A failure to communicate, among other things

[Everskyward]

This video is often shown in training when they are talking about CRM.

The probable cause of this accident was officially...

PROBABLE CAUSE: Non-standard phraseology was used by Kuala Lumpur ATC, causing the crew to misinterpret the instructions.

But there was a lot more going on. I've never seen this posted here so I thought I would share. This was a 747 but there are lessons that smaller airplane pilots can learn from it. Before you start to throw too many stones remember that these guys were not suicidal and didn't expect to end up on a hill in Malaysia that morning.

 

[PilotAlan]

I deal with communications and message transfer every day, and creating after action reports for incidents.

There is no such thing as a communications failure.
There are failures of:
1 - Technology: The participants physically could not communicate.
2 - Training: The participants either were not trained in how to use the communications system, or were not trained in alternate methods of communications.
3 - Policy: Policy either did not allow or discouraged the communication that was required.
4 - Leadership: Management and supervision did not require and reinforce the expectation that the communication occur, or saw the failure impending or occurring and did not intervene.
5 - Practice: While the ability and policy to communicate and existed, the daily practice of organization deters it. In other words, what the organization says it does and what it actually does are not the same.

Almost all "communications failures" fall into one or more of these categories. It's useful to help troubleshoot the problem and isolate the root cause.

 

[Everskyward]

Almost all "communications failures" fall into one or more of these categories. It's useful to help troubleshoot the problem and isolate the root cause.

In this case the communications failure was only a link in the accident chain even though it was noted as the probable cause. The speaker said one thing, the listeners heard something else, but what they thought they heard really didn't make any sense. There were a lot of other things going on here.

 

[PilotAlan]

In this case the communications failure was only a link in the accident chain even though it was noted as the probable cause. The speaker said one thing, the listeners heard something else, but what they thought they heard really didn't make any sense. There were a lot of other things going on here.

Agreed.
But too often I hear "communications failure", and was trying to pass some trouble identification tools. It wasn't directed at this post specifically.

 

[Fearless Tower]

The speaker said one thing, the listeners heard something else, but what they thought they heard really didn't make any sense. There were a lot of other things going on here.

Exactly. Maybe if they had the approach plate out before hand, they might have caught the error. But still not sure why it ever occured to them to descend to 400' before the FAF.

I'm kind of wondering why the FO was so suprised to get cleared for the NDB approach when they had already established that the ILS was out.....what other approach were they expecting?

 

[Ted]

That's worth watching and important lessons to learn. I'm always careful of reading approach plates. Communication in foreign countries can be difficult, although this controller actually seemed to have better grasp of English than most people.

The FO made some good points to the captain about not having the plate in front of him (he may have caught the 2400 ft listed on the plate that the captain missed). The terrain warning should've been the other indicator. Very sad.

 

[Ted]

I'm kind of wondering why the FO was so suprised to get cleared for the NDB approach when they had already established that the ILS was out.....what other approach were they expecting?

It sounded like the FO wasn't comfortable with the situation in general since it wasn't briefed very well. Not being familiar with the approaches at Kuala Lampur, who knows what they were expecting, but probably something besides the NDB. Since it's a non-radar environment (at least seems that way), ATC wasn't able to catch the low altitude.

 

[Fearless Tower]

Was that the actual CVR recording, or actors recreating it from the transcripts?

Cockpit crew did not sound at all like professional pilots.

 

[wabower]

This training vid has been around for at least 11 years and can serve as a vivid reminder. When we flew the G-whiz into KL, I remember thinking about the accident and trying to mentally reconstruct the sequence.

 

[Everskyward]

But still not sure why it ever occured to them to descend to 400' before the FAF.

That was the first thing I thought about when I heard the tape.

I'm kind of wondering why the FO was so suprised to get cleared for the NDB approach when they had already established that the ILS was out.....what other approach were they expecting?

I think the FO wanted to go around an do the ILS for the other runway. He suggests it at one point.

The FO made some good points to the captain about not having the plate in front of him (he may have caught the 2400 ft listed on the plate that the captain missed).

The FO made a more than a few comments about being uncomfortable. I think that's one of the reasons this is shown as part of a CRM presentation.

The terrain warning should've been the other indicator. Very sad.

It seems like they ignore the warnings although it's hard to tell from the tape.

Was that the actual CVR recording, or actors recreating it from the transcripts?

Cockpit crew did not sound at all like professional pilots.

I assumed it was a recreation since I didn't think they were allowed to release the CVR recording. It also sounds like someone reading a transcript. However, the controllers voice may have been real.

 

[Fearless Tower]

I assumed it was a recreation since I didn't think they were allowed to release the CVR recording. It also sounds like someone reading a transcript. However, the controllers voice may have been real.

I have seen CVR tapes released to the public in foreign investigations and sometimes even in the US IF there were released as part of a lawsuit, but I agree that it sounds like someone reading.

 

[Ted]

The FO made a more than a few comments about being uncomfortable. I think that's one of the reasons this is shown as part of a CRM presentation.

I just now noticed you mentioned it was part of a CRM presentation. My first thought listening was "Hmm. That seems like poor CRM."

It seems like they ignore the warnings although it's hard to tell from the tape.

And if it's a recreation, even harder to tell.

I'm very, very leery of terrain. Of course, hindsight is 20/20, especially when you know the outcome was death.

 

[Fearless Tower]

Reminded me of the last words on the EAL 401 transcript:

CAM-2 We did something to the altitude
CAM-1 What?
CAM-2 We're still at two thousand right?

 

[rottydaddy]

Was that the actual CVR recording, or actors recreating it from the transcripts?

Cockpit crew did not sound at all like professional pilots.

Sounds like actors, but probably using the CVR transcript as a script.


I don't know where these guys were at in their workday or workweek, but I'll bet that on top of everything else, they were fatigued. There's too much that doesn't make sense.
You really gotta wonder why they seemed surprised- and ticked off- that they had to do an NDB approach, despite having that info available before starting the approach, then being reminded after asking the tower. And then, during the final descent, to 400 (which I don't understand), the FO asks if the ILS is set up. Did he mean the one for 15, in case they decided to go missed on 33, or did he forget what they were actually trying to do?

The only part of the conversation that really makes sense to me is when The FO suggests they forget it and go for 15. He obviously had a moment of clarity, realizing they were not prepared at all to do the NDB approach under those weather conditions.