Learning from Alitalia 404 : The importantance of Crew Resource Management (CRM)

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(Last Update: 2020 Apr 28 1535Z)

The air crash of Alitalia Flight 404 (AZ404/AZA404) happened on November 14, 1990. The international passenger flight scheduled to fly from Milan, Italy, to Zürich, Switzerland, operated by Alitalia, crashed into the woodlands as it approached Zurich Airport killing all 46 people on board.[1]

A Swiss investigation concluded that the crash was caused by a short circuit, which led to the failure of the aircraft’s NAV receiver. The malfunction went unnoticed by the crew

Swiss authorities also blamed inadequate Crew Resource Management experienced when the Captain vetoed the First Officer’s attempted go-around, along with the absence of lighting on Stadlerberg Mountain and a known problem with errors in reading the drum pointer altimeter of the aircraft.

To me, it is an important case for those pilots with “Judger” Personality. Don’t be so confident – we are human – human is to err. Indeed, we should be open-minded and take advice from our partners.

After watching the whole episode of the “air crash investigation”, I suddenly think of an article from the magazine : #https://studyflying.com/technology-and-automation-seem-to-have-adverse-reaction/

There are various reasons play role in modern aircraft incident/accident:

  1. Human factor (limitations) : somatogravic illusion  – it is important for pilots to develop an effective instrument scan, but it is also very difficult because of the need to reject the balance organs’ misleading input
  2. Machine side : Flightdeck design, aircraft systems and flight management tools have changed over the past three decades
  3. Human side : changes in pilot education, sourcing, selection and training over the same period
  4. Environment side : Poor paired in terms of experience could lead to accidents
  5. Organisation side : Not sufficient manual-flying experience due to regulations and restrictions

Obviously, the human factor as well as environment side played critical role in the tragedy of AZ404 – poor paired – the non-assertive enough Co-pilot and the “judger” Captain seems to be the best pair for the ill-fated flight.

Apart from learning the root causes of the accident, I noticed various terminology which is worth to share:

  1. ILS
  2. HSI
  3. GPWS



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