CIRP, First Aid for the Psyche
Air Line Pilot, April 2001, p.10
By Jan W. Steenblik, Technical Editor
On April 28, 1988, Aloha Airlines Flight 243, then one of the most used early-model Boeing 737s, suffered explosive decompression upon climbing to FL240. The aircraft lost a 20-foot section of its upper forward fuselage. A senior flight attendant was swept to her death, and all 89 passengers were injured. By a miraculous combination of skill and luck, Capt. Robert Schornstheimer and First Officer (now Capt.) Madeline "Mimi" Tompkins managed to land the severely crippled airplane (see "All I Could See Was Blue Sky," July 1988).
The near loss of Aloha 243, plus subsequent discoveries and revelations about the geriatric problems of aging airliners, heightened concerns about these issues internationally and led the FAA and the airline industry to develop a comprehensive program to deal with aging aircraft structures.
Similarly, the loss of TWA Flight 800 and all 230 passengers and crew members on July 17, 1996, off the coast of Long Island, N.Y., triggered an international reexamination of safety issues concerning the nonstructural systems, such as electrical wiring, of aging airliners.
Both aircraft were torn apart by pressures and stresses they were not built to withstand—in Aloha 243, normal cabin pressurization pushing against a spreading series of small fuselage cracks; in TWA 800, an explosion in the center wing fuel tank.
So much for the hardware. But what about the people—those who were intimately involved with the accidents and their aftermath? To what pressures beyond their design limits were they subjected?
As it turned out, both Aloha 243 and TWA 800 have played important roles in the creation and maturation, respectively, of one of ALPA’s newest efforts of pilots helping pilots—the Association’s Critical Incident Response Program (CIRP).
Roots of CIRP
Shortly after the Aloha 243 accident, F/O Tompkins said she learned from the 13-minute ordeal that "when we combine good training and crew coordination, we can handle any crisis thrown our way."
Her post-traumatic stress disorder (PTSD), rooted in the tragedy of Aloha 243, had not yet blossomed to cast its shadow on her soul.
At first, Capt. Schornstheimer and F/O Tompkins felt that their biggest problem after the accident was dealing with the ceaseless hounding of television crews and reporters, some of whom camped in front of Capt. Schornstheimer’s house. F/O Tompkins upgraded to captain, but flew as a copilot for a few more months while Aloha replaced other aging B-737s. As a new captain, she bid freighter trips for a while to escape from reporters who’d obtained her flight schedule and booked themselves on her flights to try to get an interview with her.
As the months passed, however, she suffered flashbacks, sometimes several per day; chronic fatigue from seldom sleeping more than 4 hours at a time; and other symptoms. While Capt. Schornstheimer had a family in Hawaii to provide vital emotional support, F/O Tompkins did not.
"I’m the kind of person who doesn’t like to admit something’s bothering me," she confesses. "I was sick a lot, and I missed a lot of work."
A year and a half after the accident, Capt. Tompkins contacted ALPA’s Aeromedical Advisor, Dr. Donald Hudson, a former U.S. Air Force flight surgeon and Southeast Asia veteran who is board-certified in both aerospace medicine and psychiatry. He played a key role in helping Capt. Tompkins recover from what had become a classic case of PTSD.
Profile of PTSD
After an incident, accident, or investigation, crew members may experience stress reactions. The individual’s perception of an event is the cause of the stress. Every person reacts differently, but the reactions may be categorized in four general areas: physical, emotional, cognitive, or behavioral. Sleep problems are the most common complaints of pilots calling the ALPA Aeromedical Office.
Dr. Hudson says the Office has seen 95 cases—all delayed-onset—since 1990. The referral sources for these cases have included the ALPA Legal Department, Human Performance Committee (Pilot Assistance, Professional Standards, Aeromedical, and CIRP Committees) members, chief pilots, training committees, and friends and family members.
Dr. Hudson notes that, without treatment, "82 percent of pilots with PTSD leave the airline industry, usually within three to four years, with collateral damage to friends, family, and others around them."
Half of the pilots with PTSD have been women, typically with gender violence in their past. The men in the group have been older pilots (median age 53), usually having more severe symptoms because they were diagnosed later; six committed suicide. The males also tended to have had combat experience in Southeast Asia and suffered from reactivation of a previous trauma. Dr. Hudson and his colleagues have also observed, after a major accident, a "daisy chain" effect of stress reactions on other pilots flying the same type of airplane and/or working for the same airline.
The "view from Denver," says Dr. Hudson, is that "early intervention is the key." Consistent followup of the pilot’s case is vitally necessary and must include attending to the pilot’s physical symptoms.
The ALPA Aeromedical Office’s evaluation protocol for PTSD includes an interview at the Office’s facility in Aurora, Colo., with the pilot’s spouse or "significant other" participating; a general physical exam; a neurological exam; and an exam by other specialists if appropriate.
Regarding PTSD, Dr. Garrett O’Connor, a California psychiatrist who has worked with pilots for more than 20 years, advises that if an acute stress reaction lasts longer than 1 month, the patient is suffering from PTSD. Dr. O’Connor characterizes PTSD as a situation in which "the severity of the trauma exceeds human design capacity." Continuing the analogy, he explains, "If you enter a thunderstorm cell, the first thing you’re supposed to do is slow to maneuvering speed so the airplane will stall before it can suffer structural failure. A critical incident stress debriefing is the psychological equivalent of slowing to maneuvering speed."
ALPA’s CIRP history
Capt. Tompkins, now ALPA’s International CIRP chairperson, first described her ordeal publicly at the 1991 ALPA Air Safety Forum, and again at a human factors workshop. Some members of ALPA’s pilot volunteer air safety structure decided they needed to do something to help other ALPA members in similar situations.
ALPA’s Human Performance (now Human Factors) Committee created a project team of Capts. Tompkins, Alan Campbell (Delta, now retired), and Robert Sumwalt (US Airways), with Dr. Hudson and ALPA attorney Jim Johnson serving as advisors. "We didn’t even know the term ‘critical incident response’ yet," Capt. Tompkins recalls.
The trio learned of Dr. Jeffrey Mitchell, Ph.D., founder of the International Critical Incident Stress Foundation (ICISF) and inventor of a process for critical incident response that was being used successfully with firefighters, paramedics, and others who dealt with trauma regularly.
The team also discovered that the Canadian Air Line Pilots Association had been addressing critical incidents involving their members through CALPA’s Pilot Assistance Committees for several years. In fact, AirBC was the first airline in North America to implement a CIRP.
The ALPA team drew up a proposal for a CIRP, and the Association’s Executive Board approved it in May 1994.
ALPA held its first CIRP training course in September 1994. Less than a month later, the pilots of Simmons Airlines (now American Eagle) who had taken the training became the first ALPA team to put it to use. Simmons Flight 4184, an ATR 72, crashed in a soybean field near Roselawn, Ind., killing all 68 people aboard.
Capt. Rick Bicknell, now a Northwest first officer and an ALPA Basic Safety School CIRP instructor, worked with the Simmons crewmembers’ families. He was helped by Carolyn Burns, a mental health professional and ICISF critical incident stress debriefing (CISD) trainer who at the time worked with the Northern Illinois CISD Team. Burns consulted with Capt. Bicknell and interacted with the accident investigators who might be affected by this terrible accident.
By the end of December 1994, Alaska, Delta, Northwest, and TWA began to implement CIRPs for their employees. Since 1994, ALPA has trained and had certified by the ICISF in the CISD model more than 250 pilot CIRP volunteers and more than 20 spouse/significant others.
These volunteers were put to the test in the TWA Flight 800 accident. This tragedy was a landmark event for several reasons, not the least being that it helped cement the ALPA CIRP volunteers into a truly national (now, with Canadian pilot participation, international) group.
TWA’s Special Health Services Director Johanna O’Flaherty, a former Pan Am employee who helped with the aftermath of the Pan Am Flight 103 bombing over Lockerbie, Scotland, in 1988, knew from experience that she would need outside help.
Volunteers from other airlines were asked to travel to JFK and STL. Trained CIRP pilots from seven different airlines responded within 24 hours to the CIRP Aspen (ALPA’s voice message service) network of Capt. Greg Arikian, TWA ALPA CIRP chairperson.
These volunteers worked for more than a week to provide support to the TWA employees who, despite their own trauma and grief over the loss of so many of their friends and family members, had to continue to function at their jobs.
In September 2000, some 6 years after holding its first basic CIRP course, ALPA held a 3-day advanced course in critical incident stress management (CISM) in Springfield, Mo. Attending were 34 experienced and trained ALPA pilot peers from 15 airlines plus pilots, flight attendants, and other guests from FedEx, American, Horizon, and Carnival Cruise Lines. O’Flaherty was the ICISF-approved aviation-specific course trainer.
How it works
The two most common types of psychological "first aid" or CISM interventions that CIRP volunteers can offer to help mitigate the effect of an incident, accident, or investigation are CISDs and defusings.
A defusing is a shortened version of the CISD that usually takes place immediately, or within 8 hours, after a traumatic event. A defusing may be conducted at any time after an incident or accident, but it is more effective immediately after the event.
Shorter than a formal CISD (about 1 hour compared to 2–3 hours), a defusing is more flexible. For non-fatal accidents, the defusing may be done one-on-one over the telephone due to delays in notifying the CIRP team about the incident or to problems getting crewmembers together once they have returned home. In fact, the great majority of CIRP volunteers’ work is defusings over the telephone.
The purpose of a defusing is to give the crewmember an opportunity to talk about what happened, including the effect of the event on him or her. Stress management education is the main component of this defusing. Also, the CIRP team member will decide if a CISD is necessary.
A debriefing, or CISD, is a group discussion involving a seven-step process in which the participants talk about a traumatic event or series of traumatic events. (It is not psychotherapy.)
Usually held 3 to 7 days after a critical event, a debriefing has several goals—to mitigate the stress effects on those involved in the event, to prevent PTSD in those involved, and to serve as psychological triage to help identify early those who will need the services of a mental health professional (MHP).
For ALPA, a debriefing always involves an MHP trained in this type of debriefing, plus at least one trained peer (for example, pilot or flight attendant) for each employee group represented in the CISD.
The seven steps of a debriefing are introduction, fact, thought, reaction, symptom, teaching about stress management, and re-entry. O’Flaherty, who still works closely with the TWA pilot group, emphasizes that the "facts" in these circumstances are "the facts as they [the debriefing participants] remember them." The "facts" of a CISD are not the technical procedural facts of the event, as in an operational debriefing.
Capt. Dennis Wheeler, FedEx Pilots Association CIRP chairman, says, "We listen not so much to the facts as through the facts to find out what they’re feeling, what they’re trying to work through."
Capt. Steve Pocock, United Airlines ALPA CIRP chairman and ALPA Basic Safety School CIRP instructor, notes, "One of the most important benefits of a debriefing is that it fleshes out the overall picture, expanding it beyond the tunnel vision of [one crewmember’s] own experience."
Capt. Constantine "Connie" Kleissas (US Airways), who served until last year as a member of his pilot group’s CIRP team and now, as a member of ALPA’s Accident Investigation Board, teaches CISM at the ALPA Basic Accident Investigation School, says that ALPA has come a long way in meeting the needs of pilots involved in accidents.
As a surviving crew member of a fatal accident himself, Capt. Kleissas fully appreciates the importance of having CIRP teams trained to respond to the worst-case scenarios.
"My accident," he explains, "occurred before ALPA had formalized its CIRP. I was fortunate enough to have the key elements of a good support system in place—but frankly, that was pure luck. Others might not be so fortunate. Since the time of my accident , ALPA has done an excellent job of formalizing the successful elements needed for CIRP."
Not just for major disasters, CIRP is also for dealing with situations that stop short of causing death or serious injury. A CISD may be appropriate, for example, after running off the end of the runway, an engine fire, or an evacuation. An incident in a foreign country is particularly disturbing for crew members who are arrested and/or interrogated.
Pilot acceptance of CIRP may come slowly in some quarters. Capt. Chuck Brown (Air Nova) says that he has been referred to as the chairman of the "Feel-Good Committee." First Officer Jessica Hatfield (US Airways) believes that most pilots see CIRP as "that touchy-feely stuff."
Take it from Capt. Dick Duxbury (Northwest, Ret.), a converted skeptic who has seen the elements of CIRP work across a broad spectrum of situations: Capt. Duxbury, who received the 1995 ALPA Air Safety Award for his many years as an ALPA air safety volunteer (see "Capt. Dick Duxbury, ‘Accident Preventer,’" August 1996), admits that he doubted the value of CIRP—until he participated in the field investigation of a fatal airline accident at a small airline, providing the skills and experience he had acquired as the chief accident investigator for the Northwest pilot group.
"The pilot group was new to ALPA," he recalls. "They didn’t have any accident investigators yet. All the pilots knew each other, which is typical on a small airline. Some of their pilots volunteered to help with the accident investigation. They were there when we were putting the bodies in the body bags. These pilot volunteers were just brutalized by the accident.
"I realized we had to do something for them. I called Doc Hudson and said, ‘You have to come out here and help these guys.’ He came, and he helped them a lot. That was before we had a formal CIRP structure."
Capt. Duxbury has continued to serve in retirement as a trained ALPA CIRP volunteer. Recently, he defused a female copilot involved in an operational incident. "The vast majority of pilots who’ve been in this situation have been men, but she felt she had let down the entire female pilot community," Capt. Duxbury explains. "That was something I’d never have thought of."
Perhaps not, but as a pilot peer, he was able to listen to her story and help her realize that her reaction to the incident rang with the core truth of all such pilot experiences—they are, as Dr. Mitchell has often stressed, "the normal reactions of normal people to abnormal events."
Next month: Veteran ALPA CIRP volunteers share their experiences and lessons learned from the real world of CIRP on the line.