Developing Advanced Crew Resource Management (ACRM) Training: A Training Manual(117)

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Report 02
BGM information 800' scattered, 1200 broken, 2300' overcast, 2 mi. light snow, temp 27, dew point 21, winds 270 at 8 kts, altimeter 29.97, breaks in the overcast, NDB 34 approach in use, localizer 16/34 out of service, runway 34 plowed and sanded full width and length, braking action good reported by a vehicle. PF and PNF discussed possibility of using runway 28 due to surface wind component. Further inquiry with BGM approach confirmed runway 28 plowed and sanded full width and length and previous inbound company reported braking action as poor. Surface wind was also reported as unchanged. PF (PIC) requested and was cleared for VOR DME approach runway 28. PNF briefly studied the procedure, and then gave the approach plate to the PF. Due to the proximity of the airport, the high indicated airspeed, the excess alt and the flight crew's anticipation of the ILS 34 approach, the workload of the flight crew was quite high. The PNF went off frequency to make the range call to company. The PF descended from the published segment alt (3500' MSL) at the 18 DME position to the published straight in landing MDA of 2000' MSL. The FAF for the procedure was at the 13 DME position and the PF’s premature descent put the aircraft 1500' below the published segment alt. The airport was sighted prior to the visual descent point and the approach terminated uneventfully. Supplemental information from ACN 104150 it was discovered by approach control just as we passed the final approach fix. I was pushing the aircraft to maintain schedule.
Report 03
Received taxi instructions to runway 22 for first flight of the day. I set heading but for 220 degrees and was about to taxi when ground reported wind as 290 degrees at 8 kts (ATIS reported at 240 degrees at 9 kts). F/O and I were doing preflight checklist as we were taxiing to runway (standard procedure), and even though I had runway 22 in mind, I actually visualized runway 28 and started that way. We checked for traffic on the long runway as we crossed it on the way to
28. Just about the time we finished the checklist I realized that we had just crossed the active
runway 22. At this point we had just switched to tower frequency and he just noticed that we
were on the wrong side of 22. No traffic conflict occurred, but even though we had looked for
traffic, a conflict was possible. Factors were
first flight of the day; at familiar airport, but hadn't been there recently; performing checklist while
taxiing; and not checking HSI reading before crossing runway.

Report 04
We were cleared for takeoff when our left-hand pitot heater failed. Our MEL states we can fly w/o the left-hand pitot heater if we stay clear clouds below +4 sat and/or known icing conditions. I was not sure we could comply with those restrictions, but I decided to go anyway. Enroute we checked weather at our destination and alternates. All had high ceilings (6000'), 15+ nm plus visibility and were well above freezing (55 degrees f). We also received reports of heavy icing in clouds at 11000' MSL. Still, I elected to press on. We talked over the possible implications and possibility of losing the left-hand ASI and altimeter. We discussed the procedures for having the pilot in the right seat assume flying duties if I lost my airspeed and altimeter. We were incredibly stupid. In our descent at 9000' MSL due encountered not only very heavy icing, but moderate to severe turbulence. I almost immediately lost both my ASI and altimeter. The right seat pilot assumed flying duties. His ASI showed a warning flag so was suspect and could not be trusted. Because of the turbulence he needed both hands to control the aircraft. I had to control the throttles, monitor his flight ins from my side, assess the situation and make decisions, and handle the radios. The PF also stated he felt he wasn't turning when he was, and vice versa, obviously he was experiencing incipient vertigo due to the turbulence and loss of ins. Even though we had good gyros the loss of other primary flight ins interrupted our normal scan and confused our normal senses. To further complicate the situation, Center couldn't give us a lower alt. I finally communicated the urgency of the situation and they gave us a lower alt. At that point we couldn't maintain alt because of the turbulence anyway. Once we had a clearance to a lower alt we descended by reference to attitude only. We broke out at 5000' MSL in warmer air and almost immediately got all ins back. We made a normal approach and landing. There are many lessons to be learned here. My motivation for continuing the flight with a known deficiency was the result of pressure of a very heavy schedule with upper management aboard, and my desire not to inconvenience them. I also now realize I was getting complacent and felt I could do anything (arrogant). I am appalled by my lack of professionalism. The worst part is I know better, but I still succumbed to outside pressures. Never again. Callback conversation with reporter revealed the following: reporter reiterated self-displeasure for his actions. He said, "I did what the company pays me not to do." The reporter also said how shocked he was at the great speed with which the situation got out of control. One factor not initially related by the reporter is that at the time of the incident, the flight crew had been on duty 14 hours, and that fatigue probably affected judgment. The reporter is also the chief pilot for his company. After this incident, he called all company pilots to a meeting to discuss this incident, its causes and effects. He felt that his flight department could benefit from a discussion of the human factors issues.
　
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