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  • #31
    Gabriel,

    Don't worry, we are on the same side of the argument here... I agree this is a relatively small event. Accident was the wrong choice of words... "Serious Incident" is what the ATSB are using.

    Why the human factors/crm element failed will be interesting to discover.

    Comment


    • #32
      Originally posted by MCM View Post
      Evan,

      You say again that it takes no effort, and blame pilots for not putting in enough effort or not taking their job seriously.
      Yes, I'm saying that. But this is not about effort.

      It does not take any real effort to check the indicators. It takes discipline. There is no margin there; you have it or you don't (and the many who have it know what I'm talking about).

      But, I agree with you about, and am well aware of, the complexities and weaknesses of the human condition. Hence, the second pilot. Hence the checklist. Hence the automatic warning. We require procedural discipline precisely because we are prone to error, because these procedures are there to compensate for that.

      What I would simply like to know is how two of these three redundancies failed here, leaving only the last, inhuman line of defense. I strongly believe that the checklist was skipped over, and that's not human error, that's a lack of discipline, and that should get you kicked out of the cockpit before you perform one of the other infamous errors that 3WE has thoughtfully listed here for us—the ones that didn't end quite so uneventfully.

      Comment


      • #33
        Originally posted by Evan View Post
        Yes, I'm saying that. But this is not about effort.

        It does not take any real effort to check the indicators. It takes discipline. There is no margin there; you have it or you don't (and the many who have it know what I'm talking about).

        But, I agree with you about, and am well aware of, the complexities and weaknesses of the human condition. Hence, the second pilot. Hence the checklist. Hence the automatic warning. We require procedural discipline precisely because we are prone to error, because these procedures are there to compensate for that.

        What I would simply like to know is how two of these three redundancies failed here, leaving only the last, inhuman line of defense. I strongly believe that the checklist was skipped over, and that's not human error, that's a lack of discipline, and that should get you kicked out of the cockpit before you perform one of the other infamous errors that 3WE has thoughtfully listed here for us—the ones that didn't end quite so uneventfully.

        Time to look more closely at yourself then. If you drive a car and do not check that all the lights are working, that tyre pressures are not absolutely correct, that there is sufficient oil in the sump (don't rely on the oil pressure light to warn you of this condition) absolutely before every single trip, then you too are a danger and should not be allowed to drive your vehicle. After all, any of the things I have mentioned may be implicated in a crash that may kill many people. If you don't check daily (or weekly as my car's manual suggests) why not? To paraphrase your own comments, there is no margin for error if through neglect one of your tyres delaminates in the middle of a bend at speed with oncoming traffic...

        But hey, feel free to hold others to higher standards than you hold yourself. And no, the excuse that "nobody else does it" is not correct, I know a bloke who races cars in his spare time - he knows what can happen when a component fails, so he checks his car is perfectly roadworthy before he drives anywhere for the first time each day (used to be known as a 'first parade' service in the military). Can you explain why surgeons still leave surgical hardware inside patients, or why incorrect doses are given to patients. Can you explain why trains are routed head on into each other etc?

        Do we need a further process where the pilots have to sign off with a non-affiliated person (say the passenger in row 1A) that each checklist is done? There is only so much that can be done, there are only so many holes in the swiss cheese we can prevent from lining up. I don't hear of great gobs of passenger aircraft landing belly first unintentionally, so given the other safety system (GPWS) was still there as a backup and wasn't even used, I'd be more inclined to be worried the bloke in the fuel tanker truck next to me when I drive home tonight has a servicable vehicle.

        Comment


        • #34
          My "standard" is what the average passenger expects to be done, not to put his life in jeopardy. Do you think if each passenger was asked to affirm all this "understandable humanity" at the boarding gate, they'd even get on the airplane? They don't look at it in probabilistic terms. If pilots know things are required by safety, the passenger assumes they are going to be done.

          As for cars, the penalty for some of the oversights you mention aren't in the same galaxy as the penalty if plane safety procedures are carelessly overlooked. That is extreme irrelevance in this context.

          Comment


          • #35
            Originally posted by Evan View Post
            What I would simply like to know is how two of these three redundancies failed here, leaving only the last, inhuman line of defense. I strongly believe that the checklist was skipped over.
            According to the official preliminary report (I agree it's preliminary and things can be not as said there, but still that's the best we have by now), the crew initiated the go-arround BEFORE the GPWS warning went out.

            This mean that it was whithin your two first redundancies that the problem was detected and solved, one full minute before the landing.

            We don't know yet how this happened. Yes, they could have skipped the checklist, or they could habe been doing it when they detected the problem thanks to it.

            Please comment.

            --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
            --- Defend what you say with arguments, not by imposing your credentials ---

            Comment


            • #36
              Originally posted by EconomyClass View Post
              Do you think if each passenger was asked to affirm all this "understandable humanity" at the boarding gate, they'd even get on the airplane?
              I would imagine that, whether or not they are asked to affirm it, most passengers are perfectly aware that the people up front are, in fact, human and that a mistake can take place. They are also likely aware that only on extremely rare occasions do such mistakes lead to anything serious, so they proceed to get on the airplane.

              IOW, every passenger takes a calculated risk.

              Comment


              • #37
                Originally posted by Curtis Malone View Post
                I would imagine that, whether or not they are asked to affirm it, most passengers are perfectly aware that the people up front are, in fact, human and that a mistake can take place. They are also likely aware that only on extremely rare occasions do such mistakes lead to anything serious, so they proceed to get on the airplane.

                IOW, every passenger takes a calculated risk.
                Exactly, and they take a greater risk statistically when they drive their car. But a near miss between a couple of loaded busses doesn't make front page headlines does it?

                Comment


                • #38
                  Originally posted by EconomyClass View Post
                  My "standard" is what the average passenger expects to be done, not to put his life in jeopardy.
                  Do you think my standards are any less when I get behind the wheel of my car?

                  Originally posted by EconomyClass View Post
                  Do you think if each passenger was asked to affirm all this "understandable humanity" at the boarding gate, they'd even get on the airplane?
                  Why not? They get into cars without giving it a second thought, yet statistically air travel is far safer that driving in a car.

                  Originally posted by EconomyClass View Post
                  They don't look at it in probabilistic terms. If pilots know things are required by safety, the passenger assumes they are going to be done.
                  Just as the driver who is T-boned and killed in a car assumes the driver of another car will not try and beat the red light.

                  Originally posted by EconomyClass View Post
                  As for cars, the penalty for some of the oversights you mention aren't in the same galaxy as the penalty if plane safety procedures are carelessly overlooked. That is extreme irrelevance in this context.
                  Rubbish, around 20 years ago two busses collided head on on the Pacific Highway. Dozens killed, dozens more injured. If all of the safety systems were ignored and the pilot still dropped the plane onto its belly I'd still prefer to be onboard that plane than those busses.

                  Funny you bring up context. Ask most Aussies or tourists what they fear most about going surfing here and everybody says "Sharks". The odds of being killed by a shark are exceptionally small, the odds of even being bitten or attacked are extremely slim. It's the same with air travel - everybody panics because unlike something riskier like car crashes that we have become blase about or simply innured to, plane incidents happen so rarely, yet often seem to result in horrific deaths or injuries.

                  Yet, we have no problem jumping in a 830kg car, and drive head on toward a fully laden fuel tanker with 50,000 litres of fuel on board weighing 59 tonnes at a closing speed of 200kph, then having the truck pass around 50 cm to the right of your car. This 'near collision' may occur on a road with potholes or dead animal carcasses, in the rain and at night. Many of our higways are not divided roads, people regularly drive 1000km passing thousands of cars and trucks in this fashion. A head on crash in a car with another vehicle at that sort of closing speed is basically not survivable. Yet, neither driver has probably checked things like tyre pressures, lights, wipers, wheel bearings etc for weeks or months. The driver coming toward you has been basically given a licence because they demonstrated they could do a hill start and drive at 60 kph for 5 minutes without breaking a rule (as you were). They may not have been tested for their skills or knowledge of the road rules for 50 years. They may have been driving for 48 hours straight (no law against that if you are not driving a truck or bus).

                  So lets compare that to the airline industry, engineers check the plane every morning, pilots perform walk around checks, fuel is carefully monitored and checked. Weights are checked to see that maxima are not exceeded, the pilots with their restrictions on hours, and co-pilot who is there as a double check have both been trained to far higher comparitive standards that car drivers, They are backed up by mechanisms in the plane that will warn (GPWS) or limit dangerous manouvres (Airbus flight parameters). Traffic is kept apart by a team of professionals, whereas in the car you are trusting the driver doesn't drop their ciggie and suddenly swerve into your lane.

                  Humans are in both loops - driving the airplane and driving cars. I know which is safer because there are far more checks and redundant systems in the airline industry than on the road, I'm surprised you have problems working that out.

                  Comment


                  • #39
                    Originally posted by SYDCBRWOD View Post
                    I'm surprised you have problems working that out.
                    EconomyClass having problems working out something? I am not surprised at all.
                    (oops, sorry, am I banned?)

                    --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                    --- Defend what you say with arguments, not by imposing your credentials ---

                    Comment


                    • #40
                      Originally posted by SYDCBRWOD View Post
                      Time to look more closely at yourself then.
                      No, that time has passed. That was the time I decided I was too A.D.D. to become a commercial airline pilot, too accident-prone to take responsibility for the lives of hundreds of passengers. I hope all aspiring pilots, as well as active pilots, take this close look at themselves. But more importantly, I hope the industry takes a closer look at them.

                      Originally posted by SYDCBRWOD View Post
                      But hey, feel free to hold others to higher standards than you hold yourself.
                      Thank you. I hold pilots to the highest standard of piloting.

                      Comment


                      • #41
                        Originally posted by Gabriel View Post
                        According to the official preliminary report (I agree it's preliminary and things can be not as said there, but still that's the best we have by now), the crew initiated the go-arround BEFORE the GPWS warning went out.

                        This mean that it was whithin your two first redundancies that the problem was detected and solved, one full minute before the landing.

                        We don't know yet how this happened. Yes, they could have skipped the checklist, or they could habe been doing it when they detected the problem thanks to it.

                        Please comment.
                        If that is true, it suggests to me that one of the pilots caught it, so the first redundancy worked after all. That would make the situation less incredible to me. I am wondering though how the GWPS would trip during a GA, unless the GA was initiated only moments before the GWPS floor... a better late than never case of first redundancy. More important to me though, is skipped checklist procedure. That bothers me.

                        Why would the crew be doing a checklist for landing configuration that close to GWPS floor? If that were SOP, this would be occurring all the time.

                        Comment


                        • #42
                          Originally posted by Evan View Post
                          unless the GA was initiated only moments before the GWPS floor...
                          Well, I don't remember the exact warinig in the initial report but it was sometghing like "the GPWS landing gear warning activated as the crew was initiating the go-around"

                          Why would the crew be doing a checklist for landing configuration that close to GWPS floor?
                          Of course I don't know and the investigation might find out.
                          Maybe they had been bussy doing something else, maybe it was a tight circling approach, etc.

                          But I'm not sure if that's so low. They were at 700ft of altitude, which means about 1 minute from landing. They were in VFR and their sop called for a stabilized approach by 500ft. One criteria for the stabilized approach is that the plane is configured for landng and that the landing checklist is complete. To complete the landing checklist takes just a few seconds. So if they were doing it and there they detected the gear up problem, they were ok at least from a stabilized approach point of view.

                          If that were SOP, this would be occurring all the time.
                          No it wouldn't be happening all the time because lamost always landing gear will be down before starting the checklist.

                          Oh, and the GPWS goes off pretty often during normal operations. The GPWS cannot know if the pilot didn't notice the 1500fpm sink rate or if he is intentionaly doing it, for examle. The GPWS has more than one level of warning. It can say "five hudred, four huncred..." or "minimums". It can also say "too low, gear", or "too low, flaps", or "sink rate". When things get really dangerous it says "woop woop pull up" (meaning ok now pull up and bother latter about whether the ofending item was the flaps, the gear, or the sink rate).

                          --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                          --- Defend what you say with arguments, not by imposing your credentials ---

                          Comment


                          • #43
                            Where work is done....mistakes and errors will occur.

                            Monotony in work can be a killer because one day you will confirm something, but not actually check it.

                            It's a bit like my job. I've been administering drugs for 27 years now. Annually I am required to re-classify by examination in my knowledge of the drugs that I use and the appropriate doseages. At one time it was considered to be cheating if I referred to my reference flip pad.....but....one line in one of the training manuals states "When administering drugs, never, NEVER, EVER rely on memory. Always cross refer to your checklist"
                            It is now acceptable practise to refer to the checklist for doseages in the examinations...because that's how we do it on the road.

                            The day that I don't bother to cross check is the day that I kill someone.

                            I refer you now, back to the first line of this post.
                            If it 'ain't broken........ Don't try to mend it !

                            Comment


                            • #44
                              Originally posted by Gabriel View Post
                              No it wouldn't be happening all the time because lamost always landing gear will be down before starting the checklist.
                              Uh... I don't know Gabriel... even if it's not a to-do list, I still think that checklist needs to happen well before you get the idiot light message.

                              Comment


                              • #45


                                Oopps... Fast jet pilots aren't know to be stupid, suicidal or anything other than razor sharp. Unfortunately they are human however...

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