FINAL APPROACH DESCENT PHASE
CREW RESOURCE MANAGEMENT – BEFORE THE TERM WAS INVENTED?
Occurrence: Loss of hydraulic pressure suggesting need to shut down two adjacent engines (out of four) on a dark and dirty night.
Aircraft type: C130 Hercules ‘A’ Model
Location: East Coast of Australia between Melbourne and Sydney, 10 August 1967
Only two days before the incident described below I made my first solo route flight as captain, and on the next day I made my second, both completed before dusk. These tasks were described as ‘services’ in which these ‘A’ Model Hercules of No 36 Squadron, Royal Australian Air Force, were employed to transport army, navy and air force personnel, together with miscellaneous freight between various Bases. I was an RAF pilot on an ‘exchange’ posting, which is to say that back in the UK an RAAF pilot was enjoying a tour on an RAF transport squadron, both of us filling co-pilot slots. I had just passed my 26th birthday.
However, as the RAAF was at this time taking delivery of the up-market ‘E’ Model Hercules, several of the captains in our squadron were being moved across to join the new unit, which meant that No. 36 was in need of replacements. As I had spent some two years in the right-hand seat of the ‘A’ Model, albeit flying in both the left and right hand seats as required, for air tests and continuation training, it was thought that I could probably cope with a command on this type. Thus I found myself on the night of the 10th of August 1967 together with a co-pilot, navigator, flight engineer and loadmaster flying the second (northbound) leg of the Richmond (our Base just outside Sydney) – Laverton (outside Melbourne) – Williamtown (a Mirage fighter Base north of Sydney) – Richmond Service. Whereas my flights on the 8th and 9th had all been completed in daylight, this one was to be flown after sunset.
The first leg down to Laverton had been entirely normal, though we had noted the line of thunderstorms beneath us as we skirted Canberra, and the rain was fairly lashing down as we carried out the turnaround at Laverton before setting off for Williamtown.
For those of you who have never enjoyed a flight in the cargo compartment of a Hercules, let me explain that it resembles a large – and very capacious – truck. Passengers are seated along each side of the aircraft on skeletal/webbing seats, with their backs to the wall. There are few windows, but you get a good view of the folks opposite, of the cargo lashed to within a few inches of your feet, and of the ‘innards’ of the aircraft, by which I mean the flight control rods, the electrics and the hydraulic pipes and reservoirs. Due to the high ambient noise levels that abound once the four turbo-propeller engines have been started, voice communication is thereafter all but impossible. For this reason I clambered onto some cargo and briefed our passengers on the essentials concerning our route, time in flight, destination sequence, etc. leaving our highly professional loadmaster to address the safety features.
The Hercules cruised best at about 22,000 ft, and we were nicely established at that altitude, above the weather and approaching the half-way point when we received indications of loss of hydraulic pressure in the system powered by No. 3 and No. 4 engine engine-driven pumps (EDPs) on the right/starboard side of the aeroplane. I asked my co-pilot to fly the aircraft and the navigator to monitor him whilst the flight engineer and I went into the emergency checklist.
Now the checklist required the flight engineer to offload the two affected EDPs. ‘Offloading’ an EDP reduced its output to approximately 10% of normal – if there was still fluid in the system: it was not possible to physically isolate or to switch them off. If a pump started to break up due to total loss of fluid, the debris that resulted might possibly contaminate that particular system. At the worst, if the pump did overheat and disintegrate completely, it could damage anything around it including fuel lines etc!
Once the pumps were offloaded, the next step was to discover where the leak might be. If this could be isolated at one EDP, then the system might be restored once the engineer had topped up the hydraulic reservoir (we always carried cans of oil for this purpose) by reinstating the ‘good’ EDP. To address the risk of the faulty EDP breaking apart, the checklist required that the engine driving that pump should then be shut down (and the propeller feathered). One other thing:
hydraulic EDPs were all located on the right/starboard side of their host engine (looking from behind), which meant that any oil leaks coming from the pumps might not be seen.
So our athletic engineer (he had to be, to scale the cargo and access the reservoir) topped up the affected reservoir and returned to his seat between and behind the two pilots. He had briefed the loadmaster on what was occurring and got him to monitor our discussions on his headset via his long lead, and to report any evidence of fluid leaks around the undersides of the engines. At this stage, none had been observed.
The engineer then, having checked the reservoir contents on the gauge, reinstated the EDP on No 3 engine, whereupon hydraulic pressure returned for a brief instant then fell away whilst the contents gauge rapidly returned to zero. Could it be luck that had enabled us to identify the faulty pump first try? The next stage was for the engineer, having again offloaded the No 3 EDP, to return to the cargo hold and once again top up the reservoir, following which we would reinstate the No 4 EDP, shut down the No 3 engine and proceed with the problem nicely contained.
It was not to be, for when the No 4 EDP was reinstated, once again the pressure built for an instant before dropping off as the contents gauge returned to indicate ‘nil’. It appeared that both EDPs were now running dry, or with very little fluid in them, and I was faced with the question as to what to do next.
There was no checklist to cover our perceived situation, i.e. loss of both EDPs in one system. Should I shut down both No. 3 and No. 4 engines, should I keep one going and shut down the other, or should I keep both of them going? With one engine shut down, we would have to descend a couple of thousand feet, but could remain just above the tops of the thunderclouds, but with both secured, we would be right amongst the icing, the turbulence, the hail and the lightning – not a welcome prospect.
Now, although I thought I knew what I should do, I first put the question to our co-pilot, who was the least experienced although he had sufficient technical knowledge, and received his answer, before I turned to our flight engineer, whose previous experience as a Hercules airframe or engine mechanic well equipped him to make a sound contribution. Happily, they both voiced what was in my mind: shut down the No 3 engine but keep the No 4 going, remain above the tops of the clouds and search out a suitable airfield to which we could divert.
At this point, our navigator suggested that we should make for Richmond – our home base – since it was both the closest and the weather there was not too bad. Accordingly we declared an emergency and landed on three engines at what was then about 1030 at night.
My Squadron Commander came on board as the last propeller slowed to a halt and asked why I hadn’t shut down both No. 3 and No.4 engines! He didn’t wait for my response, but told me to see him at 1100 am the next day. Of course the thought now going through my head was, ‘Did I make the right decision? Should I have shut down both after all? When we had stopped on the ramp, I had been confident that I had managed the incident correctly, but now I really wasn’t so sure!
Well, it isn’t often that angels smile upon me, but they did the next day, for before I went before the boss, I saw that there was a newly-arrived paper amendment to the Dash-1 (aka Pilots Notes / Flight Manual equivalent) that contained A BRAND NEW EMERGENCY DRILL FOR LOSS OF TWO EDPS IN THE SAME HYDRAULIC SYSTEM! And what it said, crucially, was ‘Shut down only one of the affected engines’. So what my crew had advised me to do, and what I had taken the decision to implement, was vindicated!
QUESTIONS
1. If you were the aircraft commander, would you have done anything differently?
2. Do you ‘mug up’ on technical points only just before a routine check or training session, or do you make opportunities at other times to freshen up your knowledge?
3. Does your employer arrange for routine technical refresher sessions, where the lecturer can answer those questions that have been in your mind for some time but you felt a little too self conscious to ask training pilots? If not, could it be arranged?
WHAT CAN ONE LEARN FROM THIS?
1. When you see that a problem has arisen, get the crew to help you make decisions that will result in a successful outcome. You may know your own mind, but other professionals alongside you or in the cabin can almost certainly contribute positively to your knowledge and so better inform the decision you, as aircraft commander, must ultimately make.
2. In most circumstances that involve transport aeroplanes, you will have sufficient time to think the problem through before taking action that changes the nature of the flight, e.g. commencing a diversion, moving the aircraft from a
‘normal’ to an ‘abnormal’ state, etc. Think ahead: What if there should be a further deterioration in the aircraft state, causing the ‘abnormal’ state to become an ‘emergency’? Modern passenger-carrying civil aircraft have considerable redundancy built-in, whereby loss of one hydraulic system (of maybe three) doesn’t require an immediate diversion, but what if a second should fail? Where now will you divert to if you have elected to continue following loss of the first? (What precautions could I have taken to guard against sudden failure of and possible fire in the No 4 engine, which I had kept going?)
3. In my experience, about half of the serious in-flight problems I have encountered have not had drills in the
‘abnormal’ or ‘emergency’ checklists. To compensate, it is of some comfort to have a good knowledge of the aircraft and its systems, and to know where to turn for information when this is needed. Conversion training and routine competency/proficiency checks will never cover every eventuality. As happened to me, the first serious problem you encounter may come all too early after you have converted onto a new type or been given a command. Be prepared!
SITREP 17 – In the air & on the ground MEDICAL EMERGENCY
From a newspaper article by Claire Coleman - Daily Mail, 1 Aug 2006
Hundreds of thousands of people will be flying-off on their summer holidays in the next few weeks. For most, the greatest worry will be flight delays and, perhaps, lost luggage.
There is always the fear, of course, of succumbing to some ghastly travellers’ bug once you reach your destination. But we don't expect to be struck down on the flight itself and while the prospect of being trapped miles above-ground without professional medical help is daunting enough, when Caroline Clarke's husband fell ill on a long-haul flight, it was just the start of her nightmare.
The real problems began when the pilot decided to offload them in a notoriously dangerous African country, miles from any proper medical facility.
In April 2005, Caroline Clarke, then 57, and Philip, 60, were coming to the end of a four-month stay near Cape Town.
Caroline's mother was South African and they had spent many holidays there.
But about four weeks before they were due to return to the UK, Philip developed what he thought was mild ‘flu’.
'He had a headache he couldn't seem to shake off so he went to see the local GP, because in South Africa there's always a niggling worry that you might have been bitten by a mosquito and contracted malaria, says Caroline.
'The GP did various blood tests but they all came back-negative and he thought it was probably just a virus. Philip was always a very healthy person, very fit and active.'
However, on the day the Clarkes were, leaving, Philip was still concerned about his headache and went to the Doctor again. He was told he was fine to fly and in fact, the best thing was to get home then, if it didn't clear up, see a GP in Britain.
About three hours into the flight, Philip became very disoriented. He did not seem to know who or where he was. He kept trying to get out of his seat and up the stairs the back of the plane,' says Caroline.
'I tried to explain to him that we were on a flight back to London but he did not seem to understand. It was frightening and he became more and more difficult.
'An air stewardess took me off to have a coffee while one of her colleagues tried to calm Philip down. I just kept thinking he must have had a stroke.
'One of the crew put out a call asking if there was a doctor aboard and a Canadian GP came down and looked him over.
But she didn't seem to have any idea what was wrong with him.
Then the purser came out to say they had made radio contact with the airline's medical advisors, who suggested the plane land so that Philip could be taken to hospital as soon as possible.
The captain came along and said we were going to set-down in Nigeria in a place called Abuja,' says Caroline. As soon as he said Nigeria, I just thought: "Please, no,".
I had never been there and only knew what I had heard about the place. Not only was I frightened of going there, I instinctively felt that we would not find-the facilities we needed. But the captain was resolute and had already set course for Abuja.'
The plane landed at 3 am and when the paramedics came aboard, they suggested sedating Philip so the couple could fly on to London.
'But the pilot wouldn't listen,' says Caroline. He wanted us off the plane. So we were dumped on the runway with nothing but the clothes we stood up in, a mobile phone with almost no battery life, my wallet and our passports.
'Everything we had was in the hold and although the flight staff tried to find our suitcases while the plane refuelled, it was like looking for a needle in a haystack.
'We'd been told there would be Company’s ground staff available to help. There was a taxi waiting, but there didn't seem to be anyone else around.
'Immigration took away our passports, telling us we needed temporary visas to get into the country and after waiting for two hours we finally began what we'd been told was a ten-minute trip to the hospital.
'The journey was terrifying. The driver was going 80 mph along tiny roads and after 15 or 20 minutes we still had not reached civilisation.
'When we finally made it to the medical clinic we were shown into a room with two beds and I was told that I would be looking after my husband. Given the difficulty I had had restraining him up to that point, this was a terrifying prospect.
Caroline managed to contact one of her sons, who rang the British Consulate in Abuja. Meanwhile, Philip's condition was deteriorating.
‘He was increasingly disorientated and hyperactive,' she recalls. 'He kept dressing and undressing himself falling over and trying to escape; He wouldn't sleep and we were still no nearer a diagnosis. ;
Worse still, my fears about Nigeria had been proved right. The clinic gates were manned by armed guards and the Consulate warned me not to use any credit cards as the country was so corrupt that the safest way to buy anything was to use cash.
This became a problem when the clinic insisted that unless they received £1,000 by 5 pm that day, they would throw the couple out. The Foreign Office instructed the Consulate not to release the funds until they had received the cash in the UK.
‘So, on the Saturday of a bank holiday week-end, my sons in the UK were trying desperately to raise the cash and deliver it to a police station in time,' says Caroline. 'It was an absolute nightmare.'
To compound her problems, the couple's travel insurance had just expired. 'We'd extended our holiday and I'd forgotten to extend the insurance,' she admits. But I knew we had to get back to the UK as soon as possible and for that, the Airline we were flying with when we were off-loaded at Abuja, insisted that Philip be accompanied by a doctor.
The same demands for cash were made and amazingly, on the Sunday, her sons found the requisite £3,000 for the flights.
Caroline recalls: 'The cars that took us to the airport had guards with machine guns on board, which terrified me.
We had to tie Philip into the seat to keep him there on the return flight, arid on landing at Heathrow we were met by a private ambulance that my sons had chartered.
Once in Britain, a CAT scan showed Philip was suffering from a brain tumour that Caroline was subsequently told was inoperable. He died a month after their return from Nigeria.
'For months, I was too numbed by the shock of what had happened to think about trying to seek an explanation from the airline Caroline says. 'But everyone I spoke to was so horrified by the airline's decision to leave us in Abuja, that in January this year, I wrote to the Airline’s chief executive.
'What is the point of leaving a sick person in a place where there are no proper medical facilities and no nursing staff? No one else should have to go through the nightmare that we did.'
The European International Airline at the centre of this story says any decision like this is made based on advice from their tele-medical service. According to the Consumer Protection Group which is the passenger arm of the Civil Aviation Authority, the Carrier’s actions were within their guidelines.
'In the event of a passenger falling ill, the commander of the aircraft has every right to make a decision on where to land,' a spokesperson told Good Health. It is customary policy to make a decision to land at the nearest airport if practical.
Simon Evans, chief executive of the Air Transport Users Council, says that while the airline may have been acting according to
Simon Evans, chief executive of the Air Transport Users Council, says that while the airline may have been acting according to