Guest Nobias Posted August 30, 2003 Share Posted August 30, 2003 That's precisely it. After fifty, a hundred, five hundred times of calling "V1, Rotate" in rapid succession, it becomes almost automatic. It's the same with some checklist items. And that complacency is only exacerbated when there is another senior guy next to you and you think, "Well, I don't have to worry about what he does. I can trust him." It's always easy to sit back and say, "Well, I would never..." We would all like to think that we wouldn't, but I'm sure those guys thought that they wouldn't either. I'm not trying to defend them, just trying to understand how it happens. Link to comment Share on other sites More sharing options...
Don Hudson Posted August 30, 2003 Share Posted August 30, 2003 Hi Mitch; The quote from the report refers to the fact that CRT symbols of all kinds, in this case on the PFD (Primary Flight Display, where the airspeed is, on the left as a vertical "tape" display) can be displayed "in the same place" (overlap one another), presenting a cluttered display. On the ND (Nav Display), several pieces of information, (time, constraint data etc) can be displayed simultaneously, depending upon what is selected on the mode control panel. Normally this isn't a problem. I recall the PFD speed display on the 320 which, until the weights got into the higher range, exhibited the same characteristics as are referred to in this report: the circle and the letters "V1" overlapped one another. One got used to the display and could "see through" the overlap and probably, the long-term result could be a "new" symbol..the V1-overlapping-Rotation-Speed, etc... In the case of heavier weights, because the airspeed strip is a window which is only so many knots "wide", when the aircraft has accelerated to V1, the Rotation "circle" could still be hidden at the top of the tape in the yet-to-be-seen area...an area which would have come into view in, likely, two or three seconds at those acceleration rates. Link to comment Share on other sites More sharing options...
Guest neo Posted August 30, 2003 Share Posted August 30, 2003 I agree with V1. This was a career-ending incident for two highly experienced pilots. The first thought that should come to every pilot's mind is not condemnation of that flight crew, but a commitment to redoubling your efforts to keep human error at a minimum in your cockpit. Some observations: - Flight management systems are designed by engineers (including flight qualified engineers) who do not spend their time on the line day in and day out. Pilots are required to alter their own practices to conform to what "The Box" and the procedures established to run it require. There is a lot of work that needs to be done to make The Box work more for the pilot, rather than the other way around. - Many training pilots spend the vast majority of their time in simulators, and they become highly competent at running them. Flying in and out of busy international airports is a different environment. It doesn't require more skill than running a simulator, maybe less. But it does employ a different skill set. If this incident was one where two training captains left their usual environment and flew off to FRA, then that's not good practice. A training guy should go out with a line guy, not with another trainer. By the way, even ONE training captain heading out for his competency flight is a situation that requires a shift in thinking for both pilots in that cockpit. It's the training pilot that has left his familiar environment and the line guy that is in his own milieu. But if the perceived 'heirarchy' is that the training guy is running the show like he or she would in the simulator, then bad things can happen. - A third set of eyes (and ears) in the cockpit can be an INVALUABLE asset, in particular on long flights to foreign destinations. Fatigue, tricky R/T, foreign procedures... all combine to make errors not just possible but inevitable. I make a point of watching EVERY keystroke entered, because even though the other pilots are usually far more skilled than I, mistakes do happen. The third brain acting as an critical arbiter of what's been entered, planned, seen, heard or assumed can save the day. Three crew in the cockpit is, without a shred of doubt, a safer operating practice. The Box, to a degree, was intended to take the place of the third pilot, but The Box is as dumb as a sack of hammers. It has no ability to detect human error. It happily accepts our mistakes without complaining, and worse yet acts on them. The third pilot on the other hand is constantly reviewing what the other two have done or are about to do. That third check on the validity of entered data or chosen path of action will never be duplicated by the computer. It's an element of safety that we should never have given up. neo Link to comment Share on other sites More sharing options...
Guest neo Posted August 30, 2003 Share Posted August 30, 2003 I agree with V1. This was a career-ending incident for two highly experienced pilots. The first thought that should come to every pilot's mind is not condemnation of that flight crew, but a commitment to redoubling your efforts to keep human error at a minimum in your cockpit. Some observations: - Flight management systems are designed by engineers (including flight qualified engineers) who do not spend their time on the line day in and day out. Pilots are required to alter their own practices to conform to what "The Box" and the procedures established to run it require. There is a lot of work that needs to be done to make The Box work more for the pilot, rather than the other way around. - Many training pilots spend the vast majority of their time in simulators, and they become highly competent at running them. Flying in and out of busy international airports is a different environment. It doesn't require more skill than running a simulator, maybe less. But it does employ a different skill set. If this incident was one where two training captains left their usual environment and flew off to FRA, then that's not good practice. A training guy should go out with a line guy, not with another trainer. By the way, even ONE training captain heading out for his competency flight is a situation that requires a shift in thinking for both pilots in that cockpit. It's the training pilot that has left his familiar environment and the line guy that is in his own milieu. But if the perceived 'heirarchy' is that the training guy is running the show like he or she would in the simulator, then bad things can happen. - A third set of eyes (and ears) in the cockpit can be an INVALUABLE asset, in particular on long flights to foreign destinations. Fatigue, tricky R/T, foreign procedures... all combine to make errors not just possible but inevitable. I make a point of watching EVERY keystroke entered, because even though the other pilots are usually far more skilled than I, mistakes do happen. The third brain acting as an critical arbiter of what's been entered, planned, seen, heard or assumed can save the day. Three crew in the cockpit is, without a shred of doubt, a safer operating practice. The Box, to a degree, was intended to take the place of the third pilot, but The Box is as dumb as a sack of hammers. It has no ability to detect human error. It happily accepts our mistakes without complaining, and worse yet acts on them. The third pilot on the other hand is constantly reviewing what the other two have done or are about to do. That third check on the validity of entered data or chosen path of action will never be duplicated by the computer. It's an element of safety that we should never have given up. neo Link to comment Share on other sites More sharing options...
Don Hudson Posted August 30, 2003 Share Posted August 30, 2003 Hi Mitch;, The quote from the report refers to the fact that CRT symbols of all kinds can be displayed "in the same place" (overlap one another), presenting a cluttered display. This characteristic crowding of data has been present on all CRT displays. On the ND (Nav Display), several pieces of information, (time, constraint data etc) can be displayed simultaneously, depending upon what is selected on the mode control panel. Normally this isn't a problem and the data can be selected so as not to form a mash of pixels. On the 767, I recall the 'mash' occurring at the top of the Horizontal Situation Indicator (Airbus ND). I recall that the V1/Vr speeds on the 320 which, until the weights got into the higher range, were within a few knots as well, (by design under twin-certification rules), and exhibited the same PFD (Primary Flight Display) characteristics as are referred to in this report: the circle and the letters "V1" overlapped one another. Over time, one got used to the display and could "see through" the overlap and, perhaps, the long-term result could be a "new" symbol..the V1-overlapping-Rotation-Speed "symbol", etc...Dunno, just speculating. In the case of heavier weights however, because the airspeed strip is a window which is only so many knots "wide", when the aircraft has accelerated to V1, the Rotation "circle" could still be hidden at the top of the tape in the yet-to-be-seen area...an area which would have come into view in, likely, two or three seconds at those acceleration rates. Our 767s use an entirely different method for V-speeds...a flip-card with speeds for each weight. The V1 speed calculations can be modified from there for contamination etc, but it remains that physical bugs are set on the Airspeed indicator, and for me, a human-factors point of view might suggest that the tactile act of setting bugs may assist in reinforcing speeds, I don't know. But the value of the Airbus method may be in the flexibility of V-speed calculation... the V-speeds are tailored to each runway that the Airbus uses for departure. The goal is to lift as much weight off that runway as possible while retaining the margins necessary for a rejected take-off or to satisfy 2nd segment (400' agl to 1500' agl) climb requirements with an engine out. In other words, the speeds are fine-tuned to each runway that we use. As for "habit-formed calls"...long and very old discussion point: Habits are at once the saviour of cockpit discipline and the Achilles' Heel. The whole purpose of training is to build habits of response to minimize thinking in narrowly defined critical situations or to build familiarity in order to remove the element of surprise when something goes wrong. I suspect our most common "abnormal" these days is a go-around. One would think that such a procedure should be a non-event but for anyone who's done one (includes most of us), its a time of much higher alertness and discipline because we're off the beaten track. A return to the departure field is the same thing, as is an enroute landing or proceeding to one's alternate. There are significant human factors involved in these changes-to-the-plan which, while we train incessantly for in the simulator, nevertheless present, depending upon the situation, an element of "surprise", and a re-adjustment of thinking/planning priorities etc has to occur in a fairly short time. These are times of very high workload. Cheers, Don Link to comment Share on other sites More sharing options...
Jaydee Posted August 30, 2003 Share Posted August 30, 2003 without prejudice....the view from the right.... I believe allmost every AirBus accident since the infamous go around in France years ago has had a superviser in the cockpit for whatever reason. That alone tells a huge story. There is a huge difference between flying a desk 24/7 than flying the real thing. As well, there is a big difference between knowing what to do ( aka superviser ) and actually doing it. ( aka everyday experienced line pilot ) It should be mandatory for supervisers to fly a full block,,,,say every 3 months or so for competency, instead of the occasional juicy tid bit they steal from open time or through displacement. Also, imo, supervisers shouldn't be allowed to spend an entire career in the office.They should be rotated out every two years or so. The entire pilot rank would benefit in the long run, by getting a shot " to see both sides of the picture". It's only natural their actual flying skills / reaction times would erode over time. Link to comment Share on other sites More sharing options...
Don Hudson Posted August 30, 2003 Share Posted August 30, 2003 Neo; The Air New Zealand B767 approach/go-around into Faleolo, Samoa in July, 2000 illustrates your point as no other incident can. This is a report worth reading for human factors, crew coordination, CRM and just plain great airmanship. Anyone interested in it can find it at: http://www.caa.govt.nz/Occurrences/00-2518.htm Don Link to comment Share on other sites More sharing options...
Guest shibui Posted August 30, 2003 Share Posted August 30, 2003 Sorry, can't even remotely agree here. There is no 'third brain' required to screen the fact that 120-odd knots is an utterly wrong speed at which to commence the rotation of a 220 ton airplane. The folks in the back just want to get home to see grandma and if in your 20,000 (!) hours of brain-dead flying you have not yet got a handle on the above-mentioned logic screen, you had better (for the sake of all of us) be greeting people at Walmart instead of pushing the envelope. Link to comment Share on other sites More sharing options...
Guest shibui Posted August 30, 2003 Share Posted August 30, 2003 Rough edit: when I said "you" I don't for a moment mean 'neo' for whom I mean no disrepect. It is a distaff reference to the FRA perpetrators. I suspect that 'neo' needs no further flames this week. Confutatis maledictis flammis acribus addictis voca me cum benedictis Link to comment Share on other sites More sharing options...
Guest shibui Posted August 30, 2003 Share Posted August 30, 2003 I see clarification is required here. By 'you', I don't for a moment mean Neo himself but a rhetorical address to the two unfortunates on the flightdeck in Frankfurt. Neo does not need any further flames this week. Confutatis maledictis flammis acribus addictis voca me cum benedictis Link to comment Share on other sites More sharing options...
Mitch Cronin Posted August 30, 2003 Share Posted August 30, 2003 Shibui, there's no need to get harsh here... Re: "120-odd knots is an utterly wrong speed at which to commence the rotation of a 220 ton airplane." And it was not so. 157 was the "proper Vr", both entered and read out. Actual rotation was stated to have commenced at 133 after the incorrect call. Does the guy hauling on the stick usually confirm with his own eyeballs that the blue circle is there?"The early rotation was induced by the erroneous V1 speed. It could not be determined why neither the PF nor the PNF noticed the unusually large spread between V1 and VR when the PF read the speeds off the MCDU just before the take-off roll. It is possible that the PNF did not notice the discrepancy at that time because, having entered the data himself, he heard what he expected to hear. During take-off, the PNF, as was his habit, called V1 as he saw the speed reference index reach the "1" on the PFD, followed immediately by the "rotate" call. Had both flight crew members maintained situational awareness during the take-off roll, they would have noticed the absence of the blue circle, usually superimposed by the "1", or would have noticed that the actual indicated airspeed was well below the briefed rotation speed of 157 knots."Please forgive my limited knowledge, but is it utterly wrong to ever accept a V1 speed of 120 odd knots in a 220 ton airplane? Does runway length help determine V1 speeds, making possible such a low V1 on occasion? Or would it never be so low? Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 30, 2003 Share Posted August 30, 2003 Not a very intelligent response on the part of Air Canada, I'm afraid. Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 30, 2003 Share Posted August 30, 2003 Who said they were 'heads down'? I didn't see that in the report. Usually a crew is looking on the PFD for GS*. Part of their SOP as I understand it. Sorry. Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 30, 2003 Share Posted August 30, 2003 Are you serious? Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 30, 2003 Share Posted August 30, 2003 Mitch, depending on WAT and takeoff config you could have a V1 speed 'close' to that. Link to comment Share on other sites More sharing options...
Mitch Cronin Posted August 30, 2003 Share Posted August 30, 2003 Hi Don, I've just been reading, with interest, the NZ incident which you provided the link to in your response to Neo... I haven't gotten far yet, but my early thoughts are that the SP ought to have spoken out as soon as he noticed the DME vs altitude situation... I'll read more in a minute... It's interesting to read the various comments here... I have a suspicion that folks who have themselves made errors that, had anyone asked, they would have felt sure they never could have made prior to doing so, may be less critical of others and less likely to say "never". All experiences teach us what possibilities exist, often ones that we hadn't imagined. Permit me to wander down a rabbit trail... Having an unnatural and almost insane love of aircraft, I dabble with remote controlled little ones... I have noted over time that the folks most likely to bring their airplanes home from the little flying field in pieces, are likewise the most likely to have been cocky enough to say they "never crash". And conversely, those willing to admit they understand the inevitable (as it is with these little beasts, what with possibilities of power failures, radio frequency interuptions, momentary lapse of brain [it only takes a moment!], often exacerbated by the lack of feel, and poor wind judgement, as the flyer is not with the bird...), seem to leave the field more frequently with their little machines intact. I think the "I'd never let it happen" attitude isn't healthy. I'm inclined to think that one who recognizes the possibilities for his own errors, is more likely to make use of, and build his own, safeguards to minimize the possibilities of errors. In my line of work, as others, people range from outright cocky to those who are notably lacking in confidence. Safeguards exist and are utilized by all... But the more experienced folk are very rarely shy about having someone else check their work, even when it's not required. I believe part of what "experience" does is show us our fallibility's and help us to learn ways to guard against them. Cheers, Mitch Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 30, 2003 Share Posted August 30, 2003 cpdude very insightful. AC SOP is the same. FYI cheers Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 30, 2003 Share Posted August 30, 2003 shibui, Sorry my man. But based on your words, you just don't have a clue. What glass airplane or kind of airbus you driving? Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 30, 2003 Share Posted August 30, 2003 Mitch. Well said. Couldn't agree more. Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 30, 2003 Share Posted August 30, 2003 When times were better (much better) in the Canadian Airline industry, I just loved to hack away at Air Canada. However, as I read through the various postings on this AC875 tail strike, I’m reminded of how ‘immature’ and ‘uneducated’ we pilots can be when it comes to “learning from the mistakes of others”. I don’t know how some of you make it through your aviation day with such unprofessional (or, certainly uninformed) attitudes. How many even understand the concept of ‘learning from the mistakes of others’? The obvious hostility in most of these judgemental comments reek with such a ‘down- with-Air Canada’ sentiment, they’re ridiculous. (shakes head from side to side) There are many excellent lessons in this incident for those of you (who care) to take the time and learn something about Human Factors, Glass Cockpit Management, SOP design and development. I’d also like to think that two fairly experienced, senior Air Canada, “can’t happen to me” ACP Captains, would have lots to say and to pass on to their respective Air Canada CRM developers and Flight Safety program managers as well as Training Department personnel about this entire incident. Why weren’t they put on the lecture circuit? Air Canada pilot management should be the ones embarrassed by and hanging their heads in shame for the manner in which this incident was handled. Not the crew involved! If these guys were keel hauled and unceremoniously drummed out of the regiment, it would seem to me that ‘face saving’ was the greater concern than learning anything. How disappointing is that? (Each one of you nay sayers should have responded, VERY.) Canadian pilots (generally) like to humiliate and condemn at the drop of a hat. It’s much easier to adopt this macho ‘can’t happen to me’ attitude than putting the old grey matter to work. Unfortunately, there’s more to the equation than this simplistic mentality which obviously some of you need to rethink. For those who get it, you’re wasting your time reading more of my rant, so I’d urge you to go on to other things. For those who don’t get it, I can only hope to inspire you, as much as I can, to start engaging your brains by understanding the process more clearly and to discover what is meant by “learning the lessons”. Very simply, the video of a DC-10 landing and resultant debris on the runway and in the corn field at Sault City Airport a few years ago was proof positive that Capt. Al Haines seriously messed up and got it all wrong. So too, were the hundred and some odd lives that were lost, evidence and the result of, his messed up landing. So, why wouldn’t you have fired him and called for his head on a silver platter? Because, the entire incident was analyzed, understood, lessons learned, procedures changed, maintenance practices improved, a system redesigned and passed on to others. The entire aviation community in fact, had something to learn. One of the greatest CRM lessons on the planet! Capt. Al will tell you in his presentation what was learned in this exercise of remarkable CRM and how it was passed on to others. The entire key here is ‘passed on to others’. So we might learn from their mistakes. Why wasn’t this done in this case? I don’t get it. (shrugs shoulders in disbelief) Does it have to be catastrophic before we learn something? I don’t think so. Neither do you. If you’re out there flying airplanes, remember this, if nothing else, there are those who HAVE, those who WILL and those who say never, are full of sh*t! Link to comment Share on other sites More sharing options...
dragon Posted August 30, 2003 Share Posted August 30, 2003 Thanks for saying a lot of what I don't have time to type out right now. Link to comment Share on other sites More sharing options...
Don Hudson Posted August 30, 2003 Share Posted August 30, 2003 Mitch; Great rabbit trail. There is much in what you say regarding infallibility, human error, "cockiness", and the "I'd never allow that to happen" syndrome. The addressing of human error is the most difficult, frustrating, elusive and ephemeral goal because human beings are so "creative" at making errors... I know with absolute certainty that the most cautious, disciplined, focussed, trained and professional pilots who make great crews can and do make mistakes. A systems approach puts barriers in the way to prevent mistakes from becoming headlines. Like golf, the stock market, tennis, and other human endeavours in which we try to "beat" the odds, past performance in aviation is never a predictor of future performance or outcomes. That's why a systems approach comes close to the mark and that's how Jim Reason came up with the notion of the swiss cheese model...we have SOP's, regulations, CRM, beautifully designed aircraft, great maintenance, attentive dispatching and industrial contracts all of which focus mainly on keeping the operation safe. The books are thick because the lessons are many. The dramatic decrease in the percentage of aircraft accidents per, say, million seat-miles since the 50's is getting difficult to sustain as traffic increases however. The percentage has levelled off but as traffic increases, the actual number of incidents can increase. I suspect this is true for other professions as well, which I mention below. That is why programs like FOQA, Flight Operations Quality Assurance, are flourishing (or should be) at major carriers. An airline that knows what its airplanes are doing on a day-by-day basis and which monitors de-identified flight data for trends and for the occasional incident, is a learning organization which places flight safety above "enforcement/discipline". Certainly accountability is a serious factor, but in what form should/must "accountability" take and to whom should it be ultimately directed? The difficulty comes when an incident occurs. The airline has a legal responsibility to the regulator, to its owners/shareholders and to its training standards. Yet it has a clear responsibility to learn, and change to improve systems. How do human factors and honest mistakes get handled? With brick-bats and disciplinary measures? Recognizing either individual or systemic failures does not mean that accountability is thrown out the window, and I think that's where many folks on this thread are attempting to go. We have either a crew or a system which fouled up. We can't leave such incidents alone, yet two-weeks off, a "forced" retirement, etc can't and won't solve the original problems. It is an extremely difficult balance to maintain because some of the points made on this thread about the 20,000hrs of experience, and passengers legitimate expectations etc are very real issues. The notion of "mistake" and "recompense" (or, more harsh - firing etc) exists in almost every other profession which deals with high risk environments. The medical profession comes to mind. We know that both professions suffer human error regardless of the precautions taken. The goal of the structures I mention above is to recognize that error will occur and thus mitigate the error path which leads to an undesired outcome. We cannot demand perfection in such environments because it will never happen. Curiously however, "perfection" may result in recognizing this very fact. By acknowledging error, the path is open to prevention/correction. Much literature has been published on this of course... Don Link to comment Share on other sites More sharing options...
dragon Posted August 30, 2003 Share Posted August 30, 2003 " ... I believe the true cause of the incident is a weak procedure adopted by the company."" Can you elaborate? Link to comment Share on other sites More sharing options...
DEFCON Posted August 30, 2003 Author Share Posted August 30, 2003 I'm just guessing they were "heads down". If you were watching the PFD's and the ac spent 15 secs at 27 degrees pitch attitude and 145 kts the pilot problem would be worse than envisioned. In short, I'd bet the SOP wasn't being followed and as a result, the incident followed. Link to comment Share on other sites More sharing options...
DEFCON Posted August 30, 2003 Author Share Posted August 30, 2003 I've got to agree with shibui. The posting and acceptance of such a V speed is so far from being close to realistic that it speaks volumes with regard to pilot competence. Link to comment Share on other sites More sharing options...
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