dragon Posted August 30, 2003 Share Posted August 30, 2003 Excellent as usual Don. I too am reading the ANZ report you have provided the link to, I will respnd when time permits as I have a few thoughts on the topic. Happy weekend to you. 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...
Guest neo Posted August 30, 2003 Share Posted August 30, 2003 It appears you wish to focus on classifying the specific mistakes these pilots made as contemptible blunders, rather than seeing it as an opportunity to consider the impact that human fallibility can have on any given flight. While there's no doubt that the errors were serious, an even graver error would be to assume that you could never make an equally werious one. No one starts out the day thinking they're going to make a bone-headed cock-up; but by golly they happen. And sometimes with fatally serious consequences. So is the correct demeanor to walk into the flight planning room believing that you're invulnerable to a mistake of this caliber, or is some other point-of-view desirable? You need only ask yourself, what attitude would you prefer in your fellow crewmembers? The attitude that, 'no way that could ever happen to me' or the attitude that, 'on any given day, I could be the guy that screws it up, and I'm going to watch for it and make damn sure I don't let it happen'. My original comments had nothing to do with defending or excusing the mistakes, although I have no difficulty in recognizing them as generically human. My comments were only intended to illuminate some reasons why cockpit errors happen and to suggest ways to avoid them. neo Link to comment Share on other sites More sharing options...
Guest neo Posted August 30, 2003 Share Posted August 30, 2003 It appears you wish to focus on classifying the specific mistakes these pilots made as contemptible blunders, rather than seeing it as an opportunity to consider the impact that human fallibility can have on any given flight. While there's no doubt that the errors were serious, an even graver error would be to assume that you could never make an equally werious one. No one starts out the day thinking they're going to make a bone-headed cock-up; but by golly they happen. And sometimes with fatally serious consequences. So is the correct demeanor to walk into the flight planning room believing that you're invulnerable to a mistake of this caliber, or is some other point-of-view desirable? You need only ask yourself, what attitude would you prefer in your fellow crewmembers? The attitude that, 'no way that could ever happen to me' or the attitude that, 'on any given day, I could be the guy that screws it up, and I'm going to watch for it and make damn sure I don't let it happen'. My original comments had nothing to do with defending or excusing the mistakes, although I have no difficulty in recognizing them as generically human. My comments were only intended to illuminate some reasons why cockpit errors happen and to suggest ways to avoid them. neo Link to comment Share on other sites More sharing options...
Guest topsy1970 Posted August 30, 2003 Share Posted August 30, 2003 Intersting report also, re CRM etc. (A bit long) http://www.aaib-n.org/Rapporter%202003/report%207-03.htm Link to comment Share on other sites More sharing options...
Guest Stone Posted August 30, 2003 Share Posted August 30, 2003 I thought it was a good move. The company has already highlighted the incident in an internal safety magazine so that all other company pilots are aware and hopefully will learn from it. Simulator scenarios are being written as we speak for future training/checks. Emphasis on this is incident is being provided during current training sessions. All appropriate investigative and safety authorities have been advised. I think the Company's response is appropriate...but because you weren't there during the incident, weren't there for the investigation, and weren't there for the disciplinary hearings you obviously don't agree. So be it. Link to comment Share on other sites More sharing options...
Innuendo Posted August 30, 2003 Share Posted August 30, 2003 While reading your post I was thinking that it made a lot of sense until I got to: "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." "Captain Al Haines seriously messed up and got it all wrong." You cannot have seen the presentations on this accident if you are under the impression that Al Haines screwed up. The actions of the entire crew including a deadheading DC-10 training captain who ended up in the flight deck assisting are the reason that so many survived. For those not familiar, the aircraft sustained a COMPLETE loss of hydraulics and therefore flight controls due to a disk failure in the tail mounted engine. The flight crew controlled and got the aircraft down by manipulation of the remaining engine thrust. On the job learning with no practice and no second chances. I think you have got this one wrong. There are recurrent training courses that include presentations about this incident as examples of CRM at work. That having been said, I think your post makes some very valid points. Link to comment Share on other sites More sharing options...
Guest V1 Posted August 30, 2003 Share Posted August 30, 2003 I would love to see if there is a relation between the "can't happen to me" attitude above and the age/level of experince of the posters. The other day I was in the hardware store and an older gentleman offered to help me with my purchase. He saw that my plumbing plan was all F##KEd up. I figured I was doing great. He said "will you just listen to me young fellow" and proceded to unravel me. I was taken aback by his directness , I haven't been called "young fellow" in many years. He took a few minutes told me what I needed to know. I learned a little about plumbing from that fellow that day but more than that I learned something most important about myself in that brief exchange. Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 31, 2003 Share Posted August 31, 2003 You're right. I don't. I do appreciate the dialogue and your additional info. Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 31, 2003 Share Posted August 31, 2003 We only have to look at the liveware, software and hardware interface to even begin to understand how this could happen. Until then, all bets are off. Ask TAROM how an experienced crew could stall an A310 on an ILS into Orly. Mode confusion? False capture? My apology in advance for a rather synical question but, why wasn't that RJ crew sacked in a slightly higher profile incident. Ooops, I meant accident? Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 31, 2003 Share Posted August 31, 2003 I'd agree if the mistake were caught and reason prevailed. However, the mistake wasn't caught and the chain of events went unbroken resulting in the incident. Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 31, 2003 Share Posted August 31, 2003 Thanks for the reply. I would go on record as saying quite simply the Sault City DC-10 was anything but a screw up and remains to this very day an example to all of us flying airplanes on how to utilize and manage all available resources. My sarcasm was aimed at those who think if you screw up you are to be chastized and turfed out of the operation while every attempt to keep it quiet is made. No. I most definitely don't think Capt. Haines messed up. Link to comment Share on other sites More sharing options...
Mitch Cronin Posted August 31, 2003 Share Posted August 31, 2003 H'lo again Don... Re: "We cannot demand perfection in such environments because it will never happen. Curiously however, "perfection" may result in recognizing this very fact." Reminds me of notions I read about back in my long-hair days... In a book by "Baba Ram Dass" (aka Dr. Richard Alpert), called "Be Here Now", he talks about perfection only coming to those who aren't busily seeking it. And later, he quotes Tao Te Ching (which I think is a book): "The world is won by those who let it go. But when you try and try The world is then beyond the winning" Digression... pardon me. Getting back to the ANZ report... I wonder if you can shed some light, for me, on this paragraph:The PF also iterated that at glideslope capture he was mentally ‘ahead of the aircraft’, anticipating and planning next actions. This is normal crew behaviour, with the PF anticipating the next event and the monitoring crew keeping in sync with the aircraft. The PF is the person controlling the aircraft, the monitoring pilots ensuring everything is going to plan. There is a training lesson here for error trapping and also it raises the question whether this situation denies the PIC, if he is also the PF, the opportunity to maintain a strategic overview and to be the decision-maker in the strategic sense.I don't see how mentally flying ahead of the aircraft could possibly deny the PIC the opportunity of maintaining a strategic overview?... I'd think doing so enables a better strategic overview, or is this implying more of a strict focus on events ahead? BTW, I like that phrase, "error trapping". A clear and concise description of the intent, acknowledging that errors will come. I also found this paragraph interesting, and appropriate, I think, to consider when looking at part B of the incident discussed in this thread:"Data from the proving flights and the simulator profiles show that even a crew that is pre-briefed and anticipating the high glideslope entry speed becomes almost totally focused on the energy management and configuration task to successfully achieve the profile to the exclusion of awareness of other information and events."I would think it likely that their primary focus was not on the routine aspects of their return to departure point... so missing the nose rising for the first few moments seems, to me anyway, easy to understand. One final point... This paragraph brings a thought to follow:"A review of the achieved roster patterns, including duty and flight hours for all flight crew members preceding the date of the incident and the day of the incident, indicates that: Sufficient rest periods had been provided to ensure that the flight crew were well rested. The type of duties performed by all three flight crew members for the 8 days preceding this incident preclude circadian disruption as being a contributory cause. A member of the Company Flight Crew Fatigue Study Group conducted a post-incident interview with the flight crew. Subsequent to the interview the Flight Crew Fatigue Study Group determined that fatigue was not contributory to this incident." Must be nice! Man I wish our bunch had such concern for circadian rhythm disruptions and fatigue factors! Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 31, 2003 Share Posted August 31, 2003 Don, I raise a glass to your sensibility and professional response. I think a few good men/women would be well advised to take in the content and quality of your remarks. Cheers Link to comment Share on other sites More sharing options...
Guest Rob Assaf Posted August 31, 2003 Share Posted August 31, 2003 Now if future, if a crew has an incident that does not result in minor structural damage, do we want the crew to feel comfortable bringing the incident forward so that it can be a learning point for everyone and prevent future, possibly more serious, incidents or even accidents or do we want them in coverup mode? Just fly the a/c home and no one is the wiser? Firing over screwups is the fastest slide backward down the slippery slope of flight safety I can possibly imagine. I read the aviation safety letters that come with my AIP ammendmants (which I do, much to the humour of some of my colleagues)and I have since I started receiving them after getting my glider pilots licence at age 17. Before that I read the TSB incident reports that my Dad subscribed to when he was a private pilot. My kids asked me if I was reading them so that I would know what do to if I was in an accident, I replied that I was reading them so that I didn't get myself into or anywhere near the situation these people had gotten into. I'd have nothing to read if people didn't own up to their incident or accident details and would be left with recreating the same mistake all over again myself. Humans interacting with machines, especially computers, is a tricky bet at best. Ever been around someone installing new software or a download that is supposed to "fix" all their problems? The language is rarely anything but PG. Firing in the case of the YLW or FRA incident can hardly be viewed as constructive answer to a either a laspe in procedures or a lack of a procedure that would have prevented the occurance. Link to comment Share on other sites More sharing options...
Mitch Cronin Posted August 31, 2003 Share Posted August 31, 2003 Hmmm... Things you might have learned: You didn't know as much about plumbing as you thought? You aren't as old as you feel? Knowledge is a relative thing? Age is a relative thing? Knowledge and wisdom come to those who experience as well as listen? Old people aren't as stupid as they look? (sorry, lol) Good story V1. Cheers, Mitch Link to comment Share on other sites More sharing options...
Guest Gino Under Posted August 31, 2003 Share Posted August 31, 2003 DEFCON In a Glass Cockpit airplane (the A330 for example) 'monitoring' is a pilot's Primary role and responsibility. In compliance with SOPs to observe GS* (interception of the Glide Slope) and GS green (capture of the Glide Slope) on a coupled approach (APPR mode) is not what we could consider "heads down". Please don't think I'm trying to be-little. I simply don't know your experience or type rating. So, my apologies in advance. Link to comment Share on other sites More sharing options...
DEFCON Posted August 31, 2003 Author Share Posted August 31, 2003 Thanks GU I'm not certain I've been expressing my thoughts very clearly. I and perhaps only I believe that these two were quite busy and both heads were down trying to catch up on the required typing while the ac went hunting. This breach of protocol is something we're all probably guilty of from time to time. Unfortunately for this crew, the unexpected happened and because no one was monitoring the ac; it departed controlled flight? Link to comment Share on other sites More sharing options...
dagger Posted August 31, 2003 Share Posted August 31, 2003 "Firing over screwups is the fastest slide backward down the slippery slope of flight safety I can possibly imagine. " And a coverup by either the company or individual isn't a slip down that slippery slope? How are you going to cover it up with all the aircraft telemetry, the ATC records, even the eyewitness testimony of a concerned passenger? How would a coverup inspire confidence in our air traffic system? And the regulator is going to stand for a coverup? No, it sounds like you have no choice but to embrace full disclosure no matter what the consequences. Given the consequences, this is one area in which there should be dismissal offences, just as there are grievous errors in most occupations that will lead to dismissal, even for long-term serving veterans. Link to comment Share on other sites More sharing options...
Guest Stone Posted August 31, 2003 Share Posted August 31, 2003 Rob, this is my last post on this topic as it has been debated ad nauseum. This was not a minor incident and who said they were "fired"? Both pilots led exemplary careers and were very close to retirement anyway. They just retired a few weeks early (with dignity). I am sure the Company 'supported' them in this decision. Air Canada has always had a no consequence reporting policy. However, if you make a serious error you will probably be taken off the line and sent for retraining. If you were within a few weeks of retiring what would you chose? Retraining or early retirement? Link to comment Share on other sites More sharing options...
Guest Saltaire Posted August 31, 2003 Share Posted August 31, 2003 The 330 can have a low rotation speed. Min. ground roll with flap 3 which could be roughly 125 kts. Do you really have a clue about what your talking about? Link to comment Share on other sites More sharing options...
Don Hudson Posted August 31, 2003 Share Posted August 31, 2003 Mitch; Re "Digression... pardon me." The Tao Te Ching?...what a wonderful digression!! Story. Life (and our many individual endeavours) is about story, not profit. How many seekers' ladders are up against the wrong wall? If one would correct error one first needs to acknowledge its presence. These are not obscure, "philosophical" wanderings...these are immediate, in-yer-face realities which financial people in particular have extreme difficulty in confronting and flight safety people have extreme difficulty in communicating. Its curious how an incident or an accident has more "authority" for financial people than a the words of a flight safety officer. But that's the way it is. Don Link to comment Share on other sites More sharing options...
Arctic Ace Posted August 31, 2003 Share Posted August 31, 2003 Lets see. While on descent atc issues a runway change. The a/c is only 5 miles back from the first waypoint on the STAR. As the revised runway requires a different STAR routing and different constraints, the crew who are both unfamiliar with this airport become quite busy trying to determine their routing. They pull a no no and as the monitoring pilot is having difficulty getting it all figured out the flying pilot also becomes preoccupied with his chart. The aircraft overspeeds and the clacker sounds. The flying pilot reduces speed and they resume. Unfortunately through all the commotion they also busted their altitude. Now, while being vectored to final and in moderate turbulence with flap 1 they paint a cell at 12 o'clock and atc is vectoring them right into it. They elect to break off the approach to the right and advise atc. atc now gets rattled as they've got other a/c in the direction of their turn. atc issues an immediate climb and in the turbulence and commotion the flaps get left at 1 and a flap overspeed occurs. After another vectored approach the aircraft lands without further incident. The captain is now facing a violation for the altitude bust. He also recently heard of another crew who had "resigned" due to a tail strike and altitude bust off a false glideslope capture. I wonder if he'll report his two overspeeds considering he's not flying a magic airplane that automatically does the reporting for him?? Link to comment Share on other sites More sharing options...
Don Hudson Posted August 31, 2003 Share Posted August 31, 2003 Neo; Re "My original comments had nothing to do with defending or excusing the mistakes, although I have no difficulty in recognizing them as generically human. My comments were only intended to illuminate some reasons why cockpit errors happen and to suggest ways to avoid them." Precisely. Link to comment Share on other sites More sharing options...
Guest shibui Posted August 31, 2003 Share Posted August 31, 2003 777-300 and even if I was featherlight,80 tons under max takeoff at 220 tons I am sufficiently clued to not rotate at 127 knots. On the day I do, I hope someone leads me gently away. Link to comment Share on other sites More sharing options...
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