communication in aviation safety: lessons learned and ... - ASASI

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Manos (1981) found a positive relationship between communication and good flightperformance: “Overall, there was a tendency for crews who did not perform as well tocommunicate less, suggesting that as expected, poor crew coordination tends to result inmore marginal performance (p. 66).They also found that it was not simply the amount of communication that was importantfor effective crew coordination, but more importantly the type of information that wasshare. They found that the greater the information about flight status that was shared, thefewer errors there were in the operation of the flight. In addition the type ofcommunication ulilized also played a role: more inquiries, observations, andacknowledgements were also related to fewer operational errors, while poorcommunication, lack of understanding, and such specific communication behaviors asfrustration, anger, uncertainty, and embarrassment were related to higher operationalerrors (Foushee & Manos, 1981).Federal Aviation Administration (1997) notes that a lack of coordination among membersof the cockpit crew can lead to problems and emphasizes the importance of effectivecommunication to accomplish effective coordination. Taneja (2002) notes that lack ofeffective communication by aircrew continues to be the most causal factor in aviationaccidents. In his review of human factors in aircraft accident and incident investigations,Adams (2006) points to communication as one of the key factors leading to errors thattranspired because of poor crew coordination.Again, the cockpit crew is but one aspect of the aviation system. While criticallyimportant for the safety of any flight, they are not the only source of communication forproviding predicable behavior patterns or coordinating activity. The cabin crew is alsocharged with that task, especially when it comes to cabin safety. Burian, Kismukes, andBarshi (2003) posit the importance of communication and coordination during emergencysituations and as an example note that communication problems between the cabin andcockpit had negative consequences the evacuation of a flight into LaGuardia in 2003.Flight Safety Foundation (2003) indicates that poor communication can contribute toproblems during evacuation procedures. Transportation Safety Board of Canada (1995)reports several evacuations in which ineffective cabin crew communication jeopardizedthe chances of successful evacuations in several incidents:Effective crew coordination is crucial to a successful evacuation, but ineffectivecrew communication leads to ineffective crew coordination. As evidenced by theoccurrence data, poor crew communication may result in unnecessary injuries orfatalities and unnecessary exposure to risk for passengers and aircrew alike (p.20).Effective coordination between cabin crew and flight deck crew is also essential for thesafe operation of an aircraft. Since 9/11, effective communication from the cabin crew tothe flight crew is even more important. “The ‘sealed’ cockpit environment has increasedthe reliance on Flight Attendants for the transfer of vital information” (Callback, 2003,16
March). The FAA clearly states that effective communication between all crewmembersis a prerequisite for such coordination (Federal Aviation Administration, 1988). ASRSreinforces this point: “Flight attendants are an integral part of the aircraft crew and theirprimary responsibilities are safety related” (Callback, 2003). Rice (2001, May-June)suggests that better communication between cabin crew and flight crew have resulted infewer fatalities. Chute and Wiener (1995) make the tie between communication andsafety even more explicit:There are two critical safety obligations for the flight attendant. The first is toprevent accidents, primarily by means of conveyance of information regardinghazardous conditions to the flight deck. If the accident cannot be prevented, thesecond is to maximize survivability. Both roles require effective communicationbetween the two cultures (p. 15).There are a large number of reports that confirm the success with regard to safety ofeffective communication in the cabin-cockpit interaction (see, for example, Callback1999, August; 2003, March; 2004, February). Yet, the working and relationship andcommunication interaction between cabin crew and flight crew continues to be a vexingone. “Communication and coordination problems between cockpit crewmembers andflight attendants continue to challenge air carriers and the FAA” (Federal AviationAdministration, 2004, p. 15).Helmreich, Wiener, and Kanki (1993) and Kayten (1993) cite numerous examples wherecrew coordination problems and poor communication were contributing factors in severalaccident reports. Murphy (2001) conveys stories from flight attendants who felt that vitalinformation they tried to pass along to the cockpit was ignored. In their study of flightattendants and pilots, Chute & Wiener (1996) found cabin-cockpit communication to beineffective. Chute (2001) also maintains that cabin-cockpit communication is not alwaysnecessarily effective.In a report on evacuation procedures, the Transportation Safety Board of Canada (1995)indicated that poor communication between flight and cabin crew possibly jeopardizedsafe evacuations in several instances. Regarding one specific incident, the report statesthat:Inadequate communication between the cabin and the flight deck resulted in asignificant delay before the flight crew was aware of the existence and seriousnessof the fire and contributed to the fact that the evacuation was not initiated untilone minute 55 seconds following the rejected take-off (Transportation SafetyBoard of Canada, 1995, p. 19).Perhaps the two most dramatic examples, however, of safety problems due to poor cabincockpitcoordination and communication are the crash of the Air Ontario flight whiletaking off from Dryden, Canada on March 10, 1989 (Baker & Frost, 1994; Chute &Wiener, 1996; Merritt, 1995; Moshansky, 1992; Murphy, 2001) and the crash of theBritish Midlands flight on January 8, 1989 at Kegworth after taking off from London’s17
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Page 4 and 5: The Tenerife tragedy, the worst cra
Page 6 and 7: A B757 pilot shows that even when w
Page 8 and 9: good and "easy" visual approaches a
Page 10 and 11: proximity to Runway 09L. We felt th
Page 12 and 13: asked me my altitude and I responde
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Page 18: Heathrow Airport (Baker & Frost, 19
Page 21 and 22: NEED FOR FUTURE RESEARCH ABOUT COMM
Page 23 and 24: (2004) offers some general communic
Page 25 and 26: As important as specific topics nee
Page 27 and 28: REFERENCESAdams, D. (2006). A Layma
Page 29 and 30: Callback (2004, July). 298.Callback
Page 31 and 32: Foushee, H.C. & Manos, K.L. (1981),
Page 33 and 34: Analysis Report B2005/0118, ACT Aus
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