-paying passengers in aircraft requiring the carriage of
cabin crew". This implies that the NPRM is largely directed toward
multi-crew operations in passenger-carrying aircraft. Section
121.YY of the NPRM refers to crew-member emergency procedures
training. Each operator will be required to conduct initial and
ongoing CRM training for each crew-member position required for a
particular aircraft type.

On 16 September 1999 the Bureau received the following advice
from CASA regarding CRM training and the date of introduction of
CASR Part 121A:

"It is not anticipated that new Part 121A will be
effective before 1 January 2002. However, CASA is aware of the
importance of CRM training for crew members and will be issuing a
policy that will require operators to conduct such training. This
policy will be issued in advance of the introduction of the new
regulations and is expected to be in place by 1 July
2000."

The Bureau is currently monitoring implementation of
IR950101.

Although the crew had briefed a night visual approach to Norfolk
Island, the unicom advice regarding rain showers in the area was
clearly inconsistent with the forecast they held. Investigation of
the occurrence identified cockpit crew coordination deficiencies
that included ineffective question-and-answer communications, and
crewmembers performing tasks in isolation. The crew's performance
during the approach might have been more effective had they acted
in a manner consistent with recognised principles of crew resource
management to ensure that all resources available to the crew were
fully and effectively utilised. That the perceptions of the pilot
in command and co-pilot were different was in itself an indication
that there was a breakdown of communication and coordination
between them.

The co-pilot believed that the pilot in command did not clearly
communicate his approach intentions during the final approach
phase. In effect, the co-pilot was left out of the pilot in
command's decision-making loop. This generated a conflict in
expectations between the pilot in command and co-pilot that was not
resolved. As a result, and in view of the prevailing weather, the
co-pilot became concerned for the safety of the operation.

The approach briefing was inadequate. As the crew had flown
frequently together during the previous two years, they should have
been very familiar with one another's usual practices. The pilot in
command could have requested explicit feedback from the co-pilot to
assess his understanding of the situation. The crew's familiarity
with each other and their destination probably contributed to the
brevity of the approach briefing.

The operator had not ensured a uniform standard of crew resource
management across the company. Moreover, the safety regulator had
not provided operators engaged in multi-crew air transport
operations with specific guidance regarding crew resource
management. Consequently, the operator was left to assess issues
such as syllabus content, standard of training, qualifications of
CRM assessors and frequency of assessment.

Prior to departure from Sydney, the crew received a Norfolk
Island weather forecast that indicated conditions should be
suitable for a night visual approach. Consequently, just before
descent, the pilot in command reviewed the visual approach
procedures. During the descent, the Norfolk Island unicom service
advised that there were rain showers in the area. Subsequently, the
crew conducted a night visual approach in weather conditions where
the visibility had reduced to approximately 8,000 m in drizzle and
isolated low cloud. Sufficient fuel existed for the crew to divert
to Noumea if necessary.

During the latter stages of the approach, the co-pilot assessed
the in-flight weather as unsuitable for a night visual approach and
assumed that the pilot in command shared this view. As the approach
was continued, the co-pilot attempted on a number of occasions to
communicate his concern to the pilot in command. However, the pilot
in command initiated no significant rectifying action and continued
the approach. When the runway lighting was sighted at approximately
2NM on final the visual approach slope indicator system (VASIS)
indicated a three-lights fly-up. After the aircraft was safely
landed, the pilot in command and co-pilot discussed the conduct of
the approach. The pilot in command was somewhat surprised at the
level of the co-pilot's concern.

An amended Norfolk Island terminal area forecast (TAF) had been
issued during the time of the aircraft's approach, indicating a
deterioration in the weather. However, due to the time required to
complete normal processing procedures involved in relaying the
information to the crew, they did not receive this update.

The operator reported that some deficiencies existed in aspects
of crew coordination, and the pilot in command's knowledge of night
visual approach procedures. The operator indicated that those
issues would be addressed. The pilot in command subsequently
commenced a substantial program of training, to be followed by a
check before returning to line operations.

The pilot in command and co-pilot had flown together frequently
for the preceding two years, both at Norfolk Island and at a
previous basing in Australia. Since commencing employment with this
operator, neither the pilot in command nor the co-pilot had
received crew resource management (CRM) training, despite that
being an assessable item of crew line and currency checks. The
operator considered the occurrence to be an isolated human
performance event. The safety regulator had not promulgated
specific guidance regarding crew resource management training to
operators engaged in multi-crew air transport operations.

Aircraft Details

Manufacturer

British Aerospace PLC

Model

AVRO 146

Registration

VH-NJW

Serial number

E1223

Operation type

Air Transport High Capacity

Departure point

Sydney, NSW

Destination

Norfolk Island

Damage

Nil