Aviation Safety Letter 1/2004

Scrutinizing Aviation Culture:  Professional Courtesy

Excuse me, do you think we should bring this to the Captain's attention?

I recently encountered the term "professional courtesy" in an aviation safety context, and decided to research the subject. As expected, the term reveals many different interpretations, depending on which industry you apply it to. In the medical industry, professional courtesy is used to describe a number of analytically different practices, but the traditional definition is the practice by a physician of waiving all or a part of the fee for services provided to the physician's office staff, other physicians, and/or their families. In a court of law, where the practice of law is largely an adversarial process, attorneys are ethically bound to observe certain standards of professional courtesy between their peers.

However, "professional courtesy" does not seem to be unique to medical and law circles. I encountered the expression while reading an account of the March 10, 1989 crash of an F28 at Dryden, Ont. in Air Disasters, Volume 3 by MacArthur Job. The synopsis addresses the crucial minutes that preceded the final takeoff in a section entitled "Other crew and passengers concerns." It struck me as material worthy of an article for ASL. However, before going any further, perhaps the new cross-section of our readers aren't so familiar with the Dryden accident, so here's a quick recap of what happened, as described by the Aviation Safety Network Web site (http://www.aviation-safety.net/):

On March 10, 1989, at 11:55 EST, an Air Ontario Fokker F28 departed Thunder Bay about one hour behind schedule. The aircraft landed at Dryden at 11:39 CST. The aircraft was being refuelled with one engine running, because of an unserviceable APU [auxiliary power unit]. Although a layer of 1/8-1/4 in. of snow had accumulated on the wings, no de-icing was done because de-icing with either engine running was prohibited by both Fokker and the operator. Since no external power unit was available at Dryden, the engines couldn't be restarted in case of engine shutdown on the ground. At 12:09 CST, the aircraft started its take-off roll using the slush-covered Runway 29. The Fokker settled back after the first rotation and lifted off for the second time at the 5 700 ft point of the 6 000-ft runway. No altitude was gained and the aircraft mushed in a nose-high attitude, striking trees. The aircraft crashed and came to rest in a wooded area, 3 156 ft past the runway end and caught fire. Twenty-four of the 69 people on board died as a result of the accident. PROBABLE CAUSE: After a 20-month investigation, it was concluded "Captain Morwood, as the pilot-in-command, must bear responsibility for the decision to land and take off in Dryden on the day in question. However, it is equally clear that the air transportation system failed him by allowing him to be placed in a situation where he did not have all the necessary tools that should have supported him in making the proper decision.

The Dryden accident investigation was carried out by a Commission of Inquiry, headed by the Hon. Virgil Moshansky, a Justice of the Queen's Bench of Alberta. The Final Report of the "Moshansky Commission" consists of four volumes and a total of 191 aviation safety recommendations. This was to be the most comprehensive aircraft accident investigation in Canadian history; while today this claim may be held by the investigation into the Swissair Flight 111 accident, the Moshansky Commission had a wider mandate to investigate the entire aviation system and what allowed the circumstances surrounding the Dryden occurrence to exist. Without a doubt, those four volumes are a landmark in aviation safety in Canada, and a must-read for anyone interested or involved in aviation safety. The 191 Moshansky Commission recommendations have led to sweeping changes in the way we conduct aviation business in our country. Now back to the original topic. how a modern cultural mindset could have prevented the tragic accident in March 1989.

Moments before takeoff, the F28 was taxiing out for the final takeoff with significant amounts of snow visible on the wings, and while a flight attendant and two airline captains traveling as passengers noticed, this was never communicated to the pilots. The flight attendant, who was the only crew member to survive, testified later that she had concerns over the snow, but because she had been rebuffed by company pilots over a similar situation in the past, it influenced her decision no to go to the cockpit. This cultural barrier between cockpit and cabin crew should never happen today, given how we train and conduct proper Crew Resource Management.

While the silence of the flight attendant was disturbing for the Commission of Inquiry, the Air Disasters synopsis spells out the thoughts on the two airline pilots:

In the case of the two airline captains traveling as passengers, their lack of affirmative action was unfortunate - to say the least. As professional pilots, they had a clear understanding of the danger, and their indication of concern would at least have been considered by the usually meticulous Captain Morwood.

The reason why they did not raise their concerns differ, but there are two points on which they agree - both assumed the crew was aware of the condition of the wings, and both believed the aircraft was going to be de-iced.

While taxiing away from the terminal and backtracking on the runway, the DC-9 captain thought they were proceeding to the more remote de-icing area on the airport. This was a reasonable assumption as Air Canada often de-iced its DC-9 aircraft at locations remote from the gate. There was no doubt in his mind, he recalled, that the aircraft had to be de-iced before takeoff.

The Dash 8 captain knew the de-icing equipment at Dryden was on the apron near the terminal, and expected they were going to return there. If the aircraft was not de-iced, he believed the takeoff would be aborted should the snow not come off the wings during the take-off run [a highly dangerous practice in itself]. He also indicated that "professional courtesy" precluded an off-duty airline pilot from drawing the attention of the flightcrew to a safety concern.

The inference was that "professional courtesy" among pilots was more important than safety, suggesting an unwritten code that militated against such communications, even when a potentially life-threatening concern was involved.

Other factors could influence an off-duty airline pilot not to make known his concerns: faith in the professionalism of the duty crew; fear of offending and possible rebuke for unsolicited advice; fear of embarrassment if the concern proved groundless; and a reluctance to interfere in the busy flight deck workload.

Whatever the reason, the evidence before the Inquiry pointed to a general reluctance on the part of the cabin crew and off-duty pilots to intervene in the operation of an aircraft, even in the face of apprehended danger.

The Commission believed air carriers should counsel their pilots that not only was it acceptable, but indeed expected, that off-duty airline pilots on board should draw any perceived concerns to the attention of the captain. Considering the complexity - and size - of jet aircraft today, a flight crew could only benefit from the eyes and ears of all on board, especially from those possessing pertinent skills. - MacArthur Job, Air Disasters, Vol 3, page 62

I'll be the first to admit that it takes a lot of nerve for an off-duty pilot to step out of the passenger mentality and speak out in the manner described above. Fortunately, operational mindset changes in today's aviation industry have, in large part, taken care of this cultural pickle. Crew members now understand such advice as totally acceptable and expected. This is the right way to do business. In fact, those extra eyes and ears in the background have turned "professional courtesy" into a potential lifesaver, as opposed to a missed opportunity to avoid a tragedy.

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