Training is a topic for endless discussion in the aviation community, and for good reason. Accidents often point out gaps in training curriculums that allow hazards to grow with fatal consequences. Then, in a seemingly endless cycle of repetition, the act of closing those gaps develops new inadequacies as priorities are shifted to accommodate the existing training footprint.
Some aviation dangers, however, can never be directly addressed by training. These can only be overcome by the application of a vague set of skills commonly referred to as experience and “airmanship.”
So it was for the enhanced crew of Qantas 32, the Airbus A380 flight out of Singapore on Nov. 4, 2010 (See, “A Black Swan Event”). Their trial, triggered by the uncontained failure of the no. 2 turbofan’s intermediate pressure compressor disk, presented them with an avalanche of failures never envisioned by certification standards, and therefore, an untrainable event.
Capt. Richard de Crespigny commanded that flight, assisted by an experienced crew of two pilots, standard for that long-haul flight, plus a check captain and a check captain in training.
Confronted with a barrage of checklists and warning alarms, the crew divided up assignments and worked to understand, contain and ultimately control the situation to achieve a happy ending that really was outside the realm of experience, or reasonable expectation. “By any measure, QF32 was a success because of teamwork,” de Crespigny said, extending his praise to all involved, including cabin crew, air traffic control, airport crash fire rescue personnel and even passengers.
Discussing what his experience taught him about safety theory, de Crespigny initially said, “The Swiss cheese model is now outdated and, I would say, totally dead.” On reflection, he qualified that statement: “In black swan events, it has no application. The model is a fairly flat and constrained model.” It is based on the idea that, in the worst case, “a tiny failure will result in a few threats coming through,” he said.
“It is not designed for something like our event, a flood of problems, a flood of warnings,” a flood made somewhat more likely because “aircraft have become much more complicated. The Swiss cheese model does not apply when the cheese is overwhelmed and the water flows over the reservoir. It needs to be scaled to survive black swan events, and [human factors expert James] Reason admits it was not designed to be scalable.”
What does survive seemingly unsurvivable situations is not the result of simple rote repetition of scripted training routines but “stress-proofing practice. [You] have got to be bullet-proof, not gun-shy. Teamwork, CRM [crew resource management], experience with a level command gradient, now we truly get to a safer régime,” de Crespigny said.
Sadly, having resources in the cockpit and in other key safety positions capable of responding to such outrageous situations is a luxury not commonly available. Even in QF32 it was just a happy coincidence that gathered that team in that cockpit at that time. However, as the aviation industry continues to expand rapidly, we must be vigilant to not overlook the essential benefits of experience and airmanship. The system is designed to minimize the need for such extreme skills, but when needed, they are irreplaceable.