Leadership Under Pressure -...
Transcript of Leadership Under Pressure -...
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/