Crm course 2010

The complete CRM solution
From new recruits to
experienced crew and senior
● Instructor Selection management, ITS can
provide a solution to your
● Instructor Training
CRM training needs.
● Course Materials And because the whole
● CBT Modules structure of our training is
modular, it is possible to
pick and choose from the
COURSE complete range of options
PREPARATION we offer, and buy into any of
the elements as outlined in

● Pilot the diagram.
● Feed training outcome
into course design REMEDIAL INITIAL CRM ● Cabin Crew CRM training is at its most

● Re-train crew TRAINING COURSES ● Maintenance effective if planned and
CRM ● Management
managed as a programme of
continuous development.

training cycle ITS is in a unique position to
● CRM instructor course
● Crew Courses assist in the management of
● Debrief skills course SIMULATOR RECURRENT this process and ensure that
● Integrated SEP/CRM
● Core course INSTRUCTORS CRM COURSES all your CRM requirements
● Instructor Courses are met efficiently and cost
● Integrated CRM effectively.

BEHAVIOURAL
MARKERS
For support with any of
these items, call ITS on
● Design BM Scheme +44 (0) 7000 251 252
● Create Grading System
● Train Assessors

www.aviationteamwork.com

The Total CRM Package: The complete CRM training solution
Instructor Training
Courseware
CBT Modules

ITS offers a range of courses, training
Initial Training Courses
materials and support services which Recurrent Training Courses
together form a complete CRM
Integrated SEP/CRM Courses
training solution.
Behavioural Marker Schemes
The modular format of our courses and CRM Assessment Training Courses
courseware, along with our ability to
SFI CRM Instructor Courses
analyse your particular needs, enables us
to tailor that solution to your precise
Debrief Skills Courses
requirements. Alternatively, we can Core Courses
provide a full consultancy service to
CRMIE Service
identify your specific needs, create an
appropriate CRM programme and assist
Course design and Support
in its implementation if required. For more information on any aspect of our
CRM Training please contact us for an immediate response.
ITS is a worldwide organisation working
for 80 clients in 50 countries. We are a
UK CAA accredited provider of CRM
training and deliver courses to flight deck
crew, cabin crew, ground crew and
INTEGRATED TEAM SOLUTIONS
maintenance crew. We also run CRM
Integrated Team Solutions Limited, England
courses for senior management.
Tel: +44 (0) 7000 251 252 Fax: +44 (0) 7000 261 262
All our courses meet the requirements
of JAR OPS, the FAA and the UK CAA.
e-mail: sales@aviationteamwork.com
Website: www.aviationteamwork.com
INTEGR ATED TEAM SOLUTIONS

CRM Courseware
The CRM training packages available from ITS are designed to provide
instructors with all the material they require to deliver the appropriate
training session. In addition to the course documentation they are
complete with detailed notes to assist instructors during course
presentation.

The following sets of Initial CRM Courseware are available:

Pilot, Cabin Crew, Joint, Rotary Wing, Pre-Command and Senior Cabin
Crewmember

Course materials might include:

● Lesson Plans
● PowerPoint
● Syndicate Exercises

● Questionnaires
● Case studies
● Videos
Each set of courseware also includes all the background information necessary to
support delivery of the course and to provide additional material covering topics which
may be raised by crew for discussion.

Individual Modules

ITS also offers a range of CRM training modules covering the main elements of the CRM
syllabus. Modules are complete with training notes and supporting elements which may
include activities, PowerPoint slides or questionnaires etc. Instructors simply need to
work through all the documentation and adapt the content and presentation to suit
their own presentational style and operational requirements.

The Old Forge, Little Barrington, Burford OX18 4TE
Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242
email: sales@aviationteamwork.com

Flight Deck Course Programme
The following represents a typical Pilot Initial Course 2 day programme, though all
courses can be tailored to suit your specific requirements

Day 1

Introduction – 30 Minutes
General introduction to CRM and Human Factor related incidents and statistics
Aviation Safety Review

Company Safety Culture/SOP’s and Organisational Factors – 1 Hour
To enhance awareness of our own organization
To study the effectiveness of SOP’s
To define safety and risk in the context of CRM

Organisational Error and Error Management – 2_ Hours
To describe how organisations can create the opportunity for individual error
To illustrate the error chain

To use a case study to discuss the above
To discuss active error
To introduce 5th generation CRM training and error management

Stress, Fatigue and Vigilance – 1 Hour
To identify Stress and its causes and effects
To practice Stress management techniques
To define Fatigue and discuss different coping strategies
To discuss how Stress and Fatigue may affect vigilance

Communication and Co-ordination – 1 Hour
To review how we communicate
To identify barriers to effective communication
To highlight essential verbal communication skills
To discuss and practise scenarios involving communication

Automation – 45 Minutes
To identify the potential hazards of automation
Examine the human Error associated with Automation

1 Friary, Temple Quay, Bristol BS1 6EA
Tel: +44 (0) 7000 240 240 Tel: +44 (0) 844 303

Flight Deck Course Programme
The following represents a typical Pilot Initial Course 2 day programme, though all
courses can be tailored to suit your speciﬁc requirements

Day 2

Review of Day One – 30 Minutes

Leadership, Followership and Teamwork – 1 Hour
To illustrate the effectiveness of working in teams
To highlight effective leadership/followership skills
To evaluate teamwork and leadership using NOTECHS and a video case study

Personality/Attitude and Behaviour – 30 Minutes
To discuss behaviour and its effects on other crew members

Situational Awareness and Information Processing – 1 _ Hours
To consider the stages of the human information processing system
To explore the limitations to our information system in the context of our
working environment
To examine the elements of Situational Awareness
To illustrate and discuss causes of lack of SA and how we can enhance our SA
To examine situational awareness through a case study

Decision-Making – 1 _ Hours
Illustrate a Simple model for Decision Making
Discuss routine Decision Making
Highlight Barriers to Decision Making
To discuss and practise scenarios involving decision making
Illustrate a process for decision making

Case Study – 45 Minutes
To examine a case study involving a decompression

Course Review – 45 Minutes

1 Friary, Temple Quay, Bristol BS1 6EA
Tel: +44 (0) 7000 240 240 Tel: +44 (0) 844 303

Cabin Crew CRM
Typical Course Programme
0830 Course Introduction
Overview of course, introductions, course aims and objectives. What is CRM?

0845 The Aviation System
Description of preparation for departure, illustrating interdependence of different tasks
and reasons why delays occur. Social structure of system.

0930 Group Exercise
Syndicate exercise to illustrate teamwork

1030 Communication
Discussion of output from syndicate exercise in terms of ways of communicating.
Develop a model of communication and illustrate with examples of poor
communication. Role of communication elements in CRM.

1115 Decision-making
Discussion of output from syndicate exercise in terms of how groups made decisions.

Develop a model of decision-making and look at reasons for poor decision-making.
Introduce stress as a factor in poor decision-making.

1200 Review
Discuss lessons of mornings activity from perspective of ways of learning.
Introduce concept of perception, limitations on information processing, etc.

1230 Lunch
1300 Stress
Develop ideas about causes of stress. Discuss effects of stress and coping strategies.
Fatigue.

1345 Predictable Behaviour
Discuss concept of attitude and personality as predictable behaviour. Discuss the effects
of unacceptable behaviour in teams.

1430 Case Study
Syndicate exercise which looks at structural elements of team work.

1530 Working in Teams
Outlines key elements of team structures and processes.

1545 Error
Outlines the skill, rule and knowledge categories of error with group exercise which
looks at examples of types of error.

1630 Review and Close

Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242

Helicopter CRM Course
Typical rotary wing
Two day Initial course programme

Day 1

0900 Course Introduction
Overview of course, introductions, course aims and objectives. What is CRM?
Statistical Justiﬁcation

0930 The Rotary Wing Operating Environment
We examine the inherent dangers of the RW task, the operating requirements,
and limitations of the equipment and often the training of the aircrew.

1030 Break

1045 The Search and Rescue Task

The elements of a SAR mission are discussed in syndicates. Once completed each
syndicate delivers their plans

1230 Lunch

1330 Group Exercise
Syndicate Team Work Exercise.

1445 Communication
Develop a communication model. Discuss Barriers to communication. Discuss the
need for SOP’s and thorough training when limited time necessitates minimal
time for brieﬁng and lengthy uses of Advocacy and Inquiry. Discussion will focus
on the previous SAR syndicate discussion.

1545 Break

1600 Who’s Flying the Aircraft?
Discussion of the roles of the crew, task sharing, SOP’s and checklists.

1650 Review of Day one

Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242

Helicopter CRM Course
Typical rotary wing
Two day Initial course programme

Day 2

0900 Stress
The physiological effects. Discuss causes of stress. Stress Questionnaire. Discuss
coping strategies and importance of recognition of stress. Fatigue. Discuss the
dangers of the RTB after a stressful mission.

1030 Break

1045 Decision Making
Case study group exercise and decision making models.

1145 Errors and Mistakes

We discuss error recognition, the error chain and “The get the job done”
RW mentality.

1230 Lunch

1330 Situational Awareness
How can we get the difﬁcult jobs done safely.

1430 Behaviour
Discuss the concepts of personality and behaviour. Discuss the concepts of the
rogue aviator, the pilot that disregards limitations of himself and his machine.
Why helicopter pilots are different.

1530 Break

1545 Exercise
Problem solving, Leadership and teamwork exercise completed in syndicates.

1630 Review and conclusion

Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242

CRM Instructor Course
UK CAA approved and JAR OPS compliant
CRM Instructor Training Course

ITS offers two standard CRM instructor training courses, a 5-day course
and an 8-day course.

5-day course
This course is suitable for those instructors who are already familiar with the CRM
syllabus and focuses primarily upon facilitation skills.

8-day course
Designed for those who are new to CRM, or have only limited experience of the
subject and syllabus. On the 8-day course the first three days are spent working
through the CRM syllabus in some detail. The objective here is to ensure that all
delegates have a common understanding of the subject matter. The next five days are
spent in learning about, and practicing, CRM facilitation skills.

Open Courses in the UK

ITS regularly holds open CRM instructor training courses in the UK, which are attended

by instructors from many different countries and from a wide selection of airlines.
Contact ITS for a schedule of forthcoming courses.

The ITS open instructor courses are non-residential and the course fee includes:
● Classroom training
● Course notes
● Additional reading material
● Courseware on CD
● PowerPoint presentation
● Copyright license to use our material within your company
● Certificates on completion of the course
● Refreshments and Lunch

Private courses
ITS also offers private courses for individual clients and these courses are tailored more
closely to the individual requirements of each client and can be held in the UK or on
your own base. Private CRM instructor courses may be held on any dates that are
convenient to your company, ITS will simply need sufficient
advance notice in order that suitable instructors are available for your preferred dates.

We always assume that an instructor attending one of our CRMI courses will already
have basic classroom instructional skills.

Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242

Management CRM Training
The ITS Management CRM Course is designed for senior managers
from all support functions (ﬁnance, maintenance, operations,
personnel, marketing etc.) and examines the relationship between
senior management activity and risks in line operations.

Typical Management CRM Syllabus

● What is ‘safety’?
● Management involvement in creating ‘safety’
● Motivation
● Management view of workforce
● Workforce view of management
● Management motivation in terms of company performance
● Organisational Factors in Aircraft Accidents
● Measuring Outcomes

● Relationships between management activity and safety
● Relationships between ‘risks’ and ‘costs’
● Creating a Safety Culture

Course Duration
The Course can be run as a one-day event or, if management time
is at a premium, it can be run over two consecutive half-days

Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242

Recurrent CRM Training
Most Regulators require that, once initial CRM training has been completed,
recurrent training should refresh the entire syllabus over a given period; with
JAR OPS for example it is a 3-year period. Assuming therefore that initial
training is provided to all your crew during year 1, then during years 2-4
recurrent training should cover the entire CRM syllabus.

The usual approach to this requirement would be to take the main subject headings within the
syllabus (e.g. stress, communication, error etc) and to cover one third of these subjects in each
of the three years during the recurrent training cycle. This will ensure that, over the 3-year period
specified by JAR OPS for example, the syllabus will have been fully refreshed.
It would not be adequate to simply repeat the various sections from the initial course, however,
and so it will be necessary to produce a new set of recurrent training materials each year. This
work can be undertaken in-house, or alternatively it is a service that can be provided by ITS.
Of most importance to each client is to ensure that they derive maximum benefit from the
provision of recurrent training and so it will be essential that, whilst meeting the Regulator’s
requirements, the recurrent CRM training also addresses those issues that are of specific
importance to the airline.

ITS can provide a recurrent courseware design service that will identify the specific issues
relevant to the airline and will then design and produce appropriate recurrent training materials.
This is a collaborative exercise that will require input from the Client’s CRM instructors and
training management. The process will normally involve visits to base, an approval process
during the design period and a final workshop at which the courseware will be demonstrated
and handed-off to the CRM instructors.
Based on a 3-year contract a fixed annual fee will be agreed for the production of the
courseware. Alternatively, without a 3-year contract, the courseware can be produced annually
at prevailing charges.

There are many advantages to outsourcing this service and they include:

● Access to the substantial experience available from ITS
● Courseware designed to your particular requirements
● On-going design creativity
● Making time for more productive tasks within the organisation
In addition to constructing the courseware ITS can also deliver the courses using our own highly
trained instructors.

Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242

Evaluation of CRM Behaviours
Under JAA requirements, it is now necessary for operators to introduce
CRM assessment into recurrent training. To support you in meeting this
requirement we have introduced a new service designed to assist you in
designing and assessing behavioural markers.

Your instructors will need to evaluate such elements as teamwork, decision-making,
communication etc, in addition to the more usual technical elements. In order to do this,
you will need to develop behavioural markers and identify the appropriate operational
and training situations in which evaluation can take place.

WE CAN HELP!

ITS has practical experience of building behavioural markers for our clients and with this
knowledge, and our considerable experience in CRM course design and training, we
have produced a package designed to assist you in:

● Deciding which elements you need to assess
● Agreeing a means of assessment

● Setting relevant standards
● Preparing assessment documentation
● Ensuring standardisation of assessors
● Identifying mechanisms for remediation

The objective is to identify behaviour that is clearly related to operational performance.
The process therefore requires a detailed analysis of your operation to ensure that
individual performance-related behaviours are being assessed.
We can therefore offer you a complete solution to the design and operation of
a behavioural marker scheme to include:
● Development of your Behavioural Markers scheme
● Training your assessors in the use of the scheme
● Standardisation of assessment

For more information, or to ask us to visit your base for initial discussions, contact us by
phone, email or visit our website at www.aviationteamwork.com.

Tel: +44 (0) 7000 240 240 Fax: +44 (0) 7000 241 242

Implementing an SMS
Training Course

Based on the ICAO SMS Manual Doc 9859 (Second Edition - 2009), this
3-day course is designed to prepare organisations for the implementa-
tion of a Safety Management System.

Course Aims:

To introduce delegates to the concept of structured safety management
To outline the steps needed to implement an SMS
To identify the factors that contribute to a 'Just Culture'
To establish an effective organizational learning capability

Course Structure:

Day One
An Introduction to Safety Management
Safety, Hazard and Risk
Error and Violation
What is an SMS?
Management’s role in an SMS
Roles and Responsibilities

Day Two
Developing an Hazard register
Assessing Risk
Setting Safety Management Goals
Feedback and Reporting
SMS Documentation

Day Three

Investigation and Analysis
Emergency Response Planning
Learning from Experience – Continuous Improvement
Safety Education and Training
Developing an Implementation Plan

The course comprises a series of integrated presentations, practical exercises
and case studies.

1 Friary, Temple Quay, Bristol BS1 6EA, England

Tel: +44 (0) 7000 240 240 Tel: +44 (0) 117 344 5019

Case Study – Decompression

CASE STUDY – DECOMPRESSION

This case study is based on two actual incidents, both on Boeing 737 aircraft; the
incidents were on different airlines. All details, for both incidents, are exactly as
happened during the two events; the only changes to the data included are the flight
numbers and airlines’ names, which have been changed to maintain confidentiality.

The case study is suitable for delivery to pilot, cabin crew or joint pilot/cabin crew
CRM courses. The main objective for the case study is to support a session on
Communication and Co-ordination, although of course you may wish to use it as a
basis for other CRM elements.

You will see that the module contains the following sections:

• Lesson Plan
• Supporting Materials
• PowerPoint

Within the Supporting Materials section you will find the handouts and a detailed
report on the second incident. Also in this section are copies of pax letters, regarding
both incidents, which were sent to the airlines.

We would recommend that you allow 40 minutes to run this module in the classroom.

Objective:

• To examine two case studies involving decompressions

To be covered as follows:

• Distribute Handout 1 for first case study and ask delegates to highlight
communication and co-ordination errors
• Facilitate and discuss scenario from a communication and co-ordination
perspective
• Distribute Handout 2 for second case study and ask delegates to highlight how
this incident was handled differently, also from a communication and co-
ordination perspective,
• Facilitate and discuss scenario to highlight differences between both incidents.

Lesson Plan – Allow 40 Minutes

KEYWORD DETAIL AIDS
Slide
Case Study Case Study

Objectives Objective:

To study two actual incidents from a communication and co- Slide
ordination perspective Objective

Background This depressurisation incident occurred in 2004 on a Boeing 737-
800 a/c

There are many points for discussion in this incident, as indeed
there are on any case study – however we would like to discuss this
from a communication and co-ordination perspective.

Task Issue the Investigators summary handout sheet Handout 1
Working in groups of 3, ask class to mark the communication and
co-ordination problems that occurred – give 5 minutes to do this
Bring class together and discuss the points raised

Points for Listed below are the communication and co-ordination discussion
discussion points

• Flight crew did not brief for ‘no engine bleeds take-off’
• Bleed Air Duct Pressure indicator was not checked at any
time
• When seat belt signs came on, the SCCM interpreted this as
turbulence and made this PA to pax
• FO made RT call ‘requesting immediate descent’ instead of
announcing ‘emergency descent’ and declaring an
emergency
• Therefore ATC did not give a descent clearance until 2
minutes after the initial call
• Flight crew did not announce ‘emergency descent’ to cabin
crew and pax
• When levelled out, the FO used the cabin call button rather
than the standard NITS format
• Cabin crew failed to request a NITS briefing and therefore
did not pass any information to pax

Expect Time Pressure on the ground to be a factor
This area often suffers turbulent weather, therefore the
interpretation of the cabin crew when the seatbelt sign came on is a
factor for discussion

So we have looked at an incident whereby there were
communication and co-ordination issues involving ATC, flight deck
© Integrated and the cabin crew. Let us now consider the effect this can have on
Team Solutions Limited 2006 2
other groups of people – in this case our payload – the passengers!

communication and co-ordination issues involving ATC, flight deck
and the cabin crew. Let us now consider the effect this can have on
other groups of people – in this case our payload – the passengers!

This incident resulted in 7 pax letters written. There is nothing
unusual in that – a pax perception of time and what is happening is
often exaggerated as we all know. However, having looked at the
incident from the crew’s perspective, can we take a moment to
consider this from the pax?

This is an excerpt from a passenger letter following this incident:

Instructor to read aloud

‘Probably about 30 to 45 minutes into the flight we were told to
Pax letter fasten our seatbelts, put our seat backs upright etc as we were about
to experience some turbulence. On obeying these instructions the
plane seemed to almost hit a brick wall then drop. Just at this point
the O2 masks deployed and the a/c began a very steep descent. To
be perfectly honest, I, my wife and the rest of the pax thought we
were going down permanently. The steep descent seemed to go on
for an age. The sight of a stewardess with a look of sheer fear on
her face and tears in her eyes did nothing to calm the mood on
board. We believed we were going to die!! At no point during this
steep descent did any crew member offer any support to us! It was
every man for himself! Eventually the plane levelled off but again
no information was given to pax until a very shaky captain/FO told
us that we were diverting to Charles de Gaulle to ‘find out what the
problem was.’ Then the next piece of information that was offered
was that ‘no we are not diverting to CDG but we are diverting to
OLY instead. Why did this person not try to offer some explanation
for what was happening? Even a simple explanation like ‘don’t
worry, the engines are fine, it just appears to be a problem with the
cabin pressure.’ No we were kept in the dark and made to suffer in
silence. No information. No information. No information.

The letter then goes on to discuss the lack of support the pax had at
OLY

High workload and stress of the crew are just some of the factors
here that contribute to the lack of information experienced by the
passengers.

However, what we would like to discuss here is the impact that a
Discussion lack of communication and co-ordination from both the flight deck
crew and cabin crew can have on passengers.

© Integrated Team Solutions Limited 2006 3

Therefore looking at this incident – yes – we are just sitting in the
classroom with the benefit of hindsight.

If we consider some of the communication and co-ordination
points we raised before – here are 3 examples

Show slide
Slide Slide
• Flight crew did not announce emergency descent to cabin
crew and pax
• When levelled out, the FO used the cabin call button
rather than the standard NITS format
• Cabin crew failed to request a NITS briefing and
therefore pass any information to pax

Link into your Company SOP’s here regarding who is going to
make the PA to pax

If these communications had been given, how do you think this
Question situation from the pax perspective may have been different?

Expect answers such as:

Pax would have known there was a loss of cabin pressure if the PA
had been made. They would have known the pilots were dealing
with the situation. Even though they are briefed on the ground,
understanding the problem when faced with the situation is
completely different!

There would have been greater co-ordination after the descent and
the pax would have been briefed by the cabin crew following the
NITS briefing

We have looked at an incident in which there might have been
Summary better communication and co-ordination between the flight deck and
cabin crew.

So now let’s have a look at a second decompression and see how it
is different from the first.

This decompression incident occurred in August 2005 on a 737-300
en route from Malaga to London Gatwick.
Slide Slide

Issue the handout sheet and again, working in groups of 3, ask the
class to compare the communication and co-ordination problems in
© Integrated this incident with the first incident – give 5 minutes to do this
Team Solutions Limited 2006 4

Task class to compare the communication and co-ordination problems in Handout 2
this incident with the first incident – give 5 minutes to do this
Bring class together and discuss the points raised.

Establish the differences both from a flight deck/cabin crew and pax
perspective.

In contrast to the previous incident, this event resulted in several
pax letters written to the company praising and thanking the crew.
Here is an excerpt from one of these letters:

Instructor to read aloud
Pax letter
I was a passenger on flight ABC 123 from Mahon to London
Gatwick yesterday. I am writing to convey to you my enormous
admiration for the crew during our emergency descent. The cabin
crew were completely calm and professional. They were an
enormous help to us both practically and emotionally. It goes
without saying that I am so very grateful to the pilots who got us
safely to the ground

While in the aircraft on the tarmac at Brest Airport, the F/O came
through the cabin to speak to all the passengers which was
extremely helpful and reassuring to us all. He took a great deal of
time over this and I feel it was invaluable.

The cabin crew were marvellous while we were waiting to
disembark a very hot aircraft. They were patient and calm and very
friendly. Later in the lounge at Brest Airport they were very happy
to talk with us and showed great concern for our recovery.

I hope you will be able to pass on these sentiments to the entire
crew. It was of course an extremely frightening experience but I do
not believe the crew could possibly have been more helpful to us.
They were marvellous. I would also like to say how understanding
and helpful the crew were on the 757 which took us to London
Gatwick.

A further letter reads:

Whilst the experience was extremely distressing, we would like to
thank the captain & crew for their professionalism during the
incident, when they were clearly distressed themselves. Their
support was exemplary, particularly the way they managed to look
after everybody once we had landed.


Special thanks to the pilot, who got us down safely & then for
talking to us individually during our time at Brest airport.

We hope it hasn't put the young cabin crew staff off flying again!
They were all fantastic & should be proud of the way they
conducted themselves.

Thanks also to the crew of the 757 who rescued us & brought us
home safely. They made us feel a lot more at ease than we ever
expected to be.

Instructor note: See report if more information required


SUPPORTING MATERIALS

Content:

• Handout – Decompression 1
• Handout – Decompression 2
• Report – Decompression 2
• Pax Letters


Handout – Decompression Incident 1

Investigator’s summary

The aircraft departed London Gatwick 10 minutes early at 09:30 and after an
uneventful flight arrived at Malaga at 12:16, 19 minutes ahead of schedule. In
accordance with a request from the ramp agent, the Captain prepared to depart from
stand ahead of schedule to facilitate handling a delayed inbound flight.

A check on the expected take-off performance requirements, by both crew, confirmed
that a Bleeds-Off (no engine bleeds) take-off would be required... Shortly afterwards
the ramp agent presented the load sheet and again emphasized the urgency in vacating
the stand. The aircraft closed up and started engines at 12:42, 18 minutes ahead of
schedule and was airborne at 12:57. No special brief was given for the bleeds-off
take-off nor was the ‘Supplementary Procedures’ section of the FCOM consulted.

The crew reported that they made the standard checks on the pressurization system
every 5000 feet during the climb including a full panel scan passing Fl.100 (10000 ft)
and all parameters checked appeared normal. It has been established that the checks
on the pressurization system centered on the Cabin Altitude/Differential indicator ;
indications here would certainly approximate to ‘normal’ for as long as the APU
continued to supply a useful flow of bleed air. Limitation for APU with bleed air is
17000feet. At no time did anybody check the Bleed Air Duct Pressure indicator. This
would have indicated a bleed air supply problem, with zero indicated in the right hand
duct and a slowly reducing pressure in the left hand duct as the aircraft climbed.

After about 10-15 minutes in the cruise at Fl.320, (32000 ft) the cabin altitude horn
sounded. The crew performed the ‘recall items’ for Cabin Altitude Warning Horn’
and noted the cabin altitude at 10000feet climbing at approximately 1500fpm (feet per
minute) The Captain called for Emergency Descent and the crew then set about the
recall items for this manoeuvre. When the Captain switched on the seatbelt sign, the
SCCM interpreted this as an indication of impending turbulence and duly made the
appropriate ‘turbulence’ PA to the passengers. The oxygen masks then dropped. At
this point the FO made an RT call “Air Link 176 requests immediate descent” only to
receive “I’ll call you back’ The Captain then advised “Now. Emergency Descent”,
ATC responded with “Squawk 7700” which the FO set and then announced “Air Link
176 descending Fl.270” (27000 ft). Approximately 2 minutes after the initial call,
ATC gave their first descent clearance “Air Link 176 you can descend Fl.200” (20000
ft).

All subsequent RT communications were without complication .During the descent,
the system misconfiguration was spotted and corrected and the aircraft’s
pressurization was thereafter controlled normally. When level at Fl.100 (10000 ft),
the FO called the cabin using the cabin call button. The SCCM was informed that
there had been a rapid decompression and they were diverting to CDG, this was
subsequently changed to OLY. The remainder of the flight and landing at OLY was
without incident.


Handout – Decompression Incident 2

During the cruise at 36000’ the RH Bleed Trip Off illuminated and the cabin pressure
started to climb. The QRH drill was called for and a descent to 25000’ requested. As
the cabin approached 10000’ the cabin altitude horn sounded and therefore the rapid
depressurisation drill was performed. The cabin altitude climbed to 16000’ and the
masks deployed at 14000’. A MAYDAY was declared and Brest airport was
requested as the diversion field.

The depressurisation drill was followed, including an announcement over the
aircraft’s Public Address system to alert the cabin crew members – PA ‘Emergency
Descent’

The cabin crew immediately commenced their decompression drill, passing through
the cabin from rear (where they were in the galley at the time of the incident) to the
front and once the decompression drill had been conducted, assembled in the forward
galley for a briefing from the SCCM and checked the drills had been completed
correctly through reference to the Cabin Crew Safety Manual.

The rapid descent was carried out as per SOP’s and the aircraft levelled off at 10000’.

A further PA to calm the pax was made during the last few thousand feet of descent –
pax were told all was ok and a normal landing would take place at Brest.

Approach and landing were normal.

The aircraft was inspected at Brest and a cabin pressure run carried out after the RH
pack was reset.

A replacement 757 was dispatched to Brest and the 737-300 returned to London
Gatwick at an altitude of 10000’


Investigation into loss of cabin pressure August 2005

Aircraft : Boeing 737-300

Occurrence Date : August 2005

Flight Number : ABC 123

Flight Routing : Malaga, Spain to London Gatwick, UK

Nature of flight : Public transport – fixed wing

Occupants : 140 passengers plus 4 infants and 6 crew members

Crew : Captain, First Officer, Senior Cabin Crew Member [SCCM], 3
Cabin Crew Members

Location of incident : Approx 60 nautical miles to the east of Brest, France, at the
time of incident

Brief summary : Loss of cabin pressure whilst at cruising altitude of 36,000ft led
to rapid descent and precautionary, safe landing at
Brest, France

History of the flight
The aircraft was operating the return sector of a roundtrip between London Gatwick
and Malaga. Its outward flight left London Gatwick at 11.44 hrs Greenwich Mean
Time [GMT] (used throughout1) and landed in Malaga at 14.23 hrs. This was 14
minutes behind the planned schedule as a result of a delay in leaving London
Gatwick due to passengers arriving late at the boarding gate.

The turn-round at Malaga was routine, albeit shorter than usual as the crew sought to
make up the earlier delay. The aircraft departed Mahon at 15.00 hrs (5 minutes
behind schedule as a result of the late inbound aircraft), becoming airborne at 15.12
hrs, for the return flight to London Gatwick with 140 passengers and 4 infants aboard.
Estimated flying time was 2 hours and 44 minutes and a fuel load of 10,200 kgs was
aboard, in excess of the minimum 9,458 kgs (including statutory reserves and diversion
fuel) required for the flight. The aircraft departed at a weight of 53,633 kgs, some
7,602 kgs below its maximum take-off weight.

Departure from Malaga was uneventful; the aircraft followed a MJV2D Standard
Instrument Departure route and was given progressive climb clearance by Spanish Air
Traffic Control [ATC] to climb to its requested cruising altitude of 36,000ft for the sector
to London Gatwick. During the climb and cruise phase of the flight, cabin
pressurisation was maintained normally by the aircraft’s automatic pressurisation
controller and this item was routinely checked and found satisfactory in the “Climb”
checklist by the flight crew.

1Local time in Malaga and Brest is two hours ahead of GMT; local time at London Gatwick is one hour
ahead of GMT


Control of the aircraft passed from Spanish to French Air Traffic Control 48 minutes
after departure and the aircraft was given a direct clearance to the navigational
beacon at Agen (AGN).

At 16.42 hrs, whilst the aircraft was approaching a position abeam the navigational
beacon at Monts d’Arree (ARE) [near the French town of Lorient], a “BLEED TRIP OFF”
caution light illuminated on the Automatic Centralised Warning System panel. The
flight crew conducted the checklist drill and requested initial descent clearance from
Air Traffic Control to descend to 25,000ft, which is in line with Boeing’s Standard
Operating Procedures [SOP] if the aircraft has partial failure of its pressurisation
system.

During this initial descent, the flight crew noted that the cabin altitude (the pressure
level in the cabin relative to the outside air) was rising rapidly. As the cabin altitude
rose above 10,000ft, the cabin altitude warning horn sounded on the flight deck and
both flight crew members placed on their own oxygen masks in accordance with the
airline’s SOP. The depressurisation drill was followed, including an announcement
over the aircraft’s Public Address system to alert the cabin crew members.

The flight crew requested clearance from ATC and then initiated an emergency
descent to 10,000ft. The cabin altitude continued to rise; further attempts were
made by the crew to control the pressurisation by switching from automatic to
manual mode but these were unsuccessful.

As the cabin altitude rose through 14,000ft, the passenger oxygen masks deployed
automatically. In accordance with the pre-flight demonstration, passengers were
directed to pull the masks towards them to open the oxygen supply, place the mask
on and then breathe normally. The cabin crew immediately commenced their
decompression drill, passing through the cabin from rear (where they were in the
galley at the time of the incident) to the front and once the decompression drill had
been conducted, assembled in the forward galley for a briefing from the SCCM and
checked the drills had been completed correctly through reference to the Cabin
Crew Safety Manual.

The flight management computer [FMC] indicated that the nearest available airfield
was at Brest and the crew requested clearance to land at Brest. The remainder of
the flight was uneventful and the aircraft landed at Brest at 17.14 hrs and engines
were shut down on the parking stand at 17.16 hrs.

Injuries to Aircraft Occupants
There were no injuries to passengers arising from the incident. Three passengers
required medical attention at Brest for conditions including an asthma attack and
painful sinuses and were attended by paramedics called by Brest Airport. All were fit
to continue their journey later that evening aboard a replacement aircraft.

Notification
The airline’s 24-hour Operations Control Centre [OCC] was notified of the air diversion
by Air Traffic Control at 17.08 hrs and further confirmation was given at 17.15 hrs that
the aircraft had landed safely at Brest. This was confirmed by the Captain who used
a mobile telephone to contact the OCC at 17.25 hrs.

A plan was formulated to dispatch one of the airline’s Boeing 757 aircraft from
London Gatwick to carry an engineering team out to Brest and then to fly all


passengers from Brest to their desired destination of London Gatwick. This was
instigated at 18.04 hrs and crew members were called from home standby to
undertake this new operation. London Gatwick Airport was advised at 18.15 hrs of
the revised expected time of arrival of the flight at 23.45 hrs so that any persons
meeting the flight at London Gatwick could be given up-to-date information
regarding the delay.

Passengers remained on the 737 aircraft at Brest for a period of time until clear
information could be given of the onward flight. During this ground time, the First
Officer and crew were present in the aircraft’s cabin to reassure passengers and
explain the situation. Passengers later disembarked normally into the terminal
building at Brest and Brest Airport made provisions for food and beverages to be
provided at the airline’s request pending the arrival of the replacement aircraft.

The 757 aircraft landed at London Gatwick from its previous sector from Egypt at
20.04 hrs and was airborne to Brest at 21.08 hrs. All passengers elected to continue
their journey to London Gatwick and the aircraft landed in London Gatwick at 23.46
hrs to complete service from Malaga.

Crew details
The Aircraft Commander is a 52-year old male (Australian national) who holds a valid
UK Air Transport Pilot’s Licence [ATPL(A)]. He is an experienced 737 Captain who had
previously flown the type in Australia; joined the airline in April 2003, completed
training in May 2003 and was promoted to the role of Training Captain in October
2003.

The First Officer is a 38-year old male (UK national) who holds a valid UK Commercial
Pilot’s Licence [CPL]. He joined the airline in April 2005 and completed training in
May 2005.

Both pilots were licensed on 737-300 to -900 aircraft variants and held valid medical
certificates. The crew were properly licensed, trained and rested to undertake the
flight duty.

The four cabin crew members had all undergone initial training with the airline in April
2005 after joining the airline. The SCCM held appropriate previous flying experience
as Cabin Crew on a fixed-wing aircraft to operate in that capacity. All cabin crew
members were trained in accordance with the airline’s approved training
programme, had undergone medical examinations and were rested to undertake
the flight duty.

All crew members were interviewed by the airline’s flight crew and cabin crew
management teams following the incident.

Aircraft & Engineering
The aircraft joined the airline’s fleet in April 2003 and has completed a total of 40,537
hours and 25,998 flight cycles since new. It underwent a major maintenance
overhaul (C Check) in November 2004 and its most recent intermediate
maintenance check (A Check - required every 250 flying hours) was undertaken at
London Gatwick in August 2005. The aircraft daily inspection was conducted on the
morning prior to the aircraft’s departure to on its first sector of the day.


Flight crew members completed routine pre-flight walk-round checks of the aircraft
before both sectors with no defects or issues noted.

The aircraft was properly maintained in accordance with Boeing Maintenance
Planning Document and the airline’s maintenance procedures, which are approved
by the UK Civil Aviation Authority.

Flight recorders
The aircraft’s Cockpit Voice Recorder was retained by the French Department
General de l’Aviation Civile inspectors who visited the aircraft on arrival at Brest. The
Quick Access Recorder [QAR] data was removed from the aircraft by the airline’s
engineers on the day after the incident and analysed.

The data is consistent with the account from the flight crew. The descent profile was
analysed and in the graph below, the blue line shows the profile of the aircraft. The
QAR indicates that the aircraft descended from its cruising altitude of 36,000ft to an
altitude of 10,500ft over a period of 6.5 minutes.

Fig 1 – QAR data of descent profile between 16.42:00 hrs and 16.51:30 hrs

The average descent rate was 4,300ft per minute versus 2,000ft per minute in a
conventional descent. The maximum angle of descent recorded by the QAR was
4.92º2 and the maximum rate of descent reached at any point was 6,200ft per
minute.

Engineering examination of the aircraft
The aircraft was examined by the airline’s engineering team at Brest after their arrival
from London Gatwick aboard the 757 aircraft dispatched to carry passengers home
to London Gatwick. This indicated the presence of a problem within the air system

2 This is equivalent to a 1 in 7 gradient in a land-based descent


which uses outside air from the right-hand engine and compresses it in order to supply
the cabin air conditioning and pressurisation system whilst in flight. The structural
integrity of the aircraft’s fuselage and all external doors and hatches was assessed
and found to be intact.

A low-level ferry flight (i.e. unpressurised) with a minimum safety crew aboard was
undertaken late on the evening to return the aircraft to London Gatwick; during this
sector, a pressurisation check was carried out during which the fault was repeated
and found to be consistent with the earlier crew’s accounts.

Engineering Analysis
The 737 has two independent bleed air systems one from each engine, feeding two
totally independent air-conditioning supply systems. Under normal circumstances
each air conditioning system is designed to maintain the cabin pressure with a high
level of extra capacity in reserve.

On investigation, the airline’s engineers reset the right-hand bleed air system and
carried out a cabin pressurisation system check. This test revealed a broken clamp
round the Auxiliary Power Supply [APU] air duct sealing skirt, allowing air to leak out of
the cabin. This high leak rate explains why the flight crew were unable to maintain
the cabin altitude using only the left-hand air conditioning supply system as should
normally have been possible.

The automated safety alert systems functioned correctly in notifying the flight crew of
the bleed air valve failure and the rising cabin altitude.

The automated oxygen mask drop out system deployed correctly as designed. Each
set of four masks (left-hand side of the cabin) and three masks (right-hand side of the
cabin) is supplied by an individual oxygen generator and the passenger action of
pulling the mask towards themselves pulls the firing pin out of the oxygen generator
and thus commences a flow of oxygen. Subsequent inspection of the oxygen
system indicated that all oxygen generators had fired correctly and produced
oxygen. A small number of oxygen generators (including those in the forward and
one aft toilet, which were not occupied at the time of the incident), were not used.

Passenger reports of a burning smell towards the rear of the aircraft prior to the
incident have been investigated. No evidence of fire or smoke has been found, but
the engineering investigation indicated some residue in the aircraft’s centre rear
galley oven consistent with food debris from passenger meal service. None of the
cabin crew members recalled any such issue and all had been in the rear galley
around the time of the incident.

The individual oxygen generators above each seat row normally produce heat and a
light acrid haze when fired and it was concluded that the passenger reports of smoke
after the deployment of oxygen masks were consistent with the normal functioning of
the oxygen generators.

Repairs were effected to restore the integrity of the pressurisation system through
replacement of the air duct clamp and the aircraft was test flown two days leter with
a full pressurisation check undertaken. It was found to be functioning correctly in
both automatic and manual control modes. Further work was undertaken to
replace the oxygen generators above each passenger seat, replace all oxygen
masks (standard procedure after use), re-stow oxygen masks and then conduct a


final function check on the oxygen mask system. The next day a further test flight
was conducted before the aircraft was cleared to return to passenger service.

Incident history
No other comparable incidents of decompression have been recorded on the
airline’s fleet of aircraft. The airline operates a total of five identical Boeing 737-300s
and two Boeing 737-700 aircraft and has undertaken over 21,000 sectors without any
event of this nature.

Follow up action
The aircraft manufacturer, Boeing Airplane Company, has been notified of the failure.
The airline has undertaken a full inspection of its aircraft fleet to ensure that no similar
defects exist. There is no requirement from Boeing or the UK Civil Aviation Authority to
replace the failed component on the aircraft as part of routine maintenance checks,
but the airline is formulating procedures to replace these during each annual
overhaul of the aircraft as a precautionary measure.


INCIDENT 1 - PAX LETTER

‘Probably about 30 to 45 minutes into the flight we were told to fasten our seatbelts, put our
seat backs upright etc as we were about to experience some turbulence. On obeying these
instructions the plane seemed to almost hit a brick wall then drop.

Just at this point the O2 masks deployed and the a/c began a very steep descent. To be
perfectly honest, I, my wife and the rest of the pax thought we were going down permanently.
The steep descent seemed to go on for an age. The sight of a stewardess with a look of
sheer fear on her face and tears in her eyes did nothing to calm the mood on board. We
believed we were going to die!!

At no point during this steep descent did any crew member offer any support to us! It was
every man for himself! Eventually the plane levelled off but again no information was given to
pax until a very shaky captain/FO told us that we were diverting to Charles de Gaulle to ‘find
out what the problem was.’ Then the next piece of information that was offered was that ‘no
we are not diverting to CDG but we are diverting to OLY instead.

Why did this person not try to offer some explanation for what was happening? Even a
simple explanation like ‘don’t worry, the engines are fine, it just appears to be a problem with
the cabin pressure.’ No we were kept in the dark and made to suffer in silence. No
information. No information. No information.


INCIDENT 2 - PAX LETTER

Dear sir/madam,

We were passengers on flight ABC123 which had to emergency land in France on Friday.

Whilst the experience was extremely distressing, we would like to thank the captain & crew
for their professionalism during the incident, when they were clearly distressed themselves.
Their support was exemplorary, particularly the way they managed to look after everybody
once we had landed.

Special thanks to the pilot, who got us down safely & then for talking to us individually during
our time at Brest airport.

We hope it hasn't put the young cabin crew staff off flying again! They were all fantastic &
should be proud of the way they conducted themselves.

Thanks also to the crew of the 757 who rescued us & brought us home safely. They made us
feel a lot more at ease than we ever expected to be.

Please keep us informed regarding the cause of the emergency & once again well done to all
concerned!


CONTACT ITS

For more information or support with courseware, case studies, videos/DVDs or for
training courses please contact:

ITS
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Bristol
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England

Tel: +44 (0) 7000 240 240
+44 (0) 1451 844 303

Fax: +44 (0) 7000 241 242
+44 (0) 0117 344 5001

email: sales@avaitionteamwork.com
website: www.avaitaionteamwork.com


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