LeadershipUnderPressureCaptainRichardChampiondeCrespigny

QF32

On4November2010,anA380AirbusdepartedSingaporeforSydney.Astheaircraftclimbedover

Indonesiathereweretwoloud“booms”.TheNumber2enginehadsufferedarareexplosion;thefirst

ofit’skindinover40yearsand200millionhoursofoperatingRollsRoycejetengines.

Shrapnelfromthedisintegratingenginecutmorethan600wiresandleftmorethan100impactsinthe

wing,about200impactsonthefuselageand14holesinthefueltanks.Electricalandcontrolsystems

wereseverelydamaged.Twootherengines,inadditiontothedestroyedone,wereoperatingbelow

capacity.Fuelwasstreamingfromthewing.

DeCrespignyandhiscrewfacedan

aircraftthatwasbarelycontrollable.The

computerisedflightsystemcontinually

bombardedthemwithchecklistsand

alarms.Theymanagedtostabiliseand

thenlandtheseverelydamagedaircraft

withnoinjuryorlossoflife.Whilede

CrespignysaysanyQantascrewwould

havebeenjustassuccessful,noonehas

sincebeenabletoduplicatetheirlandingonasimulator.CaptaindeCrespignyinhisbookandvarious

interviewshighlightsanumberoflessonsforleadersunderpressure.

Lesson1.ThenuancesofCrewResourceManagement(CRM)

Crewresourcemanagementisanairforceconcept.DeCrespignyhasextensivemilitaryexperience

pilotinglargeaircraft.Asresult,healwaysmakesapointofveryclearlinesofauthorityanddelegation

amongtheflightcrew.DeCrespignywasundergoinganannualassessmentofhisskillssotherewere

twoadditionalpilotsonQF32:acheckcaptain,HarryWubben,andaseniorcheckcaptain,David

Evans,supervisingWubben.Withfirstofficer,MattHicks,andsecondofficer,MarkJohnson,there

werefivepilotsintotal.

DeCrespignypaystributetohiscolleaguesandsaysthesuccessfullandingwasateameffort.Buthe

makesthepointthatateamneedsaleader.‘Theflightdeckisnotacommittee’,hesays.

Thepilotincommandhasultimateresponsibilityfortheaircraft.Theirseatiswheretheproverbial

buckstops.Butatthesametimecontrolisoftenbestexercisedthroughdelegation.

LeadershipUnderPressureCaptainRichardChampiondeCrespigny

QF32

InthebookQF32deCrespignywritesofhisstandingordertothepilotsinthesecond-rowseats,‘Ifwe

areallupfrontlookingdown,youlookup.Ifwearealllookingup,youlookdown.’

Theever-shiftingbalancebetweenauthority,delegationandconsultationmeantdeCrespignymade

manydecisionshimself,andconsultedtheentirecrewwhentherewastime.

Lesson2.Theclichéistrue:aviate,navigate,communicate.

ThecrewofQF32wasfacedwithanunprecedentednumberofchecklistsfromtheA380’selectronic

centralisedaircraftmonitor(ECAM).DeCrespignyestimatesthereweremorethanahundredand

twenty.

‘Weweregettingchecklistafterchecklisttellinguswhatwaswrong.Ittookusanhourtoknowwhat

allthethreatswere—thenwehadtomitigatethem.’

Despitethis,thecrewadheredtooneofaviation’smosthallowed(andwise)clichés:‘aviate,

navigate,communicate’.Itmeansthefirstpriorityistokeepcontroloftheplane(Aviate),then

knowwhereyouare(Navigate),thenyoucanmakeradiocallsandcabinannouncements

(Communicate).

‘Every10minuteswereassessedthefuelandwhetherweshouldcontinuedoingchecklists,orignore

thechecklistsandjust(somehow)gettheaircraftdownontheground.Wealldiscussedit’,saysde

Crespigny.

‘Withthreatanderrormanagementyouhavetofixtheproblem—ormitigateforitsloss.It’sasee-

saw:iftheaircraftwinghadbeenonfireIwouldhaveputitstraightonthegroundorintothewater.

Butwedidn’thaveawingfiresowehadmoretime–buthowmuchmoretime?There’salsoathreat

oflandinganaircraftinanunknownstate…Ithinkifwehadthrowntheaircraftdownstraightaway

peoplemighthavedied.’

‘Nochecklistwasactionedimmediately,’deCrespignysays.‘Wediscussedeverything.Weweretrying

toassessthethreatandeitherfixit,orworkouthowwewouldmitigateit.’

DeCrespignyadmitstoreachingtasksaturationinthemidstofthischaosuntil(asheputsit),"..Ihad

myepiphany.Mymindswitched.Iinvertedthelogic.IrememberedwhatGeneKranz,NASA'sFlight

Director,saidduringtheApollo13mission:'Holdit!Idon'tcareaboutwhatwentwrong.Ineedto

knowwhatisstillworking...'Wewentbacktobasicsanditbecameeasy..."Thecrewbeganignoring

checklistsinfavourofconfirmingwhatwasstillworking.

LeadershipUnderPressureCaptainRichardChampiondeCrespigny

QF32

AhabitfromdeCrespigny’smilitarycareerasserteditselfastheypreparedtoland.Heinsistedona

controlcheck.‘It’sbredintotheairforcepsyche.Wedidadressrehearsalofthelandingat4000feet.

Ifwehadbeenlosingcontrolwewouldhavespedupandbroughttheflapsuponestep.Aswelanded

wegotspeedandstallwarnings,theywerecertainlyunexpected—butdeepdownIknewtheaircraft

wouldflybecausewe’dpracticedthelanding.”

Acontrolcheckisnotusualincivilianflying.Themilitarydoittocheckthatacombatdamagedplane

willflyasexpected.Thechecksassuredthecrewthattheplanewouldbestabledowntotherunway.

Runway20CatSingaporeis4,000meterslong.Thecrewhadcalculatedthatinitsdamagedcondition

theA380wouldneed3,900meterstostopifthePilotexecutedaperfecttouchdown.Capt.de

Crespignydidjustthatandgottheaircraftstoppedjust150metersshortoftherunway'send.

DeCrespignyisanenthusiastforallAirbusaircraft,buthesaysautomationcanmakeitmoredifficult

forpilotstohonourthecommandtoalwaysaviate.

‘Flyingisgettingmuchharderbecausethereissomuchmoreautomationandmanymoresystems.

TherearefourmillionpartsinanA380.Manufacturersmaysayautomationmakesflyingeasy,butI

maintainthatifpilotsaretorecoveranaircraftfromanunimaginablepositiontheystillneedtohave

detailedknowledgeofthataeroplane.’

Lesson3.It’snotoverafteryoutouchdown

WeeksaftertheeventdeCrespignyfoundhimselfweeping,forthefirsttimesincehismotherdied

decadesearlier.HeweptwhilerecountingtheeventtoATSBinvestigators.Therewasanotherboutof

tearsandasix-hourcartripwherehehardlyspoketohiswife,Coral.Insteadhewentoverandover

theflightinhismind.DeCrespignywasconfrontingpost-traumaticstress.

‘Pilotswhohavetheseincidents…we’veneverbeentoldwhattoexpect,nobodyaroundusknows

howtohandleusandwe’retotallyblindastohowouremotionsareaffectingourlivesandourwork,’

hesays.

‘Evenforpilotswhothinkthey’reOK,thestresstheythoughttheywerehandlingcanre-emerge.’

‘Iinsistedthatitgointhebook.I,andallmalepilotsarealphamales;wethinkwe’reindestructible.

Whensomethinghappenswethink“let’stoughenupandgetthroughit”.’

DeCrespignyinstinctivelyknewitwasmorethanaquestionoftougheningup.

LeadershipUnderPressureCaptainRichardChampiondeCrespigny

QF32

IwasscheduledtotakedeliveryofabrandnewA380threeweeksafterQF32.Icalledupmymanager

andsaid,“IamnotinaconditiontoassesswhetherIamsafetofly.Youhavetotakemeoffthistrip.”

ItturnsoutIwasn’tinafitstateatall.IwassopreoccupiedwiththeaftermathofQF32.’

HevisitedaviationpsychologistRonZuessmanwho,withabluntnessappropriatetohisspeciality,said:

‘Iknowpilots:what’syourproblem?’

ZuessmanexplainedhowdeCrespigny’stearswereadelayedexpressionofthestresshefeltduring

theemergency.‘Hesaid,“revisitit,keepdoingit–itwillgoaway–ifyoudon’trevisititthenitwill

staythereinyourmindforever,andeverytimeitre-emerges,itwillbejustaspainfulasitwasthe

firsttime.”‘Iwentaway,thoughtaboutitandrealisedthecryingwasjustnatural’.

ZuessmanthenstartedworkingonwhatdeCrespignycalls‘theloop’—hisendlessmentalreplayingof

theflight.

‘DoadealwithCoralthatyou’llstayintheloopforenoughtowritedownallthedetailsoftheflight

fortheinvestigators.AfterthreeweeksI’llteachyouaprocesstogetoutoftheloopandstart

forgetting.’

Themethodwassimple,buttookadvantageofrecentresearchonbrainfunction:‘JustasI’maboutto

serveinagameoftennisIthinkQF32’,orwhenI’mmowingthegrassIsuddenlythinkQF32,de

Crespignysays.‘Anythingthatneedsintenseconcentration,IthinkofQF32.It’sawayofmakingnew

synapseconnectionsandbreakingtheolder,post-traumaticstresssynapseconnectionsinmybrain.’

‘IntheweeksbeforeIreturnedtoflyingIwaslookingupwheneveranaircraftwentover:Iwasready

fornormalflyingduties.I’mbackflyingnow.I’msane,contentandnotafraidofanythingbecauseI

tooktimetohandlethePTS.MostimportantlyI’mnotafraidoftheaircraft.Mymessageinputtingthis

longdescriptionofpost-traumaticstressinthebookwastoletothersknowthattheseissuesarereal

andthattheycanbefixed.’

Sourcedandadaptedfromhttp://n631s.blogspot.com.au/2013/07/book-review-qf32-by-capt-richard-de.htmlandhttp://n631s.blogspot.com.au/2013/07/book-review-qf32-by-capt-richard-de.htmlandhttp://www.flightsafetyaustralia.com/2016/03/qf32-and-the-black-swan/