THE AIRLINE PILOTS FORUM & RESOURCE
Hurry-Up Syndrome |
| by Andre Ludovic -- Source: PIA Air Safety Publication |
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Take your Time!
Aviation's worst disaster, the terrible KLM / Pan Am accident at Tenerife, was due in great part to schedule pressure problems experienced by both flight crews. The Air Line Pilots Association (ALPA) conducted an eighteen month, three country investigation of this accident, with an emphasis on the human factors of flight crews performance, ALPA found that the KLM crew had strong concerns relating to duty time, specifically that they would be able to return to Amsterdam that evening and remain within their duty time regulations. They also expressed concern about the weather and its potential to delay the impending take-off. The cockpit voice recorder indicated the KLM captain said, "Hurry, or else it [the weather] will close again completely". Pan Am's crew was equally concerned with potential weather delays. They were detained for more than an hour due to the KLM flight crew's decision to refuel. The KLM aircraft and fuel trucks blocked the taxiway, thus preventing Pan Am's departure. These schedule related problems set the stage for the catastrophe that followed.
Hurry-Up Study
This review of the Hurry-up Syndrome is an adaptation of a research study in which 125 ASKS incident records that involved time related problems were studied. We define Hurry-up Syndrome as any situation where a pilot's human performance is degraded by a perceived or actual need to hurry or rush tasks or duties for any reason. These time related pressures include the need of a company agent or ground personnel to open a gate for another aircraft, pressure from ATC to expedite taxi for take-off or to meet a restriction in clearance time, the pressure to keep on schedule when delays have occurred due to maintenance or weather, or the inclination to hurry to avoid exceeding duty time regulations.
Errors and Incidents
Each time-pressure incident had a point where the error occurred (Point of Error Occurrence), and another point, either immediately or further downstream, where the result(s) of the error(s) actually manifested themselves (Point of Incident Occurrence).
Point of Error
A large majority of incidents (63 percent) had their origins in the pre-flight phase of operations.
The errors made in pre-flight and taxi-out often manifested themselves later, during take-off and departure. One reporter writes:
"...We were busy with checklists and passenger announcements, while changing to Tower frequency. [The] Tower cleared us for immediate take-off, and even though we had not finished our checklists, taxied our aircraft into position and started to advance the power for take-off. After about 1,000 feet of take-off roll, Tower cancelled out takeoff clearance... [We] asked the Tower why we had our take-off clearance cancelled ... the first officer said [that] we were not on the runway. At that point, I realized we had started our take-off roll on an active taxiway."
The next most common category for incident occurrence was the taxi-out phase. Errors can be made by one individual, or they can be made by the flight crew as a collective unit.
"... I am relatively new at this position as second officer. We had a tailwind which precludes reduced power [for take-off] in this aircraft, but they [captain and first officer] did not notice and I was so rushed that I did not back them up and notice. So we took off with reduced power. We were just in too big of a hurry to get everything down and do it correctly."
Errors of Commission
Sixty percent of human hurry-up errors are errors of commission. In the following example, the flight crew erred in not adequately examining the airport surface chart:
" Take-off was made from displaced threshold instead of beginning of paved runway. I feel some contributing factors were: Not studying airport runway chart closely enough to realize. We had an ATC delay and were at the end of our take-off release time..."
Errors of Omission
In 38 percent of instances, pilots made errors of omission. In the following report, the flight crew neglected an important element of pre-flight preparation - with annoying and unnecessary results:
"Got a pod smoke warning from central annunciate in cruise en route between Fresno and Ontario...Diverted to BFL...no evidence of fire...We found a placard, which showed the pod smoke detection system as deferred and inoperative. We were pressured to hurry, and in the process, failed to check the aircraft log prior to departure."
Various Schedule Pressures
FAA publication of on-time performance figures for air carriers leads to "keep-to-the-schedule" pressures for flight crews and other company personnel. Similarly, conducting quick turn arounds (typically for economic reasons), can also lead to schedule pressures for pilots.
ATC may contribute to the hurry-up mindset by requesting an expedited taxi or an intersection departure, by issuing a "clearance invalid if not off by... or other time-sensitive requirements (of course, ATC personnel are similarly under pressure to maximize traffic flow)." In this example, the flight crew clearly felt pressured by ATC:
" Our in bound aircraft was late arriving and upon receipt of our ATC clearance for our outbound leg, we were informed we had an xx:xx wheels-up time. Needless to say, we were rushed... about 100 yards before reaching the end of the runway we were cleared for takeoff on runway 12... taxied onto what (we) thought was 12R, but what was actually runway 17."
Predicting and Avoiding Hurry-Up Errors
Hurry-up errors appear most likely to occur in high workload operational phases, specifically in preflight and taxi-out. External distractions and schedule pressure are significant pre-disposing conditions, but why is that so in these but not in other flight phases?
Most flight phases of air carrier and commuter operations employ well designed standard procedures that are linear in nature - a given required task follows another required task. For example, in the take-off phase the application of power is followed by a check of engine performance or power, which in turn may be followed by a performance check at 80 knots, and V1, Vr, V2, gear and flap retraction respectively, depending on the particular aircraft and operator.
In contrast, duties in the pre-flight phase may be non-linear, i.e. there may be no logical or prescribed sequence. A pilot may need to deal with flight planning, weather information and changes, fuel loading, dispatch manifests and release, last-minute maintenance or MEL items, duty time requirements, or aircraft deicing at pretty much the same time. There may be no standard operating procedure (SOP) for assigning sequence or priority to these tasks, nor does one task necessarily or obviously require that another task be previously and correctly completed. Thus it may be easier to make an undetected error.
On the other hand, tasks or duties in the taxi-out phase should be linear, yet this was the second most common flight phase for error occurrence. It is possible that many flight crews have not cleanly transitioned from one flight phase to the next, and may be trying to complete pre-flight duties during taxi-out. Another thought is that pilots may experience difficulty in the transition from the non linearity of pre-flight activities to the linear duties of the taxi-out phase.
Returning to the issue of pre-flight activities, it may be appropriate to examine cockpit or crew coordination. In an in-flight phase where the flight crew is seated together with unrestricted capability for interpersonal communication, the practice of Crew Resource Management (CRM) is facilitated by physical proximity and access. In the pre-flight phase of operation, interpersonal communication may be degraded by physical separation of flight crew members, and by distraction from numerous external sources.
Recommendations
It is suggested that companies and flight personnel consider providing greater structure to preflight activities in order to reduce the frequency of time related errors. Similarly, when distraction and schedule pressure are seen to occur in this flight phase, a reasonable response is to slow down and carry out tasks in as linear a fashion as practical. Where time related presure is encountered from external sources, pilots may find it a good strategy calmly to explain the nature, probability and typical results of hurry-up errors to those who "apply the pressure".
Maintain an awareness of the potential for the Hurry-up Syndrome in pre-flight and taxi-out operational phases.
When pressures to "hurry-up" occur, particularly in the pre-flight operational phase, it is a useful strategy for pilots to take the time to prioritize their tasks.
If a procedure is interrupted for any reason, returning to the beginning of that task and starting again will significantly reduce the opportunity for error.
Practicing positive CRM technique will eliminate many errors. Effective crew coordination in "rushed" situations will catch many potential problems.
Strict adherence to checklist discipline is a key element of pre-flight and taxi-out task execution.
Defer paperwork and non-essential tasks for reducing the operational phase workload.
