Following is a rather interesting event where the PM/FO had to intervene to counter risky decision making by their PF/Captain. Since it is rather long, I have added paragraph numbers to facilitate debrief (From NASA ASRS report #1267985).
(1) We tried too many approaches and our closest alternate was unsuitable at the time we decided to deviate. We then had to deviate to a further alternate knowing that we would arrive with less than 45 minute reserve and critical fuel.
(2) My Captain did not plan a suitable alternate, and may have not researched weather despite those being his company delegated pre-flight tasks. I did not receive detailed weather briefing and deviation plan from the Captain. My Captain failed to give detailed approach briefing including visibility restrictions and deviation to alternate and had a lack of personal minimums. We may have been able to land on the first and second approach attempts but my Captain's instrument approach skills were extremely poor, resulting in full scale deflection and lack of descent rate after the FAF, so despite my advisories and attempts to correct the situation we were forced to go missed.
(3) I suggested after the first two missed approaches that we hold and assess fuel, deviation plans and weather conditions, but the Captain insisted on doing the procedure turn and attempting two more approaches. I was very distracted in my radio communications because my Captain had very poor CRM, doing many Pilot Not Flying (PNF) tasks himself without notifying or requesting that I perform them because of this he was not maintaining directional control and he was also attempting to turn for missed approach instructions before the aircraft was under control resulting in very unstable missed approaches. The two additional times we attempted approaches the weather was too showery and inconsistent, and despite receiving reports from the tower that visibility was above minimums, we did not see the runway on either approach.
(4) After four consecutive approaches we finally received a long climb and turnout from Tower for our missed approach instructions and had the chance to slow down and assess our situation. I immediately asked Captain for alternate options and requested weather for our alternates from tower. The closest alternate was low IFR and the weather we were experiencing was headed toward our alternate. I asked the Captain if we had enough fuel to deviate to farthest (second) alternate which was VFR. The Captain did not know. The Captain calculated the fuel to get there and reported could but with less than 45 min reserve. He still did not make decision to stay or to deviate.
(5) With weather still below minimums at current airport and 4 approach attempts failed and an inactive Captain, I demanded an immediate deviation to the farther (second alternate). I did not feel experienced enough or prepared to make the decision but felt at that point I had no other choice .... It was risky but at that point everything was. The Captain agreed to deviate. I requested immediate deviation from the tower and the Captain reported fuel critical and requesting priority handling. The Captain gained altitude for better fuel burn.
(6) Enroute we received a fuel low warning and the Captain did not call for QRH, so I suggested and followed QRH procedures (turning on the standby pumps). The Captain agreed. I brought up and discussed the possible scenario of engine failure due to fuel loss on approach with the Captain. The Captain decided to continue with both engines running. We briefed and discussed descent and approach in detail. My Captain decided not [to] declare emergency for fear of reprimand/paperwork. We landed with both engines running but without enough fuel to conduct a go around or missed approach. The deviation took over and hour and we had 25 minutes or less fuel for normal cruise when we touched down.
(7) I requested a post flight briefing with the Captain. I reported the details of the flight to Chief Pilot and Director of Operations (DO). I have confirmed plans to meet with the Chief Pilot and DO to discuss the details. The DO and chief pilot said they would speak with the Captain. I requested Chief Pilot give me and additional training session on actual planned alternates, fuel planning and applicable weather trends. I suggested planning materials be made more available to First Officers (FO) and that FOs should be encouraged to share that duty with the Captains.
(8) I resolved to practice a 2-approach personal minimum and only a second attempt if there are significant weather changes and if fuel generously allows. I resolved to memorize each route alternate choices and the minimum fuel for each so I know exactly when the last opportunity is to deviate, even if the captain does not, and lastly to take a much stronger stance on my responsibility to also route, fuel and weather plan and exercise full discipline in questioning the Captain when they are vague or omit details of planning and or weather.
(9) We received distracting and tempting weather updates from Tower that the visibility was increasing to "2 miles" again and "this was our only chance" just as crossing the final approach fix outboard (perfect timing for procedure turn and not for hold) which made the temptation of trying again hard to suppress. This helped contribute to the momentum of the situation resulting in four continuous approach attempts in the minimum amount of time. We failed to realize each visibility report from the tower was not accurate or if it was, they were, conditions were changing so rapidly we did not have time complete our approaches.
(10) This was the first time I was ever forced to go missed on a non-training flight, exercise personal approach minimums or deviate in flying career so though I had the right instincts I had a lack of insight on the overall situation and the experience not just to suggest, but to demand to hold and deviate earlier. The Captain had an attitude like he had to begrudgingly use the QRH I called for it after the fuel warning. He also harbored an attitude that everything was someone else's fault - it was the plane, or the weather or my fault as a new FO.
(11) My company has showed the attitude and specifically said in training multiple times that FOs are not responsible and do not need to be trained on routes, alternates, and fuel planning which are considered captains duties. This creates a poor attitude and culture for FOs. Captains briefing FOs on above topics was suggested but nowhere and no time stressed. Materials for actual routes flown, alternates used and fuel plans are either nonexistent or not readily available for FOs. Additionally, the Company has a reputation of protecting Captains who have received multiple serious complaints.
Discussion questions:
(A) Paragraph 2 outlines the FO’s complaints of lack of contingency preparation and poor pilotage by the Captain. Additionally, in paragraph 7, the FO relates that the Company didn’t supply training or planning materials to their FOs. This process appears to make FOs dependent on the quality of their Captains decision making. What are the safety holes in this Company’s procedures/culture?
(B) The poor weather and ATC-prompting led to the crew attempting 4 unsuccessful approaches. After 2, the FO suggested taking a delay to assess their options. The Captain chose to quickly try 2 more approaches (4 total). Clearly, the FO was becoming frustrated and unconfident in the Captain’s abilities and leadership. Additionally, the FO appeared concerned about the Captain’s increasingly risky choices. In paragraph 8, the FO relates some personal limitations that they planned to use in the future (only 2 approach attempts unless weather is improving). What can we infer about the FO’s mindset during this event?
(C) Paragraphs 4 and 5 tell a story of the FO trying to guide the Captain into making a decisive, safe decision. When the Captain remains indecisive, the FO “demanded an immediate deviation to the farther (second alternate)” despite the fuel risk (note: the closer alternate had similar (poor) weather like the destination). Coupled with their later comments, we can infer that the FO did not have ready “trigger points” to guide their interventions. In this case, it seems that the accumulation of factors tipped the scales enough that they demanded the diversion. Notice the social dynamic here. We can infer that the Captain was teetering between sticking with another try at the scheduled destination and diverting. The FO’s insistence seemed to be enough to trigger the diversion. Notice the hazardous situation created by mindset, wishful thinking, indecision, and crew discordance. What might have happened if the FO had not ultimately insisted on the diversion?
(D) In paragraph 6, we see how the Captain remained concerned about the “administrative consequences” of the diversion which led to their resistance to perform the QRH low fuel procedure or declare minimum or emergency fuel. This is fairly common in situations like this. What advantages would they have gained by declaring minimum fuel? Emergency fuel?
(E) Paragraph 8 reflects the advantages of establishing and rehearsing decision trigger points – in this case, the number of approach attempts and divert fuel. We typically fail to act decisively during real world situations when we haven’t set and rehearsed our trigger points. Otherwise, we revert to rationalization and plan continuation bias. What do you think of the FO’s resolutions?
(F) Paragraph 9 reports the outside factors that influenced the Captain’s decision making. ATC contributed to their wishful thinking by giving their optimistic forecasts. What can we do to temper the detrimental effects of outside forces?
(G) Paragraph 10 and 11 speak to the airline’s culture and the overall risk management mindset. If you were employed at this airline, how would you calibrate your risk assessment to manage the your decision making and assertiveness?
(H) We value the advantages achieved by a crew developing a shared mental model, capable leadership, and assertive monitoring pilots (PMs). How could this airline improve in these three areas?
Following is my personal analysis of the questions I posed (in blue). Please feel free to comment and add your voice to the discussion.
Discussion questions:
(A) Paragraph 2 outlines the FO’s complaints of lack of contingency preparation and poor pilotage by the Captain. Additionally, in paragraph 7, the FO relates that the Company didn’t supply training or planning materials to their FOs. This process appears to make FOs dependent on the quality of their Captains decision making. What are the safety holes in this Company’s procedures/culture?
A cornerstone of effective CRM is the process of building and communicating a shared mental model within the flight crew. Otherwise, we become dependent on perfect performance by a single individual – a standard that we can’t fully achieve or rely upon. When skilled Captains guide the process of building shared mental models, they acknowledge that a second set of trained eyes can detect conditions and vulnerabilities that they might otherwise miss. In Master Airline Pilot, I examine a host of biases that adversely affect our personal mindset. These biases become more powerful and debilitating as stress and complexity increase.
While Master Class Pilots are less susceptible, they are still vulnerable to their biases. We rely on the other members of our crew to shine the light of awareness into our blind spots. From this FO’s report, it appears that this airline provides planning materials only to the Captain. In this case, the Captain felt that the fuel load was adequate, given the forecast weather. Perhaps the FO would have offered a different opinion. Lacking an informed shared mental model, the FO appears to have deferred to the Captain’s game plan. Imagine if this FO wouldn’t have felt empowered to assert their opinion after the 4th unsuccessful approach.
(B) The poor weather and ATC-prompting led to the crew attempting 4 unsuccessful approaches. After 2, the FO suggested taking a delay to assess their options. The Captain chose to quickly try 2 more approaches (4 total). Clearly, the FO was becoming frustrated and unconfident in the Captain’s abilities and leadership. Additionally, the FO appeared concerned about the Captain’s increasingly risky choices. In paragraph 8, the FO relates some personal limitations that they planned to use in the future (only 2 approach attempts unless weather is improving). What can we infer about the FO’s mindset during this event?
We can envision this FO initially deferring to the Captain’s leadership. Following several unsuccessful approaches, we see the FO becoming increasingly concerned that the Captain lacked a viable contingency plan. Encouraged by ATC, the Captain might have continued attempting approaches until forced into an emergency fuel situation. This option became especially scary because of the Captain’s marginal pilot skills. Early, we might have labeled the FO’s mindset as hopeful. After a couple of failed approaches, they appeared to become deeply concerned. After the fourth approach, their concerns rose to the point where they became very concerned as they assertively “demanded an immediate diversion”.
(C) Paragraphs 4 and 5 tell a story of the FO trying to guide the Captain into making a decisive, safe decision. When the Captain remains indecisive, the FO “demanded an immediate deviation to the farther (second alternate)” despite the fuel risk (note: the closer alternate had similar (poor) weather like the destination). Coupled with their later comments, we can infer that the FO did not have ready “trigger points” to guide their interventions. In this case, it seems that the accumulation of factors tipped the scales enough that they demanded the diversion. Notice the social dynamic here. We can infer that the Captain was teetering between sticking with another try at the scheduled destination and diverting. The FO’s insistence seemed to be enough to trigger the diversion. Notice the hazardous situation created by mindset, wishful thinking, indecision, and crew discordance. What might have happened if the FO had not ultimately insisted on the diversion?
This highlights the importance of pre-considering, pre-determining, and pre-rehearsing trigger points. Many of us lack calm, reasoned, timely, and accurate thinking while we are immersed in stressful, time-pressured, and ambiguous situations. We perform much better when we perform these mental steps ahead of time. What’s more, the process exercises the mental processes of considering, determining, and rehearsing when we do it over and over again. Like performing an intricate physical task, we must practice regularly and creatively.
Next, consider the crew dimension. If this crew would have formed a shared mental model before departure, it would have included a plan for how many approaches would be attempted, which alternate would be appropriate, and the triggers/decision points that would govern each contingency option. Lacking this, the crew appeared to succumb to plan continuation bias until the FO insisted on diverting.
(D)In paragraph 6, we see how the Captain remained concerned about the “administrative consequences” of the diversion which led to their resistance to perform the QRH low fuel procedure or declare minimum or emergency fuel. This is fairly common in situations like this. What advantages would they have gained by declaring minimum fuel? Emergency fuel?
We can imagine this Captain’s mindset. After 4 unsuccessful approach attempts and an FO effectively threatening mutiny if they didn’t divert, they became motivated to protect their decision to divert and “stay out of trouble”. Acknowledging and declaring the emergency fuel situation would highlight their poor Captaincy. Ignoring “emergency options” had a way of softening the consequences of their earlier poor decisions.
The danger is that by not declaring minimum or emergency fuel, they effectively hoped that ATC would provide them with the most expeditious routing and most efficient diversion altitude. What if ATC would have started vectoring them normally within the traffic flow? They might have further exacerbated their increasingly critical fuel state.
(E) Paragraph 8 reflects the advantages of establishing and rehearsing decision trigger points – in this case, the number of approach attempts and divert fuel. We typically fail to act decisively during real world situations when we haven’t set and rehearsed our trigger points. Otherwise, we revert to rationalization and plan continuation bias. What do you think of the FO’s resolutions?
We could cynically call this “too much, too late”, but that would miss the growth aspect. The process of developing aviation wisdom involves both encountering and imagining difficult situations. Clearly, this FO has vowed that they will never let a Captain put them in a situation like this again. Their vow to attempt “only two approaches unless weather is improving” is a great starting point, but they need to understand that their next situational encounter will be different. Rigid rules of thumb tend to crumble under real-world environments. With wisdom, we develop sliding scales of risk tolerance and real-world complexity. The greater the complexity/novelty/uncertainty, the lower we need to set our risk tolerance threshold. In Master Airline Pilot, I recount a flight where I was the only flight to divert during a convective weather microburst event. It turned out that the crosswind event was short-lived. After my initial windshear encounter, I elected to immediately divert. Very early in my diversion climbout, ATC offered me the option of returning for an approach attempt. It probably would have worked, but the added factors of uncertainty, traffic saturation, and my narrowing fuel margin made continuing the diversion the safest choice.
(F) Paragraph 9 reports the outside factors that influenced the Captain’s decision making. ATC contributed to their wishful thinking by giving their optimistic forecasts. What can we do to temper the detrimental effects of outside forces?
As stated in the previous answer, we need to refine our ability to slide our risk tolerance threshold downward as complexity/novelty/uncertainty rise. Plan continuation bias is a constant threat within deteriorating situations. It is extremely important that we learn the right lessons from our close calls. Built-in safety margins allow us to mismanage situations and still achieve successful outcomes. If this leads us to learn that we can push borderline situations further, we can become blinded to the point where manageable situations crossover into failing situations. We know that there is a failure point, but we can’t accurately detect it while in-the-moment. It is better to transition to a contingency plan early instead of forcing our original game plan to the invisible point of failure.
(G) Paragraph 10 and 11 speak to the airline’s culture and the overall risk management mindset. If you were employed at this airline, how would you calibrate your risk assessment to manage the your decision making and assertiveness?
As an FO at this airline, I would take a proactive role in studying the weather and fuel load decision making by my Captains and Dispatchers. I would ask my Captains about their contingency game plans, when we would switch to them, what indications we should monitor, and how our crew roles would be managed. When conditions threaten failure, I would predetermine and rehearse my trigger points and the level of assertiveness I would apply to my callouts, when expressing concern, and ultimately, how I would intervene.
(H) We value the advantages achieved by a crew developing a shared mental model, capable leadership, and assertive monitoring pilots (PMs). How could this airline improve in these three areas?
This event should serve as a great learning opportunity for everyone at that airline. Upon learning about this event, the safety department could interview the crew and develop a training module that would benefit the future risk management and decision making of all of their pilots. They should focus their emphasis on the types and characteristics of indications that emerge along a real-world timeline. They could use it to encourage introspection and discussion to improve crew effectiveness in any situation that contains similar features.
