Originally posted by elaw
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Air Canada pulls a Hans Solo
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Originally posted by Evan View PostSo, are pilots 'addicted' to autotune?
At 2:00 AM biotime, the way you usually do it might have some influence (and also affect confirmation bias some too!)
Please note that another aircraft was not 100% sure of things that night but had some other things go their way.Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.
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A lot of the fallout from this is focusing on fatigue, but I think that is missing some key points. Several things stick out for me in this incident and the subsequent report which strikes close to home for me because I have flown that very flight numerous times with AC.
A) The report talks about the mostly useless flight information that the poor pilots need to parse through, with no semblance of priority. Yet another example of when too much procedure works against the safety culture it was designed to support.
To quote one of the investigators:
The current system prioritizes protecting the regulatory authorities and airports. It lays an impossibly heavy burden on individual pilots, crews and dispatchers to sort through literally dozens of irrelevant items to find the critical or merely important ones. When one is invariably missed, and a violation or incident occurs, the pilot is blamed for not finding the needle in the haystack!
C) Like one of the investigators, I am somewhat shocked with how cavalier EVERYONE was about this incident for a long time. I am certainly skeptical about the PIC who didn't report the incident to AC until late afternoon the next day, AND who frankly pretended it was just a small deal. As the comments of one of the investigators states:
In reality, the overflying crew may have been in a poor position to fully understand their proximity to disaster because of their perspective, looking down at night, and their workload, as they executed functions necessary to landing then undertook a go-around.
However, I find the overall reporting very lamentable as the same investigator stated in his closing comments:
I am left concerned that post-incident forensic analysis of a cockpit voice recorder, while vital, cannot replace immediate, safety-focused interventions designed to take crews involved in near miss situations out of service until they can be assessed as safe to continue. Whether it is industry, the FAA, or airports that stand up a more effective “if you see something, say something” style system regarding dangerous operational behavior, it is clear to me that the need exists.
But I also understand why... This quote is the best from one of the other investigators:
[quote]Non-punitive response - Image recording technology currently exists in every other mode of public transportation except commercial aviation. Some pilot groups are concerned about the right to privacy and that the information gathered will be used punitively. Workplace right-to-privacy has been extensively litigated but in safety-critical positions, it must take a backseat to human life. Most importantly, the data, gathered routinely before an accident, will be invaluable in preventing the next tragedy. This approach has been highly effective in FOQA. There may be some technical challenges to address but the payoff in increased safety and accountability will be significant.
One of the strongest attributes of aviation is the concept of just culture or non-punitive corrective action. When a mistake is made, most people put their best foot forward and attempt to minimize a critical error, which is perfectly understandable. Some supervisors want to mete out sanctions to “teach a lesson” or to make an example of the crew. Unless someone is habitually error prone and they shouldn’t be in a safety-critical position, punitive response is completely ill-suited to critical performance environments.
It’s almost a certainty this crew will never make such a mistake again and my hope is that they will continue to fly to the normal end of their careers.
Everyone will gain much more from being introspective rather than judgmental on this incident. We should reward all aviation personnel and celebrate when someone self-confesses a mistake and learns from it. More importantly, the system learns from it and can take steps to eliminate event precursors. This is a key factor in the decades-long decline in commercial aviation’s accident rate. Fortunately, we’ll get another chance to put some fixes in place to make a highly improbable event even less likely to reoccur.[quote]
In my own field of work, we have incidents and incident reports, and I can't highlight how important this is. If the company or regulatory environment has a culture of blame then it creates an environment where information is withheld due to fear -- and justifiably so. I suspect this is the case in many corporate environments, and I suspect in some investigations. I don't know if the movie Sully mis-characterized that particular investigation, but if there is any truth to it, it would explain a lot of the behaviour here.
This was really a fascinating incident and so close to a huge disaster.
Again, especially worth reading was the comments from the pilots of the aircraft overflown, and the Board member statements. Good job on the investigation IMO.
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Originally posted by Schwartz View PostObviously, the AC pilots were not using the ILS so they didn't have this extra layer of safety.
The second issue is that I strongly believe expectation bias and other human factors are still not adequately emphasized in pilot training, neither in initial training nor in recurrent/supplementary training. It is AS IMPORTANT as fundamentals if we want to reduce aviation accidents.
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Originally posted by Evan View PostI see two major issues here. One, the crew didn't tune the ILS per company procedure. The reports cites a lack of resource in the company A320 database as a factor and I'm not quite clear how those two things reconcile. But I would hope that tuning the ILS for EVERY visual approach to a major airfield is company procedure, and that this procedure is effectively instilled in their pilots minds.
[quot]Now, the aggies on this forum might find that excessive, but it is, as you point out, that extra layer of safety that often saves the day in these rare circumstances, and seriously, how long does it take to tune the ILS?[/quote]
I am all for using this extra layer of safety, but not doing it should be still extremely safe and these mistakes should still not happen,. What do you if the runway lacks an ILS or it is out of service? Cancel the flight? Divert?
The second issue is that I strongly believe expectation bias and other human factors are still not adequately emphasized in pilot training, neither in initial training nor in recurrent/supplementary training. It is AS IMPORTANT as fundamentals if we want to reduce aviation accidents.
--- 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 ---
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Originally posted by Gabriel View PostIt is, and it is done automatically when they select the corresponding approach in the FMS. And that is true for EVERY approach in the operator's FMS database, except this one particular approach to this one particular runway in this one particular airport. Now, do you understand how human factors might have played a role in them NOT following the company established procedures?
I am all for using this extra layer of safety, but not doing it should be still extremely safe and these mistakes should still not happen,. What do you if the runway lacks an ILS or it is out of service? Cancel the flight? Divert?
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Originally posted by Gabriel View PostIt is, and it is done automatically when they select the corresponding approach in the FMS. And that is true for EVERY approach in the operator's FMS database, except this one particular approach to this one particular runway in this one particular airport. Now, do you understand how human factors might have played a role in them NOT following the company established procedures?
The DAL flight did use it
The second issue is that I strongly believe expectation bias and other human factors are still not adequately emphasized in pilot training, neither in initial training nor in recurrent/supplementary training. It is AS IMPORTANT as fundamentals if we want to reduce aviation accidents.
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Originally posted by Schwartz View PostThey also spoke about this in the report. They reviewed the expectation bias training program from AC and the comments were positive. These pilots had not yet received it.
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Originally posted by Evan View PostYet, they were licensed commercial pilots. Do you see what I'm saying? This can't simply be 'supplemental' anymore.
About 3 months before this incident, Air Canada implemented training on plan continuation and expectation bias. The training, which was provided to company pilots during annual recurrent training, comprised a video titled “Understanding Gut Feel,” which explained that a gut feeling was a sense of knowing things before a person could consciously know, communicate, or explain them. The video also explained that a gut feeling indicated a potential threat resulting from a situation that was different or strange or had changed. The NTSB reviewed the video and the planned PowerPoint presentation (to be introduced during the 2018/2019 training cycle) and found that they provided a good overview of the hazards of expectation bias and stressed monitoring and active questioning to mitigate the hazards.
The incident captain and first officer did not receive this training before the incident flight and were scheduled to receive the training during their next annual recurrent training. Such training might have provided the captain and first officer with techniques to actively question their expectations, recognize their error, and act sooner. For example, during postincident interviews, the first officer stated that, when he looked up after the captain asked him to contact the controller to verify that the runway was clear, he thought that something was not right but could not resolve what he was seeing. The training video provided pilots with a process for assessing such a feeling. Specifically, the video presented a basic strategy for listening to gut feelings when evaluating a situation, as expressed by the acronym “LIVE”: listen (to signals), investigate (what has changed or is different), validate (test and confirm a theory about what is different), and express (communicate the concern to others). Although the flight crewmembers eventually recognized (just before initiating the go-around) that the situation was not what they expected, they missed opportunities earlier in the approach (as indicated in sections 2.3.1 and 2.3.2) to reassess their expectations.
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Originally posted by Evan View PostNow, the aggies on this forum might find that excessive, but it is, as you point out, that extra layer of safety that often saves the day in these rare circumstances, and seriously, how long does it take to tune the ILS?
Being serious for a moment- I asked a pilot if there should not be some sort of formal procedure for when you don't tune the ILS/Localizer/GPS Magenta line...I would think that approach lights, and REILS and VASI/PAPI locations might be useful to identify runways vs. taxiways. However, my suggestion was deemed to be of no value.
Also, when I have been able to see out of the side window, there's a lot of runways with lots of parallel strips of concrete at many airports, I can see how one could mix up taxiways from runways.Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.
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How timely:
But the public is only learning about the five-year-old inspection results now because Air Canada had taken the federal government to court to try to block portions of the records from being released through Access to Information legislation. The airline said disclosure would be “misleading” and bad for business.
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Originally posted by Schwartz View PostI agree. It wasn't supplemental, just new. It was a timing thing in this case. It had just been rolled out in the past year, and they hadn't received their annual training yet. From the report:
Personally, I think any of these things are limited in their value, because when it comes down to the crunch, if there is a stressor of urgency and time pressure, it will lead toward expectation bias. It is how our brains are designed to make sure we can react without over analyzing things and becoming paralyzed from indecision.
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