Singapore Airlines B777 in trouble at 500 feet: Why first officer couldn't be assertive

I am a true believer that society and culture cannot be separated from work and training. However best the training may be, it is under a controlled environment and the performance indicators needed to be achieved are briefed beforehand. The crew members undergoing training work together to achieve their objective and they are driven by performance indicators required to be achieved to declare them competent.

In the real world, the motivation, drive and targets are not briefed as well as they are in a training environment. There are a lot of distractions, and personal cultures and behavioural influences are a lot more active as compared to a training environment.

On September 2, 2019, at about 0133 local time, a Boeing B777-300ER took off from Pudong Airport in Shanghai. The flight crew engaged Autopilot 1 (A/P) after the takeoff. The pitch mode selected at the time of A/P engagement was Vertical Navigation (VNAV). Shortly after, the 'DON’T SINK' caution alert from the Enhanced Ground Proximity Warning System (EGPWS) was activated three times. 

The flight crew carried out troubleshooting and engaged the Flight Level Change (FLCH) mode on the Mode Control Panel (MCP) to make the aircraft climb. After the caution alert stopped, the flight crew reverted to the VNAV mode.

Subsequently, another 'DON’T SINK' caution alert was activated, followed by a 'PULL UP' warning alert. In response to the warning alert, the flight crew disengaged the A/P, increased the engine thrust and pitched the aircraft to climb.

The warning alert stopped and the flight proceeded without further incident. Read the full report here.

The First Officer (FO) of this Singapore Airlines Boeing 777 departing from Shanghai, China was a Multi Crew Pilot Licence (MPL) holder with over 1,700 hours of flight experience on that aircraft type. The essence of an MPL training programme is multi-crew coordination and threat error management.

Therefore, it can safely be assumed that the crew had demonstrated all the qualities and behavioural indicators as desired by the training curriculum modelled and designed for Singapore Airlines.

Then why was the FO not assertive enough and why was threat error management weak when changes in the flight management system by the Captain made the B777 level off at 500 feet after takeoff and activated the Ground Proximity Warning System (GPWS)?

SOP compliance

A change in the Standard Instrument Departure (SID) is considered a threat and to mitigate the risk of errors, the company Standard Operating Procedure (SOP) requires both the cockpit crew to be present while programming the Flight Management Computer (FMC) while preparing the cockpit prior to commencement of the flight.

Time pressure when a flight is delayed is also a threat. Why did the highly-trained crew of the B777 succumb to pressure and let the errors pass to activate the GPWS warnings?

The crew were facing difficulties obtaining pre-departure clearance on the data link as well as loading the flight plan automatically via the data link.

Also read: Air India A321 tail strike offers valuable lessons on psychology of surprise

Therefore, the Captain decided to programme the FMC manually as per SOP, in case the data link doesn’t work, but he decided to do it when the FO was carrying out the exterior inspection. This wasn’t a part of the SOP.

The FO came back and managed to obtain the pre-departure clearance through the data link and informed the Captain that the SID that had been programmed was not the one that had been cleared by the Air Traffic Control (ATC).

The Captain then changed the SID to what was cleared but manually inserted a speed and altitude constraint at a waypoint that they were to overfly soon after departure.

FMC changes

SID programmed by the Captain with speed/altitude constraint

During the briefing, the pilot-in-command (PIC) noticed on the FMC that the first waypoint of SID HSN 12X was PD062 and that, unlike waypoint HSH on SID HSN 22X, there was no speed/altitude crossing constraint indicated for PD062 (the FMC display was '—/—–').

The picture on the left showing the default speed/altitude constraint of '—/—–' at PD062 on SID HSN 12X and the right picture showing the PIC’s inputs

So he decided to enter the speed constraint of 250 knots (463 kmph) into the FMC and he keyed in a speed/altitude constraint of '250/0500' for PD062 using the Control Display Unit (CDU). The FO observed the PIC’s inputs as part of the cross-checking process and accepted the inputs as correct. 

Flight Mode Annunciator changes callout

After the aircraft was established in a climb with the landing gear retracted, the PIC called for A/P engagement as the aircraft climbed through an altitude of approximately 360 feet. The FO engaged the A/P.

According to the FO, when the aircraft was climbing past 400 feet above ground level (AGL), the Flight Mode Annunciation (FMA) on the Primary Flight Display (PFD) changed from 'HOLD/LNAV/TO/GA' to 'SPEED/LNAV/VNAV PTH16'. The FO called out 'SPEED, VNAV PTH17'. He made the callout twice. However, according to the PIC, he did not hear the FO’s callouts. The FO did not pursue seeking a response from the PIC. 

The aircraft continued to climb. The PIC noted from his PFD that the aircraft had climbed past 500 feet AGL. Both the PIC and FO then noticed the increasing speed trend arrow on the speed tape located on the left side of the PFD. This indicated that the aircraft was accelerating. At this time, the PIC believed that the aircraft had crossed 1,000 feet AGL, and he called for flaps to be retracted. The FO retracted the flaps in stages as commanded. 

GPWS warning

During the initial stage of the flap retraction, a 'DON’T SINK' caution alert-19 from the EGPWS was activated. Nine seconds after the 'DON’T SINK' caution alert, a second 'DON’T SINK' caution alert was activated. At this time, the flaps were still being retracted and the flight crew were still troubleshooting the first caution alert. This was followed by a third 'DON’T SINK' caution alert a further nine seconds later. The flight crew then realised that the aircraft had levelled off and they needed to reinitiate a climb. 

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The PIC engaged the FLCH on the MCP. However, two seconds later, he re-engaged the VNAV mode by engaging the VNAV switch, which removed the FLCH mode. The PIC thought that he had resolved the issue as the 'DON’T SINK' caution alert had ceased. However, according to the Quick Access Recorder (QAR) data, the short FLCH engagement resulted in no appreciable change in altitude as the aircraft was oscillating between 480 to 500 feet AGL. 

The FO alerted the PIC that they needed to cancel the speed/altitude constraint and the FO pushed the altitude selector button on the MCP to delete the programmed speed/altitude constraint. After doing so, there was no more issue with the aircraft climbing to the intended altitude and the flight proceeded to Singapore without further incident. 

mindFly analysis

Professor Geert Hofstede conducted one of the most comprehensive studies of how values in the workplace are influenced by culture. He defines culture as "the collective programming of the mind distinguishing the members of one group or category of people from others".

Power distance

Singapore scores high on this dimension (score of 74). With a Confucian background, the Chinese normally have a syncretic approach to religion, which is also the dominant approach in Singapore. One of the key principles of Confucian teaching is the stability of society, which is based on unequal relationships between people.

Confucius distinguished five basic relationships: ruler-subject; father-son; elder brother-younger brother; husband-wife; and senior friend-junior friend. These relationships are based on mutual and complementary obligations. Here we can see the high Power Distance Index (PDI) as a consequence.

Power is centralised and managers rely on their bosses and on rules. Employees expect to be told what to do. Control is expected and attitude towards managers is formal. Communication is indirect and the information flow is selective. We can see the high PDI also in the government’s defined 'shared value': Nation before community and society above self.

Individualism

Communication is indirect and harmony of the group has to be maintained. Open conflicts are to be avoided. A 'yes' doesn’t necessarily mean 'yes'; politeness takes precedence over honest feedback. The relationship has a moral basis and this always has priority over task fulfilment. The face of others has to be respected, and especially as a manager, calmness and respectability are very important.

Uncertainty avoidance

Singapore scores eight on this dimension and thus scores very low. In Singapore, people abide by many rules not because they have the need for structure but because of high PDI. Singaporeans call their society a "Fine country. You’ll get a fine for everything."

Keeping these three dimensions in perspective, one can safely conclude that society has a very strong role in the upbringing of an individual. This creeps into the work culture too. However good a training programme is, if the corporate culture is unable to override the national and/or personal culture, training in a controlled environment will not translate into performance in the real situation.

It is imperative that while designing a training curriculum according to the instructional design methodology recommended by the International Civil Aviation Organisation (ICAO), cultural and organisational aspects are kept at the forefront while carrying out a detailed task analysis.

Analysis should include a study of the organisational system in which personnel must work, the critical aspects of individual functions of the profession and the performance levels required for each function in that profession. This analysis is referred to as task analysis.

(This article first appeared in safetymatters.co.in)

(Cover image courtesy Wikimedia Commons/tjdarmstadt)