On January 8, 1989, a Boeing 737 operated by British Midland Airways crashed into the embankment of the M1 motorway near Kegworth in Leicestshire. The aircraft had been making a routine flight from London's Heathrow Airfast to Belfast in Northern Ireland when the air crew heard a loud pounding noise and experienced severe vibrations.
Smoke poured into the cabin and several passengers reported seeing fire and sparks coming from a port (left) engine. The pilot was advised to divert to East Midlands Airport for an emergency landing and the captain disengaged the autopilot. After being mistakenly told that it was the starboard (right) engine that was malfunctioning, the pilot shut it down even though it was the other engine that was causing the problem. Since the engine shutdown also ended the smoke coming into the cockpit, the pilots mistakenly believed that the problem had been solved. While the flight attendants and passengers could still see the flames coming from the malfunctioning port engine, they failed to notify the pilots.
As the plane approached the East Midlands airport, the port engine failed completely. Although the pilots tried restarting the other engine, the plane was travelling too slowly by that point and crashed into the motorway. Of the 118 passengers on board, thirty-nine were killed and eight died later. Of the 79 survivors, 74 suffered serious injuries. No one on the motorway was injured. In the final report on the disaster, the Air Accident Investigations Branch concluded that "had some initiative been taken by one or more of the cabin crew who had seen the distress of the left engine, this accident could have been prevented."
But how common are air disasters that happen because flight crew members are reluctant to speak up when something is wrong? A recent review published in Aviation Psychology and Applied Human Factors argues that flight attendants and other members of the flight crew who have lower ranking are often afraid to contradict the pilots, even in critical situations. This reluctance can often spell the difference between life and death.
One graphic example where staying silent can be fatal was the 1977 air disaster on the Spanish Island of Tenerife when two Boeing 747 passenger planes collided. With more than 583 fatalities, this is still the deadliest accident in aviation history. One of the factors linked to the accident was miscommunication between the captain of one of the planes taking off with proper clearance, apparently because less experienced members of the flight crew were reluctant to contradict him.
As Nadine Bienefeld and Gudela Grote of the Department of Management, Technology and Economics at ETH Zurich point out, crew members' failure to speak up can have devastating consequences. According to the United States National Transportation and Safety Board (NTSB), 84 per cent of the 37 accidents linked to crew error between 1978 and 1990 happened because first officers were reluctant to contradict senior pilots when they made errors or unwise decisions. Despite formal recommendations following many air disasters (including the 1977 Tenerife air disaster), junior flight crew members are still reluctant to speak out about potential problems.
According to the Air Accident Investigation Branch report into airplane accidents, surviving crew members often report having a bad "gut feeling" that something was wrong immediately prior to the crash but choose not to speak up. While many airlines have tried encouraging junior crew members to be more proactive in sharing their concerns with pilots (including teaching assertiveness skills in crew resource management (CRM) training), recent accidents show that the problem is still there.
In their formal study of why crew members frequently choose to keep quiet about potential problems, Professors Grote and Bierfeld examined 1751 cockpit and cabin crew members of a large European airline. Along with observing more than 500 crew members in a flight simulator, they also carried out an online survey of crew members using company e-mail. Based on their results and previous research into organizational psychology, reasons for staying quiet about safety concerns included:
- status differences
- fear of damaging relationship with the rest of the crew
- lack of experience
- feeling that nothing would be done (futility)
- fear of being labelled as a "troublemaker" or complainer
- time pressure
Overall, at least 48 per cent of the crew members in the study reported staying silent about safety issues on one or more previous occasions. Flight attendants in particular reported that fear of punishment was their main reason for staying silent. Other cabin crew members such as pursers were more worried about problems with efficiency or passenger comfort. Fear of punishment was a major factor there as well.
In cockpit crews, first officers stated that they were often reluctant to speak up out of fear of being labelled as a troublemaker or damaging their working relationship with the pilot. Even airplane captains reported being reluctant to speak out on safety issues at times for fear of damaging their working relationship with the rest of the crew. Gender, age or length of time that they were employed did not seem to influence the results for any crew members.
Overall, the researchers found that staying silent was still fairly common among crew members, even when they knew about serious safety concerns. This was despite graphic air accidents and three decades of air training designed to encourage crew members to speak up. The results were especially suprising since the airline in question had a good history of air safety and a history of safety training that was well above the common standard in the airline industry worldwide.
One of the practical suggestions that Bienefeld and Grote made was that airlines need to improve the working climate in airlines to allow even low-ranking flight attendants to approach air crew directly about safety concerns (which they called psychological safety). That includes training crew members to raise their concerns as safely and effectlvely as possible without fear of punishment or damaging their professional relationship with other crew members. That may mean a radical reshaping of air safety training for all airlines worldwide.
Whether this happens in time to prevent future air disasters such as the ones at Kegworth and Tenerife remains to be seen.