Air Niugini plane misses runway, lands in sea off Micronesia island

[flashcrash]

Put this PIC in an American Airline flight and very likely what you'll have is the FO calling "we lost visual, go around; GPWS warning, go around, I have the plane, go around, flaps 15" and then filling a report on the incident. After that, if this PIC doesn't quickly adapt to AA's culture, he won't last.

The point you're making about the power of company culture vs procedure is definitely thought-provoking. For what it's worth, I found this in the Air Niugini Standard Operating Procedure Manual:

"When a crew member notices a significant deviation from standard procedures during a normal flight regime, he should communicate this immediately to the crew member flying. If he does not receive a response to his challenge either verbally or by corrective action, he should immediately repeat the challenge. If there is still no response to the second challenge, then he should take over the control of the aircraft and restore a safe flight condition while he obtains assistance to determine the cause of the problem. All crew members are to be aware of this challenge and response philosophy. If they are challenged, they must be prepared to respond immediately, either verbally or by taking corrective action" (Section 2.5.1)

[3WE]

I found this in the Air Niugini Standard Operating Procedure Manual

I've become a grumpy old man.

Yes, I'm sure that IS in their manual.

And, yes it SHOULD be done.

But the fact that someone wrote a bunch of stuff in a manual versus how you actually do it in the real world while balancing common sense, the written procedure and true right and wrong is why Evan and I argue all the time.

And none of what I say or you say or Evan and Gabriel says, or the manual says means anything if they simply blow off what's in the manual (or get in the habit of effectively flying blind below minimums with apparently inadequate attention to the altimeter reaching zero.)

Or if there's a culture that the manual is only suggestions...

[Gabriel]

The point you're making about the power of company culture vs procedure is definitely thought-provoking. For what it's worth, I found this in the Air Niugini Standard Operating Procedure Manual:

"When a crew member notices a significant deviation from standard procedures during a normal flight regime, he should communicate this immediately to the crew member flying. If he does not receive a response to his challenge either verbally or by corrective action, he should immediately repeat the challenge. If there is still no response to the second challenge, then he should take over the control of the aircraft and restore a safe flight condition while he obtains assistance to determine the cause of the problem. All crew members are to be aware of this challenge and response philosophy. If they are challenged, they must be prepared to respond immediately, either verbally or by taking corrective action" (Section 2.5.1)

That something is in a SOP, procedure, manual, training verbiage or policy doesn't mean AT ALL that it is what is being done or that it is part of the culture.

Watch the movie that I recommended to Evan.

Culture is how we behave normally in our daily life / work, especially when we are not doing something for the culture.

EDIT: I made this post before reading 3WE's answer. Spot on!

[Evan]

On the contrary, it is very rarely the trend within an individual person. Because these persons can't survive with such trends in a company with a strong safety culture. They either adapt to the culture, or leave, or are fired.

Or crash, then get fired. I think you are right that it is often a culture at fault, but there are also instances of a certain pilot who just can't be bothered with 'nanny-state' safety procedures because he has stupendous airmanship and doesn't need them (see: Cowboy). If he is accompanied by a culture that tends to embrace the cockpit gradient philosophy (see: Asia), he can get away with a lot.

Watch the movie Whisky Romeo Zulu (based on a true story, available in Amazon Prime and YouTube)) and observe how a company culture is stronger than an individual. This works both for good and for bad.

Is there a subtitled version out yet? The film chronicles an extreme example of broken safety culture (dispatching aircraft with no functioning primary instrument) that hopefully no longer exists. But who knows. There's always AirAsia.

[flashcrash]

That something is in a SOP, procedure, manual, training verbiage or policy doesn't mean AT ALL that it is what is being done or that it is part of the culture. Watch the movie that I recommended to Evan.

Saw it in Paraguay in 2006. Great movie. Purpose of the post was to demonstrate the size of the discrepancy between culture and written procedure, reinforcing your point. Hence the phrase “culture VS procedure”. That said, culture notwithstanding, both pilots were ultimately judged against that specific procedure, as the report demonstrates.

[flashcrash]

Is there a subtitled version out yet?

Must be. The version I saw had subtitles. Try youtube?

[Gabriel]

Or crash, then get fired. I think you are right that it is often a culture at fault, but there are also instances of a certain pilot who just can't be bothered with 'nanny-state' safety procedures because he has stupendous airmanship and doesn't need them (see: Cowboy). If he is accompanied by a culture that tends to embrace the cockpit gradient philosophy (see: Asia), he can get away with a lot.

Then it is still a culture issue, not an individual issue. In a company that allows this kind of behavior, you will never have just one individual pilot with that behavior.

Is there a subtitled version out yet?

Yes, I saw it with subtitles in English. I don't remember where but probably in Amazon Prime.

The film chronicles an extreme example of broken safety culture (dispatching aircraft with no functioning primary instrument) that hopefully no longer exists. But who knows. There's always AirAsia.

The airline (LAPA) doesn't longer exist. It didn't survive for a long time after the accident.

As I don't remember who said: If you think that safety is expensive, try with an accident.

[ATLcrew]

What in the hell are you guys arguing about?

They're sparring about who can do this aviationing blabber gooder.

[flashcrash]

Seems NTSB has filed a dissent against the PNG report. Not against the causal factors but against the report's recommendations. My apologies if you guys were already aware.

[Gabriel]

Seems NTSB has filed a dissent against the PNG report. Not against the causal factors but against the report's recommendations. My apologies if you guys were already aware.

The PFD showed a red text "PULL UP" warning. The investigators concluded that if the pull up warning had been aural, this would likely called the attention of the crew who then would have executed a go around. The NTSB disagreed, saying after all the indications and warnings (including aural warnings) that the crew disregarded, there is no reason to think that they would not have disregarded this additional one too.

Is that what you are talking about?

[Evan]

The PFD showed a red text "PULL UP" warning. The investigators concluded that if the pull up warning had been aural, this would likely called the attention of the crew who then would have executed a go around. The NTSB disagreed, saying after all the indications and warnings (including aural warnings) that the crew disregarded, there is no reason to think that they would not have disregarded this additional one too.

Is that what you are talking about?

Agreed. This was not loss of situational awareness, as the report suggests. This was loss of positional awareness. The were well aware of the situation.

[flashcrash]

Is that what you are talking about?

It is. I thought the wording of the NTSB comment was eloquent. And if I'm characterizing your previous posts and Evan's correctly, I think it goes to the heart of what you were both saying:

"NTSB staff believes the disregard of the alerts, disregard of the PFD display guidance, and the continuation of an unstable approach demonstrate that any additional guidance, alert, or warning would be similarly disregarded by the flight crew and ineffective in preventing the accident."

[Gabriel]

It is. I thought the wording of the NTSB comment was eloquent. And if I'm characterizing your previous posts and Evan's correctly, I think it goes to the heart of what you were both saying:

"NTSB staff believes the disregard of the alerts, disregard of the PFD display guidance, and the continuation of an unstable approach demonstrate that any additional guidance, alert, or warning would be similarly disregarded by the flight crew and ineffective in preventing the accident."

That said, even if it would not have helped in this specific case, I do wonder, if the system detects a situation that warrants a pull up alert, then why doesn't the aural warning says "woop woop, pull up!" instead of saying "glideslope" and sending a "pull up" SMS to the PFD.

[Evan]

That said, even if it would not have helped in this specific case, I do wonder, if the system detects a situation that warrants a pull up alert, then why doesn't the aural warning says "woop woop, pull up!" instead of saying "glideslope" and sending a "pull up" SMS to the PFD.

Have a look at appendix H on the report. It appears that altitude callouts should have priority over SINK RATE and GLIDESLOPE, but that isn't what happened here.

[flashcrash]

Have a look at appendix H on the report. It appears that altitude callouts should have priority over SINK RATE and GLIDESLOPE

Interesting! I searched for the original document on the FAA website and found it here:

http://rgl.faa.gov/Regulatory_and_Gu...FILE/C151b.pdf

Table 4-2 confirms the accuracy of the table reproduced in the report. But to my untrained eye it does seem a little confusing, since the SINK-RATE PULL UP call-out is assigned a higher priority than an ALTITUDE call-out. Admittedly this isn't the same thing as a GLIDESLOPE call out though.

Do we know for certain there was no ALTITUDE callout before the aircraft hit the water?