Crm course 2010

CRM training cycle

CRM training cycle

COURSEPREPARATION

From new recruits to

experienced crew and senior

management, ITS can

provide a solution to your

CRM training needs.

And because the whole

structure of our training is

modular, it is possible to

pick and choose from the

complete range of options

we offer, and buy into any of

the elements as outlined in

the diagram.

CRM training is at its most

effective if planned and

managed as a programme of

continuous development.

ITS is in a unique position to

assist in the management of

this process and ensure that

all your CRM requirements

are met efficiently and cost

effectively.

For support with any ofthese items, call ITS on +44 (0) 7000 251 252

● Instructor Selection

● Instructor Training

● Course Materials

● CBT Modules

● Feed training outcome

into course design

● Re-train crew

● CRM instructor course

● Debrief skills course

● Core course

● Integrated CRM

● Design BM Scheme

● Create Grading System

● Train Assessors

● Pilot

● Cabin Crew

● Maintenance

● Management

● Crew Courses

● Integrated SEP/CRM

● Instructor Courses

The complete CRM solutionThe complete CRM solution

INITIAL CRMCOURSES

RECURRENT CRM COURSES

BEHAVIOURALMARKERS

SIMULATORINSTRUCTORS

REMEDIALTRAINING

INTEGRATED TEAM SOLUTIONS

Integrated Team Solutions Limited, England

Tel: +44 (0) 7000 251 252 Fax: +44 (0) 7000 261 262

e-mail: [email protected]: www.aviationteamwork.com

The Total CRM Package:

Instructor Training

Courseware

CBT Modules

Initial Training Courses

Recurrent Training Courses

Integrated SEP/CRM Courses

Behavioural Marker Schemes

CRM Assessment Training Courses

SFI CRM Instructor Courses

Debrief Skills Courses

Core Courses

CRMIE Service

Course design and Support

For more information on any aspect of our CRM Training please contact us for an immediate response.

ITS offers a range of courses, training

materials and support services which

together form a complete CRM

training solution.

The modular format of our courses and

courseware, along with our ability to

analyse your particular needs, enables us

to tailor that solution to your precise

requirements. Alternatively, we can

provide a full consultancy service to

identify your specific needs, create an

appropriate CRM programme and assist

in its implementation if required.

ITS is a worldwide organisation working

for 80 clients in 50 countries. We are a

UK CAA accredited provider of CRM

training and deliver courses to flight deck

crew, cabin crew, ground crew and

maintenance crew. We also run CRM

courses for senior management.

All our courses meet the requirements

of JAR OPS, the FAA and the UK CAA.

The complete CRM training solution

I N T E G R A T E D T E A M S O L U T I O N S

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The Old Forge, Little Barrington, Burford OX18 4TE

Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242email: [email protected]

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CRM Courseware

The CRM training packages available from ITS are designed to provideinstructors with all the material they require to deliver the appropriatetraining session. In addition to the course documentation they arecomplete with detailed notes to assist instructors during coursepresentation.

The following sets of Initial CRM Courseware are available:

Pilot, Cabin Crew, Joint, Rotary Wing, Pre-Command and Senior CabinCrewmember

Course materials might include:

● Lesson Plans

● PowerPoint

● Syndicate Exercises

● Questionnaires

● Case studies

● Videos

Each set of courseware also includes all the background information necessary tosupport delivery of the course and to provide additional material covering topics whichmay be raised by crew for discussion.

Individual Modules

ITS also offers a range of CRM training modules covering the main elements of the CRMsyllabus. Modules are complete with training notes and supporting elements which mayinclude activities, PowerPoint slides or questionnaires etc. Instructors simply need towork through all the documentation and adapt the content and presentation to suittheir own presentational style and operational requirements.

1 Friary, Temple Quay, Bristol BS1 6EA

Tel: +44 (0) 7000 240 240 Tel: +44 (0) 844 303email: [email protected]

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Flight Deck Course ProgrammeThe following represents a typical Pilot Initial Course 2 day programme, though all courses can be tailored to suit your specific requirements

Day 1

Introduction – 30 MinutesGeneral introduction to CRM and Human Factor related incidents and statisticsAviation Safety Review

Company Safety Culture/SOP’s and Organisational Factors – 1 Hour To enhance awareness of our own organizationTo study the effectiveness of SOP’sTo define safety and risk in the context of CRM

Organisational Error and Error Management – 2_ HoursTo describe how organisations can create the opportunity for individual errorTo illustrate the error chainTo use a case study to discuss the aboveTo discuss active errorTo introduce 5th generation CRM training and error management

Stress, Fatigue and Vigilance – 1 HourTo identify Stress and its causes and effectsTo practice Stress management techniquesTo define Fatigue and discuss different coping strategiesTo discuss how Stress and Fatigue may affect vigilance

Communication and Co-ordination – 1 HourTo review how we communicateTo identify barriers to effective communicationTo highlight essential verbal communication skillsTo discuss and practise scenarios involving communication

Automation – 45 MinutesTo identify the potential hazards of automationExamine the human Error associated with Automation

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Flight Deck Course ProgrammeThe following represents a typical Pilot Initial Course 2 day programme, though all courses can be tailored to suit your specific requirements

Day 2

Review of Day One – 30 Minutes

Leadership, Followership and Teamwork – 1 HourTo illustrate the effectiveness of working in teamsTo highlight effective leadership/followership skillsTo evaluate teamwork and leadership using NOTECHS and a video case study

Personality/Attitude and Behaviour – 30 MinutesTo discuss behaviour and its effects on other crew members

Situational Awareness and Information Processing – 1 _ HoursTo consider the stages of the human information processing systemTo explore the limitations to our information system in the context of our working environmentTo examine the elements of Situational Awareness To illustrate and discuss causes of lack of SA and how we can enhance our SATo examine situational awareness through a case study

Decision-Making – 1 _ Hours Illustrate a Simple model for Decision MakingDiscuss routine Decision MakingHighlight Barriers to Decision MakingTo discuss and practise scenarios involving decision makingIllustrate a process for decision making

Case Study – 45 MinutesTo examine a case study involving a decompression

Course Review – 45 Minutes

1 Friary, Temple Quay, Bristol BS1 6EA

Tel: +44 (0) 7000 240 240 Tel: +44 (0) 844 303email: [email protected]



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Typical Course Programme

0830 Course IntroductionOverview of course, introductions, course aims and objectives. What is CRM?

0845 The Aviation SystemDescription of preparation for departure, illustrating interdependence of different tasksand reasons why delays occur. Social structure of system.

0930 Group ExerciseSyndicate exercise to illustrate teamwork

1030 CommunicationDiscussion of output from syndicate exercise in terms of ways of communicating.Develop a model of communication and illustrate with examples of poorcommunication. Role of communication elements in CRM.

1115 Decision-makingDiscussion of output from syndicate exercise in terms of how groups made decisions.Develop a model of decision-making and look at reasons for poor decision-making.Introduce stress as a factor in poor decision-making.

1200 ReviewDiscuss lessons of mornings activity from perspective of ways of learning.Introduce concept of perception, limitations on information processing, etc.

1230 Lunch

1300 StressDevelop ideas about causes of stress. Discuss effects of stress and coping strategies.Fatigue.

1345 Predictable BehaviourDiscuss concept of attitude and personality as predictable behaviour. Discuss the effectsof unacceptable behaviour in teams.

1430 Case StudySyndicate exercise which looks at structural elements of team work.

1530 Working in TeamsOutlines key elements of team structures and processes.

1545 ErrorOutlines the skill, rule and knowledge categories of error with group exercise whichlooks at examples of types of error.

1630 Review and Close

Cabin Crew CRM



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Helicopter CRM CourseTypical rotary wingTwo day Initial course programme

Day 1

0900 Course Introduction

Overview of course, introductions, course aims and objectives. What is CRM?Statistical Justification

0930 The Rotary Wing Operating Environment

We examine the inherent dangers of the RW task, the operating requirements,and limitations of the equipment and often the training of the aircrew.

1030 Break

1045 The Search and Rescue Task

The elements of a SAR mission are discussed in syndicates. Once completed eachsyndicate delivers their plans

1230 Lunch

1330 Group Exercise

Syndicate Team Work Exercise.

1445 Communication

Develop a communication model. Discuss Barriers to communication. Discuss theneed for SOP’s and thorough training when limited time necessitates minimal time for briefing and lengthy uses of Advocacy and Inquiry. Discussion will focus on the previous SAR syndicate discussion.

1545 Break

1600 Who’s Flying the Aircraft?

Discussion of the roles of the crew, task sharing, SOP’s and checklists.

1650 Review of Day one



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Helicopter CRM CourseTypical rotary wingTwo day Initial course programme

Day 2

0900 Stress

The physiological effects. Discuss causes of stress. Stress Questionnaire. Discuss coping strategies and importance of recognition of stress. Fatigue. Discuss the dangers of the RTB after a stressful mission.

1030 Break

1045 Decision Making

Case study group exercise and decision making models.

1145 Errors and Mistakes

We discuss error recognition, the error chain and “The get the job done”RW mentality.

1230 Lunch

1330 Situational Awareness

How can we get the difficult jobs done safely.

1430 Behaviour

Discuss the concepts of personality and behaviour. Discuss the concepts of the rogue aviator, the pilot that disregards limitations of himself and his machine.Why helicopter pilots are different.

1530 Break

1545 Exercise

Problem solving, Leadership and teamwork exercise completed in syndicates.

1630 Review and conclusion



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CRM Instructor CourseUK CAA approved and JAR OPS compliantCRM Instructor Training Course

ITS offers two standard CRM instructor training courses, a 5-day courseand an 8-day course.

5-day course

This course is suitable for those instructors who are already familiar with the CRMsyllabus and focuses primarily upon facilitation skills.

8-day course

Designed for those who are new to CRM, or have only limited experience of thesubject and syllabus. On the 8-day course the first three days are spent workingthrough the CRM syllabus in some detail. The objective here is to ensure that alldelegates have a common understanding of the subject matter. The next five days arespent in learning about, and practicing, CRM facilitation skills.

Open Courses in the UK

ITS regularly holds open CRM instructor training courses in the UK, which are attendedby instructors from many different countries and from a wide selection of airlines.Contact ITS for a schedule of forthcoming courses.

The ITS open instructor courses are non-residential and the course fee includes:

● Classroom training

● Course notes

● Additional reading material

● Courseware on CD

● PowerPoint presentation

● Copyright license to use our material within your company

● Certificates on completion of the course

● Refreshments and Lunch

Private courses

ITS also offers private courses for individual clients and these courses are tailored moreclosely to the individual requirements of each client and can be held in the UK or onyour own base. Private CRM instructor courses may be held on any dates that areconvenient to your company, ITS will simply need sufficientadvance notice in order that suitable instructors are available for your preferred dates.

We always assume that an instructor attending one of our CRMI courses will alreadyhave basic classroom instructional skills.



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Management CRM Training

The ITS Management CRM Course is designed for senior managersfrom all support functions (finance, maintenance, operations,personnel, marketing etc.) and examines the relationship betweensenior management activity and risks in line operations.

Typical Management CRM Syllabus

● What is ‘safety’?

● Management involvement in creating ‘safety’

● Motivation

● Management view of workforce

● Workforce view of management

● Management motivation in terms of company performance

● Organisational Factors in Aircraft Accidents

● Measuring Outcomes

● Relationships between management activity and safety

● Relationships between ‘risks’ and ‘costs’

● Creating a Safety Culture

Course Duration

The Course can be run as a one-day event or, if management timeis at a premium, it can be run over two consecutive half-days



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Recurrent CRM Training

Most Regulators require that, once initial CRM training has been completed,recurrent training should refresh the entire syllabus over a given period; withJAR OPS for example it is a 3-year period. Assuming therefore that initialtraining is provided to all your crew during year 1, then during years 2-4recurrent training should cover the entire CRM syllabus.

The usual approach to this requirement would be to take the main subject headings within thesyllabus (e.g. stress, communication, error etc) and to cover one third of these subjects in eachof the three years during the recurrent training cycle. This will ensure that, over the 3-year periodspecified by JAR OPS for example, the syllabus will have been fully refreshed.

It would not be adequate to simply repeat the various sections from the initial course, however,and so it will be necessary to produce a new set of recurrent training materials each year. Thiswork can be undertaken in-house, or alternatively it is a service that can be provided by ITS.

Of most importance to each client is to ensure that they derive maximum benefit from theprovision of recurrent training and so it will be essential that, whilst meeting the Regulator’srequirements, the recurrent CRM training also addresses those issues that are of specificimportance to the airline.

ITS can provide a recurrent courseware design service that will identify the specific issuesrelevant to the airline and will then design and produce appropriate recurrent training materials.This is a collaborative exercise that will require input from the Client’s CRM instructors andtraining management. The process will normally involve visits to base, an approval processduring the design period and a final workshop at which the courseware will be demonstratedand handed-off to the CRM instructors.

Based on a 3-year contract a fixed annual fee will be agreed for the production of thecourseware. Alternatively, without a 3-year contract, the courseware can be produced annuallyat prevailing charges.

There are many advantages to outsourcing this service and they include:

● Access to the substantial experience available from ITS

● Courseware designed to your particular requirements

● On-going design creativity

● Making time for more productive tasks within the organisation

In addition to constructing the courseware ITS can also deliver the courses using our own highlytrained instructors.



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Evaluation of CRM Behaviours

Under JAA requirements, it is now necessary for operators to introduceCRM assessment into recurrent training. To support you in meeting thisrequirement we have introduced a new service designed to assist you indesigning and assessing behavioural markers.

Your instructors will need to evaluate such elements as teamwork, decision-making,communication etc, in addition to the more usual technical elements. In order to do this,you will need to develop behavioural markers and identify the appropriate operationaland training situations in which evaluation can take place.

WE CAN HELP!

ITS has practical experience of building behavioural markers for our clients and with thisknowledge, and our considerable experience in CRM course design and training, wehave produced a package designed to assist you in:

● Deciding which elements you need to assess

● Agreeing a means of assessment

● Setting relevant standards

● Preparing assessment documentation

● Ensuring standardisation of assessors

● Identifying mechanisms for remediation

The objective is to identify behaviour that is clearly related to operational performance.The process therefore requires a detailed analysis of your operation to ensure thatindividual performance-related behaviours are being assessed.

We can therefore offer you a complete solution to the design and operation ofa behavioural marker scheme to include:

● Development of your Behavioural Markers scheme

● Training your assessors in the use of the scheme

● Standardisation of assessment

For more information, or to ask us to visit your base for initial discussions, contact us byphone, email or visit our website at www.aviationteamwork.com.

1 Friary, Temple Quay, Bristol BS1 6EA, England

Tel: +44 (0) 7000 240 240 Tel: +44 (0) 117 344 5019

email: [email protected]

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Implementing an SMSTraining Course

Based on the ICAO SMS Manual Doc 9859 (Second Edition - 2009), this3-day course is designed to prepare organisations for the implementa-tion of a Safety Management System.

Course Aims:

To introduce delegates to the concept of structured safety managementTo outline the steps needed to implement an SMSTo identify the factors that contribute to a 'Just Culture'To establish an effective organizational learning capability

Course Structure:

Day OneAn Introduction to Safety ManagementSafety, Hazard and RiskError and ViolationWhat is an SMS?Management’s role in an SMSRoles and Responsibilities

Day TwoDeveloping an Hazard registerAssessing RiskSetting Safety Management GoalsFeedback and ReportingSMS Documentation

Day Three

Investigation and AnalysisEmergency Response PlanningLearning from Experience – Continuous ImprovementSafety Education and TrainingDeveloping an Implementation Plan

The course comprises a series of integrated presentations, practical exercisesand case studies.

Case Study – Decompression

CASE STUDY – DECOMPRESSION

This case study is based on two actual incidents, both on Boeing 737 aircraft; theincidents were on different airlines. All details, for both incidents, are exactly ashappened during the two events; the only changes to the data included are the flightnumbers and airlines’ names, which have been changed to maintain confidentiality.

The case study is suitable for delivery to pilot, cabin crew or joint pilot/cabin crewCRM courses. The main objective for the case study is to support a session onCommunication and Co-ordination, although of course you may wish to use it as abasis for other CRM elements.

You will see that the module contains the following sections:

• Lesson Plan• Supporting Materials• PowerPoint

Within the Supporting Materials section you will find the handouts and a detailedreport on the second incident. Also in this section are copies of pax letters, regardingboth incidents, which were sent to the airlines.

We would recommend that you allow 40 minutes to run this module in the classroom.

Objective:

• To examine two case studies involving decompressions

To be covered as follows:

• Distribute Handout 1 for first case study and ask delegates to highlightcommunication and co-ordination errors

• Facilitate and discuss scenario from a communication and co-ordinationperspective

• Distribute Handout 2 for second case study and ask delegates to highlight howthis incident was handled differently, also from a communication and co-ordination perspective,

• Facilitate and discuss scenario to highlight differences between both incidents.

Lesson Plan – Allow 40 Minutes

© Integrated Team Solutions Limited 2006 2

KEYWORD DETAIL AIDS

Objectives

Background

Task

Points fordiscussion

Case Study

Objective:

To study two actual incidents from a communication and co-ordination perspective

This depressurisation incident occurred in 2004 on a Boeing 737-800 a/c

There are many points for discussion in this incident, as indeedthere are on any case study – however we would like to discuss thisfrom a communication and co-ordination perspective.

Issue the Investigators summary handout sheetWorking in groups of 3, ask class to mark the communication andco-ordination problems that occurred – give 5 minutes to do thisBring class together and discuss the points raised

Listed below are the communication and co-ordination discussionpoints

• Flight crew did not brief for ‘no engine bleeds take-off’• Bleed Air Duct Pressure indicator was not checked at any

time• When seat belt signs came on, the SCCM interpreted this as

turbulence and made this PA to pax• FO made RT call ‘requesting immediate descent’ instead of

announcing ‘emergency descent’ and declaring anemergency

• Therefore ATC did not give a descent clearance until 2minutes after the initial call

• Flight crew did not announce ‘emergency descent’ to cabincrew and pax

• When levelled out, the FO used the cabin call button ratherthan the standard NITS format

• Cabin crew failed to request a NITS briefing and thereforedid not pass any information to pax

Expect Time Pressure on the ground to be a factorThis area often suffers turbulent weather, therefore theinterpretation of the cabin crew when the seatbelt sign came on is afactor for discussion

So we have looked at an incident whereby there werecommunication and co-ordination issues involving ATC, flight deckand the cabin crew. Let us now consider the effect this can have onother groups of people – in this case our payload – the passengers!

SlideCase Study

SlideObjective

Handout 1


Pax letter

Discussion

communication and co-ordination issues involving ATC, flight deckand the cabin crew. Let us now consider the effect this can have onother groups of people – in this case our payload – the passengers!

This incident resulted in 7 pax letters written. There is nothingunusual in that – a pax perception of time and what is happening isoften exaggerated as we all know. However, having looked at theincident from the crew’s perspective, can we take a moment toconsider this from the pax?

This is an excerpt from a passenger letter following this incident:

Instructor to read aloud

‘Probably about 30 to 45 minutes into the flight we were told tofasten our seatbelts, put our seat backs upright etc as we were aboutto experience some turbulence. On obeying these instructions theplane seemed to almost hit a brick wall then drop. Just at this pointthe O2 masks deployed and the a/c began a very steep descent. Tobe perfectly honest, I, my wife and the rest of the pax thought wewere going down permanently. The steep descent seemed to go onfor an age. The sight of a stewardess with a look of sheer fear onher face and tears in her eyes did nothing to calm the mood onboard. We believed we were going to die!! At no point during thissteep descent did any crew member offer any support to us! It wasevery man for himself! Eventually the plane levelled off but againno information was given to pax until a very shaky captain/FO toldus that we were diverting to Charles de Gaulle to ‘find out what theproblem was.’ Then the next piece of information that was offeredwas that ‘no we are not diverting to CDG but we are diverting toOLY instead. Why did this person not try to offer some explanationfor what was happening? Even a simple explanation like ‘don’tworry, the engines are fine, it just appears to be a problem with thecabin pressure.’ No we were kept in the dark and made to suffer insilence. No information. No information. No information.

The letter then goes on to discuss the lack of support the pax had atOLY

High workload and stress of the crew are just some of the factorshere that contribute to the lack of information experienced by thepassengers.

However, what we would like to discuss here is the impact that alack of communication and co-ordination from both the flight deckcrew and cabin crew can have on passengers.


Slide

Question

Summary

Slide

Therefore looking at this incident – yes – we are just sitting in theclassroom with the benefit of hindsight.

If we consider some of the communication and co-ordinationpoints we raised before – here are 3 examples

Show slide

• Flight crew did not announce emergency descent to cabincrew and pax

• When levelled out, the FO used the cabin call buttonrather than the standard NITS format

• Cabin crew failed to request a NITS briefing andtherefore pass any information to pax

Link into your Company SOP’s here regarding who is going tomake the PA to pax

If these communications had been given, how do you think thissituation from the pax perspective may have been different?

Expect answers such as:

Pax would have known there was a loss of cabin pressure if the PAhad been made. They would have known the pilots were dealingwith the situation. Even though they are briefed on the ground,understanding the problem when faced with the situation iscompletely different!

There would have been greater co-ordination after the descent andthe pax would have been briefed by the cabin crew following theNITS briefing

We have looked at an incident in which there might have beenbetter communication and co-ordination between the flight deck andcabin crew.

So now let’s have a look at a second decompression and see how itis different from the first.

This decompression incident occurred in August 2005 on a 737-300en route from Malaga to London Gatwick.

Issue the handout sheet and again, working in groups of 3, ask theclass to compare the communication and co-ordination problems inthis incident with the first incident – give 5 minutes to do this

Slide

Slide


Task

Pax letter

class to compare the communication and co-ordination problems inthis incident with the first incident – give 5 minutes to do thisBring class together and discuss the points raised.

Establish the differences both from a flight deck/cabin crew and paxperspective.

In contrast to the previous incident, this event resulted in severalpax letters written to the company praising and thanking the crew.Here is an excerpt from one of these letters:

Instructor to read aloud

I was a passenger on flight ABC 123 from Mahon to LondonGatwick yesterday. I am writing to convey to you my enormousadmiration for the crew during our emergency descent. The cabincrew were completely calm and professional. They were anenormous help to us both practically and emotionally. It goeswithout saying that I am so very grateful to the pilots who got ussafely to the ground

While in the aircraft on the tarmac at Brest Airport, the F/O camethrough the cabin to speak to all the passengers which wasextremely helpful and reassuring to us all. He took a great deal oftime over this and I feel it was invaluable.

The cabin crew were marvellous while we were waiting todisembark a very hot aircraft. They were patient and calm and veryfriendly. Later in the lounge at Brest Airport they were very happyto talk with us and showed great concern for our recovery.

I hope you will be able to pass on these sentiments to the entirecrew. It was of course an extremely frightening experience but I donot believe the crew could possibly have been more helpful to us.They were marvellous. I would also like to say how understandingand helpful the crew were on the 757 which took us to LondonGatwick.

A further letter reads:

Whilst the experience was extremely distressing, we would like tothank the captain & crew for their professionalism during theincident, when they were clearly distressed themselves. Theirsupport was exemplary, particularly the way they managed to lookafter everybody once we had landed.

Handout 2


Special thanks to the pilot, who got us down safely & then fortalking to us individually during our time at Brest airport. We hope it hasn't put the young cabin crew staff off flying again!They were all fantastic & should be proud of the way theyconducted themselves. Thanks also to the crew of the 757 who rescued us & brought ushome safely. They made us feel a lot more at ease than we everexpected to be. Instructor note: See report if more information required


SUPPORTING MATERIALS

Content:

• Handout – Decompression 1• Handout – Decompression 2• Report – Decompression 2• Pax Letters


Handout – Decompression Incident 1

Investigator’s summary

The aircraft departed London Gatwick 10 minutes early at 09:30 and after anuneventful flight arrived at Malaga at 12:16, 19 minutes ahead of schedule. Inaccordance with a request from the ramp agent, the Captain prepared to depart fromstand ahead of schedule to facilitate handling a delayed inbound flight.

A check on the expected take-off performance requirements, by both crew, confirmedthat a Bleeds-Off (no engine bleeds) take-off would be required... Shortly afterwardsthe ramp agent presented the load sheet and again emphasized the urgency in vacatingthe stand. The aircraft closed up and started engines at 12:42, 18 minutes ahead ofschedule and was airborne at 12:57. No special brief was given for the bleeds-offtake-off nor was the ‘Supplementary Procedures’ section of the FCOM consulted.

The crew reported that they made the standard checks on the pressurization systemevery 5000 feet during the climb including a full panel scan passing Fl.100 (10000 ft)and all parameters checked appeared normal. It has been established that the checkson the pressurization system centered on the Cabin Altitude/Differential indicator ;indications here would certainly approximate to ‘normal’ for as long as the APUcontinued to supply a useful flow of bleed air. Limitation for APU with bleed air is17000feet. At no time did anybody check the Bleed Air Duct Pressure indicator. Thiswould have indicated a bleed air supply problem, with zero indicated in the right handduct and a slowly reducing pressure in the left hand duct as the aircraft climbed.

After about 10-15 minutes in the cruise at Fl.320, (32000 ft) the cabin altitude hornsounded. The crew performed the ‘recall items’ for Cabin Altitude Warning Horn’and noted the cabin altitude at 10000feet climbing at approximately 1500fpm (feet perminute) The Captain called for Emergency Descent and the crew then set about therecall items for this manoeuvre. When the Captain switched on the seatbelt sign, theSCCM interpreted this as an indication of impending turbulence and duly made theappropriate ‘turbulence’ PA to the passengers. The oxygen masks then dropped. Atthis point the FO made an RT call “Air Link 176 requests immediate descent” only toreceive “I’ll call you back’ The Captain then advised “Now. Emergency Descent”,ATC responded with “Squawk 7700” which the FO set and then announced “Air Link176 descending Fl.270” (27000 ft). Approximately 2 minutes after the initial call,ATC gave their first descent clearance “Air Link 176 you can descend Fl.200” (20000ft).

All subsequent RT communications were without complication .During the descent,the system misconfiguration was spotted and corrected and the aircraft’spressurization was thereafter controlled normally. When level at Fl.100 (10000 ft),the FO called the cabin using the cabin call button. The SCCM was informed thatthere had been a rapid decompression and they were diverting to CDG, this wassubsequently changed to OLY. The remainder of the flight and landing at OLY waswithout incident.


Handout – Decompression Incident 2

During the cruise at 36000’ the RH Bleed Trip Off illuminated and the cabin pressurestarted to climb. The QRH drill was called for and a descent to 25000’ requested. Asthe cabin approached 10000’ the cabin altitude horn sounded and therefore the rapiddepressurisation drill was performed. The cabin altitude climbed to 16000’ and themasks deployed at 14000’. A MAYDAY was declared and Brest airport wasrequested as the diversion field.

The depressurisation drill was followed, including an announcement over theaircraft’s Public Address system to alert the cabin crew members – PA ‘EmergencyDescent’

The cabin crew immediately commenced their decompression drill, passing throughthe cabin from rear (where they were in the galley at the time of the incident) to thefront and once the decompression drill had been conducted, assembled in the forwardgalley for a briefing from the SCCM and checked the drills had been completedcorrectly through reference to the Cabin Crew Safety Manual.

The rapid descent was carried out as per SOP’s and the aircraft levelled off at 10000’.

A further PA to calm the pax was made during the last few thousand feet of descent –pax were told all was ok and a normal landing would take place at Brest.

Approach and landing were normal.

The aircraft was inspected at Brest and a cabin pressure run carried out after the RHpack was reset.

A replacement 757 was dispatched to Brest and the 737-300 returned to LondonGatwick at an altitude of 10000’


Investigation into loss of cabin pressure August 2005

Aircraft : Boeing 737-300

Occurrence Date : August 2005

Flight Number : ABC 123

Flight Routing : Malaga, Spain to London Gatwick, UK

Nature of flight : Public transport – fixed wing

Occupants : 140 passengers plus 4 infants and 6 crew members

Crew : Captain, First Officer, Senior Cabin Crew Member [SCCM], 3Cabin Crew Members

Location of incident : Approx 60 nautical miles to the east of Brest, France, at thetime of incident

Brief summary : Loss of cabin pressure whilst at cruising altitude of 36,000ft ledto rapid descent and precautionary, safe landing atBrest, France

History of the flightThe aircraft was operating the return sector of a roundtrip between London Gatwickand Malaga. Its outward flight left London Gatwick at 11.44 hrs Greenwich MeanTime [GMT] (used throughout1) and landed in Malaga at 14.23 hrs. This was 14minutes behind the planned schedule as a result of a delay in leaving LondonGatwick due to passengers arriving late at the boarding gate.

The turn-round at Malaga was routine, albeit shorter than usual as the crew sought tomake up the earlier delay. The aircraft departed Mahon at 15.00 hrs (5 minutesbehind schedule as a result of the late inbound aircraft), becoming airborne at 15.12hrs, for the return flight to London Gatwick with 140 passengers and 4 infants aboard.Estimated flying time was 2 hours and 44 minutes and a fuel load of 10,200 kgs wasaboard, in excess of the minimum 9,458 kgs (including statutory reserves and diversionfuel) required for the flight. The aircraft departed at a weight of 53,633 kgs, some7,602 kgs below its maximum take-off weight.

Departure from Malaga was uneventful; the aircraft followed a MJV2D StandardInstrument Departure route and was given progressive climb clearance by Spanish AirTraffic Control [ATC] to climb to its requested cruising altitude of 36,000ft for the sectorto London Gatwick. During the climb and cruise phase of the flight, cabinpressurisation was maintained normally by the aircraft’s automatic pressurisationcontroller and this item was routinely checked and found satisfactory in the “Climb”checklist by the flight crew.

1 Local time in Malaga and Brest is two hours ahead of GMT; local time at London Gatwick is one hourahead of GMT


Control of the aircraft passed from Spanish to French Air Traffic Control 48 minutesafter departure and the aircraft was given a direct clearance to the navigationalbeacon at Agen (AGN).

At 16.42 hrs, whilst the aircraft was approaching a position abeam the navigationalbeacon at Monts d’Arree (ARE) [near the French town of Lorient], a “BLEED TRIP OFF”caution light illuminated on the Automatic Centralised Warning System panel. Theflight crew conducted the checklist drill and requested initial descent clearance fromAir Traffic Control to descend to 25,000ft, which is in line with Boeing’s StandardOperating Procedures [SOP] if the aircraft has partial failure of its pressurisationsystem.

During this initial descent, the flight crew noted that the cabin altitude (the pressurelevel in the cabin relative to the outside air) was rising rapidly. As the cabin altituderose above 10,000ft, the cabin altitude warning horn sounded on the flight deck andboth flight crew members placed on their own oxygen masks in accordance with theairline’s SOP. The depressurisation drill was followed, including an announcementover the aircraft’s Public Address system to alert the cabin crew members.

The flight crew requested clearance from ATC and then initiated an emergencydescent to 10,000ft. The cabin altitude continued to rise; further attempts weremade by the crew to control the pressurisation by switching from automatic tomanual mode but these were unsuccessful.

As the cabin altitude rose through 14,000ft, the passenger oxygen masks deployedautomatically. In accordance with the pre-flight demonstration, passengers weredirected to pull the masks towards them to open the oxygen supply, place the maskon and then breathe normally. The cabin crew immediately commenced theirdecompression drill, passing through the cabin from rear (where they were in thegalley at the time of the incident) to the front and once the decompression drill hadbeen conducted, assembled in the forward galley for a briefing from the SCCM andchecked the drills had been completed correctly through reference to the CabinCrew Safety Manual.

The flight management computer [FMC] indicated that the nearest available airfieldwas at Brest and the crew requested clearance to land at Brest. The remainder ofthe flight was uneventful and the aircraft landed at Brest at 17.14 hrs and engineswere shut down on the parking stand at 17.16 hrs.

Injuries to Aircraft OccupantsThere were no injuries to passengers arising from the incident. Three passengersrequired medical attention at Brest for conditions including an asthma attack andpainful sinuses and were attended by paramedics called by Brest Airport. All were fitto continue their journey later that evening aboard a replacement aircraft.

NotificationThe airline’s 24-hour Operations Control Centre [OCC] was notified of the air diversionby Air Traffic Control at 17.08 hrs and further confirmation was given at 17.15 hrs thatthe aircraft had landed safely at Brest. This was confirmed by the Captain who useda mobile telephone to contact the OCC at 17.25 hrs.

A plan was formulated to dispatch one of the airline’s Boeing 757 aircraft fromLondon Gatwick to carry an engineering team out to Brest and then to fly all


passengers from Brest to their desired destination of London Gatwick. This wasinstigated at 18.04 hrs and crew members were called from home standby toundertake this new operation. London Gatwick Airport was advised at 18.15 hrs ofthe revised expected time of arrival of the flight at 23.45 hrs so that any personsmeeting the flight at London Gatwick could be given up-to-date informationregarding the delay.

Passengers remained on the 737 aircraft at Brest for a period of time until clearinformation could be given of the onward flight. During this ground time, the FirstOfficer and crew were present in the aircraft’s cabin to reassure passengers andexplain the situation. Passengers later disembarked normally into the terminalbuilding at Brest and Brest Airport made provisions for food and beverages to beprovided at the airline’s request pending the arrival of the replacement aircraft.

The 757 aircraft landed at London Gatwick from its previous sector from Egypt at20.04 hrs and was airborne to Brest at 21.08 hrs. All passengers elected to continuetheir journey to London Gatwick and the aircraft landed in London Gatwick at 23.46hrs to complete service from Malaga.

Crew detailsThe Aircraft Commander is a 52-year old male (Australian national) who holds a validUK Air Transport Pilot’s Licence [ATPL(A)]. He is an experienced 737 Captain who hadpreviously flown the type in Australia; joined the airline in April 2003, completedtraining in May 2003 and was promoted to the role of Training Captain in October2003.

The First Officer is a 38-year old male (UK national) who holds a valid UK CommercialPilot’s Licence [CPL]. He joined the airline in April 2005 and completed training inMay 2005.

Both pilots were licensed on 737-300 to -900 aircraft variants and held valid medicalcertificates. The crew were properly licensed, trained and rested to undertake theflight duty.

The four cabin crew members had all undergone initial training with the airline in April2005 after joining the airline. The SCCM held appropriate previous flying experienceas Cabin Crew on a fixed-wing aircraft to operate in that capacity. All cabin crewmembers were trained in accordance with the airline’s approved trainingprogramme, had undergone medical examinations and were rested to undertakethe flight duty.

All crew members were interviewed by the airline’s flight crew and cabin crewmanagement teams following the incident.

Aircraft & EngineeringThe aircraft joined the airline’s fleet in April 2003 and has completed a total of 40,537hours and 25,998 flight cycles since new. It underwent a major maintenanceoverhaul (C Check) in November 2004 and its most recent intermediatemaintenance check (A Check - required every 250 flying hours) was undertaken atLondon Gatwick in August 2005. The aircraft daily inspection was conducted on themorning prior to the aircraft’s departure to on its first sector of the day.


Flight crew members completed routine pre-flight walk-round checks of the aircraftbefore both sectors with no defects or issues noted.

The aircraft was properly maintained in accordance with Boeing MaintenancePlanning Document and the airline’s maintenance procedures, which are approvedby the UK Civil Aviation Authority.

Flight recordersThe aircraft’s Cockpit Voice Recorder was retained by the French DepartmentGeneral de l’Aviation Civile inspectors who visited the aircraft on arrival at Brest. TheQuick Access Recorder [QAR] data was removed from the aircraft by the airline’sengineers on the day after the incident and analysed.

The data is consistent with the account from the flight crew. The descent profile wasanalysed and in the graph below, the blue line shows the profile of the aircraft. TheQAR indicates that the aircraft descended from its cruising altitude of 36,000ft to analtitude of 10,500ft over a period of 6.5 minutes.

Fig 1 – QAR data of descent profile between 16.42:00 hrs and 16.51:30 hrs

The average descent rate was 4,300ft per minute versus 2,000ft per minute in aconventional descent. The maximum angle of descent recorded by the QAR was4.92º2 and the maximum rate of descent reached at any point was 6,200ft perminute.

Engineering examination of the aircraftThe aircraft was examined by the airline’s engineering team at Brest after their arrivalfrom London Gatwick aboard the 757 aircraft dispatched to carry passengers hometo London Gatwick. This indicated the presence of a problem within the air system

2 This is equivalent to a 1 in 7 gradient in a land-based descent


which uses outside air from the right-hand engine and compresses it in order to supplythe cabin air conditioning and pressurisation system whilst in flight. The structuralintegrity of the aircraft’s fuselage and all external doors and hatches was assessedand found to be intact.

A low-level ferry flight (i.e. unpressurised) with a minimum safety crew aboard wasundertaken late on the evening to return the aircraft to London Gatwick; during thissector, a pressurisation check was carried out during which the fault was repeatedand found to be consistent with the earlier crew’s accounts.

Engineering AnalysisThe 737 has two independent bleed air systems one from each engine, feeding twototally independent air-conditioning supply systems. Under normal circumstanceseach air conditioning system is designed to maintain the cabin pressure with a highlevel of extra capacity in reserve.

On investigation, the airline’s engineers reset the right-hand bleed air system andcarried out a cabin pressurisation system check. This test revealed a broken clampround the Auxiliary Power Supply [APU] air duct sealing skirt, allowing air to leak out ofthe cabin. This high leak rate explains why the flight crew were unable to maintainthe cabin altitude using only the left-hand air conditioning supply system as shouldnormally have been possible.

The automated safety alert systems functioned correctly in notifying the flight crew ofthe bleed air valve failure and the rising cabin altitude.

The automated oxygen mask drop out system deployed correctly as designed. Eachset of four masks (left-hand side of the cabin) and three masks (right-hand side of thecabin) is supplied by an individual oxygen generator and the passenger action ofpulling the mask towards themselves pulls the firing pin out of the oxygen generatorand thus commences a flow of oxygen. Subsequent inspection of the oxygensystem indicated that all oxygen generators had fired correctly and producedoxygen. A small number of oxygen generators (including those in the forward andone aft toilet, which were not occupied at the time of the incident), were not used.

Passenger reports of a burning smell towards the rear of the aircraft prior to theincident have been investigated. No evidence of fire or smoke has been found, butthe engineering investigation indicated some residue in the aircraft’s centre reargalley oven consistent with food debris from passenger meal service. None of thecabin crew members recalled any such issue and all had been in the rear galleyaround the time of the incident.

The individual oxygen generators above each seat row normally produce heat and alight acrid haze when fired and it was concluded that the passenger reports of smokeafter the deployment of oxygen masks were consistent with the normal functioning ofthe oxygen generators.

Repairs were effected to restore the integrity of the pressurisation system throughreplacement of the air duct clamp and the aircraft was test flown two days leter witha full pressurisation check undertaken. It was found to be functioning correctly inboth automatic and manual control modes. Further work was undertaken toreplace the oxygen generators above each passenger seat, replace all oxygenmasks (standard procedure after use), re-stow oxygen masks and then conduct a


final function check on the oxygen mask system. The next day a further test flightwas conducted before the aircraft was cleared to return to passenger service.

Incident historyNo other comparable incidents of decompression have been recorded on theairline’s fleet of aircraft. The airline operates a total of five identical Boeing 737-300sand two Boeing 737-700 aircraft and has undertaken over 21,000 sectors without anyevent of this nature.

Follow up actionThe aircraft manufacturer, Boeing Airplane Company, has been notified of the failure.The airline has undertaken a full inspection of its aircraft fleet to ensure that no similardefects exist. There is no requirement from Boeing or the UK Civil Aviation Authority toreplace the failed component on the aircraft as part of routine maintenance checks,but the airline is formulating procedures to replace these during each annualoverhaul of the aircraft as a precautionary measure.


INCIDENT 1 - PAX LETTER

‘Probably about 30 to 45 minutes into the flight we were told to fasten our seatbelts, put ourseat backs upright etc as we were about to experience some turbulence. On obeying theseinstructions the plane seemed to almost hit a brick wall then drop.

Just at this point the O2 masks deployed and the a/c began a very steep descent. To beperfectly honest, I, my wife and the rest of the pax thought we were going down permanently.The steep descent seemed to go on for an age. The sight of a stewardess with a look ofsheer fear on her face and tears in her eyes did nothing to calm the mood on board. Webelieved we were going to die!!

At no point during this steep descent did any crew member offer any support to us! It wasevery man for himself! Eventually the plane levelled off but again no information was given topax until a very shaky captain/FO told us that we were diverting to Charles de Gaulle to ‘findout what the problem was.’ Then the next piece of information that was offered was that ‘nowe are not diverting to CDG but we are diverting to OLY instead.

Why did this person not try to offer some explanation for what was happening? Even asimple explanation like ‘don’t worry, the engines are fine, it just appears to be a problem withthe cabin pressure.’ No we were kept in the dark and made to suffer in silence. Noinformation. No information. No information.


INCIDENT 2 - PAX LETTER

Dear sir/madam, We were passengers on flight ABC123 which had to emergency land in France on Friday. Whilst the experience was extremely distressing, we would like to thank the captain & crewfor their professionalism during the incident, when they were clearly distressed themselves.Their support was exemplorary, particularly the way they managed to look after everybodyonce we had landed. Special thanks to the pilot, who got us down safely & then for talking to us individually duringour time at Brest airport. We hope it hasn't put the young cabin crew staff off flying again! They were all fantastic &should be proud of the way they conducted themselves. Thanks also to the crew of the 757 who rescued us & brought us home safely. They made usfeel a lot more at ease than we ever expected to be. Please keep us informed regarding the cause of the emergency & once again well done to allconcerned!


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