The good, the bad and the ugly of human factors

[Gabriel]

This came too close to disaster to be brushed off. If the pilot did, indeed, confuse his left/right pedal inputs, I'm sorry but that person shouldn't be considered commercial pilot material.

I disagree. While it might be the case that this particular pilot has some kind or condition that predisposes this error, I think that it is something that can happen to ANY of us say 0.01 times in our lifetime. That means that it will just happen to 1 out of 100 persons once in their life, randomly, and they are never going to do it again. So excluding them from the pool after the fact would not benefit anybody. Most of the times the mistake will be identified and corrected quickly before causing any harm. Very seldom it will be also identified and corrected very quickly but still too late to avoid harm and you end with an airplane write-off or, in the case of my children's elementary school, one parent dead and 3 kids injured.

This is not too dissimilar to calling your dog's name when you intended to call your child.

[Gabriel]

let's talk about the fact that this particular pilot had over 19,000 hours flying time and 3000 hours on type. under evan's rules, a guy with a likely major error free career deserves to get axed.

I agree. Now, if (and I said IF) this pilot had a condition (perhaps a newly acquired one) that makes him more likely to make this kind of honest errors, then yes, he would need to get axed. He would still not deserve it, but the flying public would.

[Evan]

I disagree. While it might be the case that this particular pilot has some kind or condition that predisposes this error...

There are conditions caused by brain lesions that can result in this kind of 'unthinkable' mistake of proprioception. I think, at least, this pilot needs to be closely examined and tested for reflex actions.

I think that it is something that can happen to ANY of us say 0.01 times in our lifetime.

So, one hundredth of one time. I'm cool with that.

[Gabriel]

There are conditions caused by brain lesions that can result in this kind of 'unthinkable' mistake of proprioception. I think, at least, this pilot needs to be closely examined and tested for reflex actions.

I would not disagree with that. But you thrown him under the bus no questions asked.

So, one hundredth of one time. I'm cool with that.

Yes, but when you have 2 million pilots worldwide, that means that 20,000 of them will make such and error once in their lifetime. That would still count as several occurrences per year globally, most of them inconsequential and unnoticed.

[TeeVee]

There are conditions caused by brain lesions that can result in this kind of 'unthinkable' mistake of proprioception. I think, at least, this pilot needs to be closely examined and tested for reflex actions.



So, one hundredth of one time. I'm cool with that.

and there are things called cerebral vascular accidents (strokes), aneurysms, myocardial infarctions, pulmonary emboli etc, etc. so are you advocating that all airline pilots go for total body CAT scans on, say a quarterly basis? can't be too safe ya know! a stroke could easily cause failed perception which could lead to wrong control inputs. aneurysms as well. shoot, any number of things could and do happen. pilots even die in the cockpit.

this was a case of pilot error. thankfully it resulted in nothing more severe than a broke airplane.

[3WE]

I half ass skimmed all the discussion as to whether this is a mental illness, or pure brain fart…I’m thinking that is mostly after the fact things, that are probably not_of PRACTICAL value for prevention (other than we already subject pilots to a decent medical exam.)

I’m more interested in the prevention side of things.

I have an unfounded ass-umption that this happens a lot, but that it’s recognized extremely quickly and corrected.

So how is it that the pilot and the FO let this go the two extra seconds whatever?

While I want to be the classic ass hat complainer that we need to fix this safety loop hole, the counter argument is that maybe there is no fix* or maybe it’s not a significant problem? I dunno.

*Footnote: Evan’s computer-operated airplanes are an option.

[Evan]

I half ass skimmed all the discussion as to whether this is a mental illness, or pure brain fart…I’m thinking that is mostly after the fact things, that are probably not_of PRACTICAL value for prevention (other than we already subject pilots to a decent medical exam.)

I’m more interested in the prevention side of things.

I have an unfounded ass-umption that this happens a lot, but that it’s recognized extremely quickly and corrected.

So how is it that the pilot and the FO let this go the two extra seconds whatever?

While I want to be the classic ass hat complainer that we need to fix this safety loop hole, the counter argument is that maybe there is no fix* or maybe it’s not a significant problem? I dunno.

*Footnote: Evan’s computer-operated airplanes are an option.

By the time a pilot gets to that many hours, I have to believe rudder is as instinctual as yoke. Left wing dips. Turn yoke to right. Nose goes left. Push right rudder pedal. Engraved muscle memory requiring no critical thinking.

This isn't an error of judgment. It's a human-factors phenomena. Stress, frustration, fatigue, whatever caused it, it just can't be happening a lot. Something has to go wrong in the reason-to-motor skill pathway.

Automation in yaw and steering during rollout is already a proven, commonly used technology.

Automation in yaw and steering during the takeoff roll seems like a no-brainer: like a set of digital rails on the runway. Runways are in all cases straight-ahead courses. Once the airplane is lined up, all the automation needs to know is the (exact) runway heading.

Certainly, problems could occur. If the automation is following the LOC (as RWY does on the Airbus), that signal can become distorted. Adding alternate or secondary references (GPS, internal guidance, map data, lateral acceleration) would allow it to be fail-safe. It could have safe deviation limits and allow pilot inputs (with breakout force) to take priority. As with every takeoff, the crew would have to be closely monitoring and prepared to step in at any moment.

Take-off TL position could activate it. Air/ground mode (and slow ground speed in these case of rejected takeoff) could inactivate it. All large modern transport aircraft have the means to control rudder and nose-wheel steering digitally.

So I'm not really understanding why we aren't doing this. This seems like a wake-up call if ever I saw one.

[3WE]

[Blah, blah, blah x a big number]

So I'm not really understanding why we aren't doing this. This seems like a wake-up call if ever I saw one.

https://youtu.be/xt0V0_1MS0Q

[Gabriel]

By the time a pilot gets to that many hours, I have to believe rudder is as instinctual as yoke. Left wing dips. Turn yoke to right. Nose goes left. Push right rudder pedal. Engraved muscle memory requiring no critical thinking.

Some of us over there might not fully agree with that.