TOWARDS THE ZERO ACCIDENT GOAL: ASSISTING THE FIRST OFFICER MONITOR AND CHALLENGE CAPTAIN ERRORS



window." (from a confidential report submitted to the NASA/FAA Aviation

Safety Reporting System; quoted in Ginnett, 1993, p. 74).

Two researchers write similarly about the difficulty of the first officer to get
the attention of the captain that an error was being made, referring to “a co-pilot,
concerned that take-off thrust was not properly set during a departure in a snow
storm, failing to get the attention of the captain
[Hesitant Challenging] with the
aircraft stalling and crashing into the Potomac River” (Helmreich and Foushee,
1993, p. 6).

Wiener et al (1993) have classified typical crew errors. If we investigate
this classification we find that several are related to elements of the Milgram
experiment. Three of these errors may be related to, Lack of Monitoring: “failure
to set priorities”, “inadequate monitoring”, and “failure to utilize available data.” A
fourth error is related to Hesitant Challenging: “failure to communicate intent and
plans.” (Wiener et al, 1993, p xvii).

A CASE STUDY WITH A COCKPIT VOICE RECORDING

On December 1, 1993, Express II Airlines Inc. / Northwest Airlink Flight 5719
descended too quickly and crashed before it hit the runway in Hibbing, Minnesota. All
sixteen people on board died. According to the NTSB (NTSB, 1994a) the crash was
caused by several factors: the captain flew the airplane inappropriately; did not
“exercise proper crew coordination”; the first officer did not properly monitor [Lack of
Monitoring] and alert the captain of the problematic descent [Hesitant Challenging]; the
captain intimidated his first officer; there was inadequate airline oversight of the captain,



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