Air Canada pulls a Hans Solo

[Evan]

NTSB report is out: https://www.ntsb.gov/investigations/...ts/AIR1801.pdf

So, are pilots 'addicted' to autotune?

[flashcrash]

So, are pilots 'addicted' to autotune?

Expectation bias running rampant. And the part about the taxiway looking like a runway definitely raised an eyebrow.

[3WE]

So, are pilots 'addicted' to autotune?

Still waiting for a report of some personal bicycle operations where one might view human response to a list of repeated measures and the exact accuracy to which each activity is completed.

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.

[ATLcrew]

I think you fly mostly domestic. I used to get a lot of transatlantic flights where the back 40 was pretty sparsely populated. You could usually find an empty middle row to lie back on. Especially on Delta.

Whatever you say.

[HalcyonDays]

..... I used to get a lot of transatlantic flights where the back 40 was pretty sparsely populated. You could usually find an empty middle row to lie back on.

Further to ATL’s comment, which century was this ?

[Schwartz]

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!

B) I think it is interesting that a plane that arrived prior to the AC incident (DAL) was also very confused by what they saw/understood about the runway 28R that night. It appears they couldn't reconcile what they were seeing with what they were being told, but followed the instruments to help them land. Obviously, the AC pilots were not using the ILS so they didn't have this extra layer of safety.

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.

But I am under no illusions that they rode the edge of the envelope in trying to downplay the incident and ensure the CVR was not available for investigation to protect themselves.

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.

His full comments are very good and worth the read, he talks about at least 11 different people from the incident aircraft, other aircraft, and the controller all of whom had a lot of information, but were all too busy or scared to say anything.

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.

[Evan]

Obviously, the AC pilots were not using the ILS so they didn't have this extra layer of safety.

I 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. 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?

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.

[Gabriel]

I 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.

It 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?

[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.

I agree (yes).

[Evan]

It 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?

Yes I do. So we are back to 'are pilots addicted to autotune?' Ok, not really.

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?

'Should not happen' isn't much of a defense. If a major airfield lacks ILS I would start by firing the management. If it's U/S, then it's U/S, you do it with some extra caution, but that's no reason to not make it a standard procedure.

[Schwartz]

It 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?

They did fault the pilots for poor CRM. Interesting one of the threats they both discussed was their alertness level. I think the FO had a higher workload because of the autopilot mode selected by the captain. I believe he even comments about it in the debriefing. I doubt this was a "didn't know how to do it" problem. It was a "it's too hard" while I am too busy problem.

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.

They 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.

[Evan]

They 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.

Yet, they were licensed commercial pilots. Do you see what I'm saying? This can't simply be 'supplemental' anymore.

[Schwartz]

Yet, they were licensed commercial pilots. Do you see what I'm saying? This can't simply be 'supplemental' anymore.

I 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:

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.

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.

[3WE]

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?

Maybe you should go back to the second post on this thread...and know what, maybe all the words don't matter in that post.

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.

[Schwartz]

How timely:

https://www.thestar.com/news/investigations/2018/10/15/air-canada-employees-feared-reprisal-for-reporting-safety-concerns-transport-canada-found.html

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.

[Evan]

I 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.

That's encouraging. I think anything is limited in value, but the value is still significant enough.