Chapter Twenty Eight
“Konnie, what is the point of calling this group together if the data on the CVR and DFDR tapes doesn’t exonerate the pilot from culpability in the crash?” Wayne took a seat at the conference room table.
“This is not the tape we think will change the minds of a jury.”
“You’ve got another tape from the crash?”
“Not at all.”
“It’s a totally different tape,” Gail said.
“From where?” Wayne asked.
“From captain Jakyll’s last training session,” Gail informed him.
“From his training session!” Wayne exclaimed. “I’ve never heard of such a thing being admitted in a court of law.”
“Exactly,” Konnie grinned.
“What relevance could a training tape have to the cause of the crash?”
“Everything,” Gail said.
“Let’s not be too hasty here, Gail,” Konnie suggested. “Let’s allow the counselor to decide for himself the relevance of this information.”
“Glad you could join us, Mr. Johnston,” Gail acknowledged Dirk’s return.
“Hey, you asked if the air traffic controller you heard on the tape would be willing to cooperate with us on this investigation,” Dirk said. “I was just talking to him on the phone . . .”
“And what did he say?”
“He said . . . ah . . . absolutely.”
“Outstanding!” Konnie knew that the insights from the air traffic controller would only enhance their efforts to prove that this crash was not simply another case of pilot error.
“So can we get to this mysterious training tape?” Wayne asked. “And by the way, can I use this descent profile chart as one of my exhibits?”
“We can provide you with a much better reenactment of the descent profile than this,” Gail replied.
“And what would that be?”
“We have the ability to duplicate the information on this chart in a rather new technology that simultaneously displays the indications of the flight instruments as seen by the flight crew, along with a three dimensional image of the aircraft as it maneuvers during the approach.”
“So,” Wayne said, “you could provide me with an audio visual presentation that accurately links the conversations on the CVR with a real time reenactment of the aircraft as it maneuvers for a landing?”
“Absolutely!”
“I’m beginning to see some potential for your proposal here,” Wayne confided. “Now what about this training tape?”
“Let’s direct our attention to the screen on Gail’s laptop,” Konnie requested.
Gail inserted a disk and began the video of captain Jakyll’s last training session at Consolidated Airlines. The image on the screen was in black and white, rather grainy in nature, and poorly focused. “The quality of the tape is due to the fact that it is shot in the very low light conditions of a simulator flight deck. In order to produce a satisfactory visual image for the pilots looking out of the windows of the simulator, a very dark flight deck environment is required. A special S-VHS camera is utilized that reproduces a visual image not unlike the night vision technology the military utilizes.”
“How is it that you have this video?” Wayne inquired. “I’ve been practicing aviation law for quite some time, and have never heard of evidence like this being introduced.”
“And this will probably be the only time you ever will,” Gail matter-of-factly replied.
“And why is that?” Dirk interrupted.
“We, like all other air carriers, have an explicit agreement with our pilots that video footage of their training sessions will only be utilized for debriefing purposes immediately after the training session, and will then be erased.”
“So why wasn’t this tape erased?” Wayne asked.
“It was brought to me after the training session by the Check Airman that administered the LOFT to captain Jaykle.”
“LOFT ?” Dirk asked.
“It’s an acronym for Line Oriented Flight Training,” Gail explained. “It involves a simulator training scenario that takes place in a real time flight environment. In other words a crew starts out at the gate at one airport and flies to another. The important factor to keep in mind here is that this is classified as training. As I was saying, the Check Airman was so concerned by the behavior of the captain during the training session that he wanted to bring it to my attention. He felt very strongly that something should be done to address the issues that you are about to see on the video. I thanked him, and assured him that I would look into his concerns. He made me promise that I would not mention to anyone that he had shown me the video, and more importantly that I would erase the tape.”
“Which you didn’t do,” Dirk chided her.
“Actually, I did. But not before I transferred it to the disk you are viewing now.”
“And what makes you so sure that this type of evidence will never be made available for legal proceedings in the future?” Wayne inquired.
“Because once the word gets out that we kept a LOFT tape and used it in court, I can guarantee that the plug on every video camera in every simulator in the free world will be pulled! Why don’t we just watch the video, and I think that will lend some perspective to both my actions and your questions. This video segment begins with the flight already descending for an approach into Wilkes-Barre Scranton, Pennsylvania. The LOFT scenario departed Columbus, Ohio. The flight time is quite short, and requires the crew to safely and efficiently transition from the high task loading environment of a terminal departure to the terminal arrival phase of flight.”
“Perhaps you should elaborate a bit on the term ‘task loading’ and it’s relevance to flight safety issues,” Konnie suggested to Gail.
“Task loading refers to the relationship between how many tasks a pilot has to accomplish and the available time he has to complete those tasks. One of the objectives of LOFT is to create a flight scenario where you not only evaluate the crew’s compliance with SOPs in a normal operational environment, but also address the crew’s propensity to commit errors as they become rushed while attempting to deal with both normal and non-normal situations that might occur during a flight. Takeoffs and landings are by far the busiest or highest task loading phases of flight for crews. If an aircraft malfunction or non-normal event occurs during these phases of flight, the potential for an operational error to occur is greatly increased. LOFT scenarios are designed to expose crews to realistic situations such as these, and let them consider how best to deal with these extremely challenging circumstances. The Wilkes-Barre airport presents flight crews with unique challenges. The terrain is mountainous. Any deviations in altitude or approach tracking can put the aircraft dangerously close to the mountains. Precise understanding of approach procedures is essential. In this scenario we create several realistic events that could cause the crew to commit errors while attempting to accomplish this approach. For example, we have the air traffic controller keep the aircraft at cruise altitude too long, making it difficult for the crew to descend for the approach. We then increase the task loading by changing the runway at the last minute, forcing the crew into a rushed situation to prepare for the new approach. While this is going on, we fail the primary flight instrument the captain is utilizing to ensure the aircraft is maintaining the correct flight attitude. He must recognize this failure, and transfer control of the aircraft to the first officer. The first officer must then immediately assume control of the aircraft and continue the approach. Due to very strong crosswinds, the approach controller does not vector the aircraft to the final approach course correctly, resulting in the aircraft being excessively high on the descent path. The first officer must recognize this as the captain no longer has accurate flight guidance available to him. The correct course of action is to discontinue the approach, and come back around for another approach.”
“My lord, Gail,” Konnie said. “What sort of masochist do you have designing your LOFT?”
“I thought the same thing when our LOFT design team brought this proposal to me,” she confided. “When I asked them why they designed the scenario this way, they said they didn’t. The LOFT was based on events that actually transpired on one of our charter flights into Wilkes-Barre. I argued that I thought the task loading was far too excessive, but they commented that it was only for training purposes and not for an evaluation. I had to agree. If there are no further questions, I’ll start the video.”
The screen on the lap top darkened, and the image of two figures seated in a dimly lit cockpit appeared. Even though the camera angle was from above and behind, the image of the deceased Don Jakyll occupying the captain’s seat had a sobering effect on everyone.
“Don, the new heading is zero six zero,” the first officer informed the captain in an effort to point out that he had not turned to the new heading assigned by the controller.
“I’m in the turn, but it’s not . . . something’s wrong with my ADI.” Don discovered his primary flight attitude instrument was malfunctioning.
“We’ve got a comparator light. According to the standby indicator yours is the one that’s failed,” the first officer determined.
“The comparator system constantly monitors and compares the indications between the captain’s and first officer’s primary flight instruments,” Gail explained as the video continued to roll. “If there is a significant difference between any of the monitored instruments, a warning light will illuminate.”
“Damn, what else can go wrong!” Don exclaimed in an increasingly agitated tone. “You take the airplane. I’ll work the radios,” Don directed the first officer.
“I have the aircraft” the first officer responded. “B channel of the auto-pilot is coming on.” He engaged the auto-pilot associated with the first officer’s flight instruments.
“O.K., you fly, I’ll brief,” Don instructed the first officer as he began to review the pertinent details of new instrument approach procedure they would soon accomplish.
“I don’t have my plate out yet,” the first officer responded indicating that he had not removed the approach chart from his manual, and would therefore not be able to monitor the briefing to ensure the information was correctly reviewed.
“Don’t worry. I think after three decades of flying, I can brief an approach correctly.” He sarcastically rebuffed the first officer’s attempt to comply with company procedures for briefing an approach. “I’ll set your stuff up for you.” He indicated he would tune the first officer’s radios for the approach as well as his own. “The frequency is one oh nine nine, the course is two twenty five, the DH is eleven eighty three, and the MSA is four thousand,” Don began his hurried approach briefing. “Anything to add to that?” Don rhetorically inquired to give the first officer the chance to correct any of the information.
“Not a thing,” was all the first officer could reply since he had never been given a chance to access his approach plate, and therefore had no clue if the information Don was providing was accurate.
“Consolidated one twenty three, turn left three three zero, descend to four thousand, and reduce your speed to one hundred ninety knots,” the approach controller instructed.
“Left to three four zero, down to three thousand, and slow to . . . what was that speed again?” Don responded.
“Negative one twenty three. That was left to three three zero, descend to four thousand, and the speed was one ninety.” The controller corrected Don’s erroneous readback.
“You can tell from Don’s intonation and error in reading back that last clearance that he is making operational errors when subjected to increased task loading,” Gail said.
“So he makes mistakes when he gets rushed,” Wayne replied. “We all do that.”
“I agree. But I think you’ll see that the ramifications of his ‘mistakes’ can be disastrous.”
“So how do we take your conclusion and connect that back to a training liability on the part of the company?” Wayne asked.
“That the whole point of this meeting today,” Konnie interrupted. “We can demonstrate beyond a reasonable doubt that this captain’s ability to safely operate an aircraft is significantly diminished when he encounters increased task loading or stressful situations. I further suggest we can demonstrate that an industry standard for dealing with these pilot performance deficiencies exists, and that Consolidated Airlines is fully aware of these standards and willfully disregards them. They are therefore liable for the actions of this pilot as a result of failing to properly train him.”
“And who are we going to get to testify that the airline is aware of these performance standards, and willfully ignores them?” Wayne asked.
“I will,” Gail replied without hesitation.
“You mean you are willing to testify in a court of law that the very department that you are in charge of is intentionally negligent?”
“I’m hoping you can control the questioning so that I a come off as a ‘whistle blowing good guy,’” Gail suggested.
“Oh, I can make you appear to be a saint with the noblest intentions, but I can’t promise that of their attorney.”
“I’ll take my chances.”
“And I can assure you of my full cooperation as an outside expert witness to corroborate her testimony,” Konnie offered.
“That will be immensely helpful,” Wayne replied. “But do you really think there is a training solution to what we have seen here so far? And do you further believe that we can show a valid curriculum exists to change the behavior of this pilot in what you call ‘high task loading’ situations?”
“Absolutely,” Konnie replied without hesitation. “Let’s continue the video, and I think it will become clearer to all of us.”
“Left to three thirty and down to four,” Don replied to the controller’s clearance.
“Damn, I hate sitting over here without being able to tell if we’re right side up or not.” Don complained about the failure of his attitude indicator. “Don’t screw this approach up,” he cautioned the first officer.
“After that briefing you gave, I just might,” the first officer responded. “Do you mind if I get my approach plate out now so that I have some clue as to what this procedure is supposed to look like?”
“Don’t get smart with me,” Don snapped back. “I told you how the procedure was to be flown, and of course I expect you to get your chart out. I’ll watch the airplane while you find it.”
The first officer could be observed reaching down by his right knee to retrieve the leather bound seven-ring binder that contained the approach chart for runway 22. Even though the simulator camera displayed his image from behind in the dim light of the nighttime flight deck, it was obvious from his body language that the first officer was none too happy with Don’s demeanor. As he was opening the binder, the approach controller issued a new clearance to flight one twenty three.
“Consolidated one twenty three, turn left two five zero, maintain three thousand until established, you’re cleared for the ILS two two approach,” the controller instructed as he issued the clearance for the approach. From here on out, the navigation to the runway would be strictly the responsibility of the pilot flying the aircraft. Don could be observed leaning over the center radio pedestal of the cockpit to watch the flight instruments of the first officer as his were inoperative.
“He cleared us down to three,” Don announced in a tone that continued to increase is its level of anxiousness.
“Don, I heard the damn clearance,” the first officer retorted in a tone indicating he had taken just about all the verbal abuse he was willing to take. “Look, it’s dark, there’s mountains all over the place here, and we’ve got a forty knot cross wind up here. I’ll just stay at four thousand until we pick up the final approach course, and then follow the glide slope down . . . if that’s O.K. with you.”
“Fine!” Don snapped. “But keep an eye on that glide slope. I can’t see yours from over here, and I don’t know if mine is working or not.”
“Whatever,” the first officer could barely be heard to utter under his breath. “I’ve got the localizer now,” he announced more clearly. “I’ll just wait for the glide . . . what the hell . . .?”
“What?”
“The glide slope’s pegged full down!” the first officer announced. “I was looking for it to come down from the top, but it’s full scale down!”
“Stop the video,” Dirk requested. “What’s all this panic over this glide slope thing?”
“Normally the aircraft is vectored for the approach in such a way that it approaches the glide slope from underneath the normal descent path to the runway. In this scenario, the Check Airman is supposed to bring the flight onto the approach course slightly above the glide path at an altitude of three thousand feet. If the crew recognizes this situation quickly enough, they should have no problem correcting their descent rate to safely establish the aircraft on the correct descent path to the runway,” Gail explained. “However, the first officer elected not to descend from four to three thousand feet. By the time he intercepted the localizer which provides the lateral alignment to the runway, he was so far above the descent path that the glideslope indicator was deflected full scale down. In other words, he had no way of knowing how far above they glide slope he was, because the indicator was at its limit.”
“So this must be a bad thing,” Dirk surmised.
“Yes and no. It’s not unheard of for this to happen in the real world. However it is not the sort of thing we would design into a training scenario. But in this case, the crew did it to themselves by not complying with the controller’s clearance to descend correctly.”
“So what should they do now?” Dirk asked.
“As we say on the line, it’s all in the recovery.”
“Damn it! I told you to descend to three!” Don exclaimed.
“I’ll get ’er down,” the first officer replied. “Gear down, landing checklist.” The first officer excitedly commanded as he reached across the center panel and pulled the speed brake lever to the full aft position. Don’s arm could be observed reaching over and across the first officer’s to push the landing gear handle down. His voice could then be heard hurriedly reciting the landing checklist items.
“Consolidated one twenty three,” the controller’s voice said. “Are you going to be able to get down from there? I can give you a turn back around if you need it.”
“We’ll be all right,” Don snapped back into the radio. “Now get this thing down,” Don angrily commanded of the first officer. “More flaps, push the nose down—” He began to yell at the First Officer, but was interrupted.
“Don, you wanna fly this approach, or do you want me to?”
“You know damn good and well I can’t shoot this approach, I don’t have an ADI,” Don replied through clenched teeth.
“Flaps thirty then.” The first officer responded in a tone no less acerbic than Don’s. Don reached for the flap handle and placed it in the detent for landing.
“Don, we don’t seem to be catching the glide slope,” the first officer said nervously. “How far from the runway are we?”
“I’m showing six miles, and three thousand feet above the ground,” Don informed him.
“That puts us about a thousand feet above the glide slope,” the first officer replied. “Maybe we should take that vector back around for another approach.”
“I don’t want another vector,” Don shot back. “Now just push the nose down further and catch the glide slope.”
The first officer shook his head in disgust, softly uttered an expletive, and pushed forward on the control wheel. There was a brief period of silence, and then the first officer pleaded, “I’m really not comfortable with this. Let’s go around.”
“No, damn it. We’ve still got room to get down,” Don adamantly said.
There was a few moments of silence, and the first officer disgustedly announced, “Screw this! Go around!” His arm could be seen pushing the thrust levers forward to increase the engine power to a level necessary to begin a climb.
“No, damn it. We’ve still got time to get down.” Don reached forward to pull back on the thrust levers.
“Knock it off, Don.” The first officer pushed the Don’s hand away from the throttles.
“I said—” Don was interrupted by the machine gun-like rattling noise produced by the aircraft’s stall warning system.
“Firewall thrust!” The first officer advanced the thrust levers to the full forward position.
“Ah, I think that’s enough, guys,” the Check Airman’s voice could be heard on the tape as he leaned forward into view of the camera. “Why don’t we just take a break? I have the simulator. You guys just sit back and relax.” He pushed the appropriate buttons on his control panel to stop the simulator.
Gail depressed a key on her laptop, and the video image disappeared from the screen.