The Weekly Reflektion Week 26 / 2020

The Staines air disaster in 1972 remains the deadliest air accident (as opposed to terrorist incident) in the United Kingdom. The investigation found that it was the indirect result of an ongoing industrial dispute with BEA. The summer is often the time for the risk for industrial disputes to increase. We should consider the possible side effects.

Monitoring the psycho-social situation in an organisation is considered important, but are we conscious of the importance of the signals? If your organisation does not do this, maybe it would be a good idea. How do you look for signals?

Captain Stanley Key, a former World War 2 RAF pilot was the Captain of BEA (British European Airways) flight 548 from London Heathrow to Brussels on the 18th of June 1972. At the time, a pilot’s strike was under discussion, with the older pilots strongly against strike action, and the younger pilots just as strongly for the strike. Key was a very vocal member of the anti-strike camp. A group of 22 BEA Trident co-pilots known as supervisory first officers (SFOs) were already on strike, citing their low status and high workload. To help train newly qualified co-pilots, SFOs were told to occupy only the third flight deck seat of the Trident as a “P3”, operating the aircraft’s systems and helping the captain and the co-pilot. As a result of being limited to this role, BEA Trident SFOs were denied experience of aircraft handling, which led to loss of pay, which they resented. In addition, their status led to a regular anomaly: experienced SFO could only assist while less-experienced co-pilots actually flew the aircraft. This conflict situation led to a poor working environment on the flight deck.

Pilots were complaining that the inexperienced co-pilots they were being forced to fly with would be of limited use in an emergency, and several near misses indicated that they may have been correct.  Just prior to this flight, Key got into a quarrel with a co-pilot on the ground, described by an observer as the most violent argument he had ever heard. The relevance of this will become clear. Feelings were running high. The co-pilot for flight BEA 548 was 22 years old, inexperienced with his training schedule on the Trident not being completed. He witnessed this argument and seeing Key’s anger, it was speculated in the investigation report that this may have made him reluctant to challenge the pilot during the flight.

Another 3-man BEA flight crew had to travel to Brussels to pick up another plane, and the pilot from this crew was allocated the observers seat in the cockpit. The flight, with 118 passengers and crew, took off from Heathrow, but stalled 3 minutes after take-off, and crashed in Staines, beside the busy A30 main road, killing all on board. The lack of voice recording in the cockpit hindered the investigation in clarifying what happened during those three minutes, but a post-mortem on the pilot showed he had suffered a ‘potentially distressing arterial event’ brought on by high blood pressure, possibly as a result of the violent argument prior to take-off. This event was described as weak blood vessels within the fatty build-up in the arteries bursting, tearing open a piece of his arterial lining which would have caused distress or pain which could have affected his concentration or his judgement. It was thought ‘inconceivable’ that a pilot with his experience would have made the errors necessary to cause the stall situation and resulting crash. The co-pilot should have corrected these errors but did not. This was attributed to lack of experience, possible reluctance to challenge and possible distraction with passengers in the cockpit. Co-pilot training covered taking over from the pilot in case of collapse, but not in the case of subtle incapacitation.

The Trident aircraft were known to be susceptible to stalling, and a stall recovery system was in place to combat such an event, but it could “operate in an unconventional and unexpected manner” as noted in the investigation report. The stall recovery system had, on occasions, operated when it should not have done, and there were signals that pilots were commonly over-riding it. Amendments to the pilot training syllabus to cover these points were recommended by the investigation. Additional recommendations were made regarding a legal requirement for cockpit voice recording, and avoidance of personnel in the cockpit who do not have a flight function.

A poor working environment, or conflicts within an organisation or a team, can cause loss of focus on what is required to succeed. How do you monitor the working environment in your organisation, and possible conflicts or distractions in your team? There will be signals that when seen together and in context could give you an early warning of challenges.

Reflekt AS