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  • #16
    Originally posted by BoeingBobby View Post
    You are right, I still have connections there, and because there were conflicting posts on both PPrune and APC, I called a friend that is a check airman there. They have all been briefed on the incident.

    And I agree with you both that ITS would not have done this either. He has been a freight dog long enough to know the things that will bite you.

    So, we have a crew, (10-year Captain and a new First Officer, I have not been told of a third pilot) Late at night out of Narita up against the airport curfew. The pilot flying got the ATIS off of ACARS and entered the data into the FMS along with the data from the OFP (official flight plan) and the weight and balance (that is done by ground crew Evan). The ACARS now spits out take-off performance data. This is now entered into the FMS again by the pilot flying, and now verified by the pilot monitoring. Check lists complete, call for push-back. Start engines, wave off the ground crew and another check list. Hello ground Polar 213 heavy ready to taxi stand 208. A thick Japanese accent reads back, Polar 213 please be advised of runway change, now departing runway 34 right, clear taxi runway 34 right, whiskey 5, whiskey, whiskey 10, Charlie, bravo 10 for 34 right read back. It is a long and not east to follow taxi! Pilot flying tells the pilot monitoring, I will taxi the aircraft, you change the runway and the take-off data. Well when you do that you get a big fat TAKE-OFF SPEEDS DELETED, in the CDU. So now the pilot monitoring re-inputs the new V speeds. Problem is, that they had a de-rated power setting of TO2 in the FMS from the 13123’ runway they had originally planned on taking-off from, and now they are taking off from an 8202’ one. The V speeds were right for the shorter runway, but they missed that the de-rate had been removed in the new data, and was now calling for a setting of TO (full thrust). THE PILOT FLYING DID NOT VERIFY THE NEW INFORMATION! They departed the pavement with 85 meters (279’) to spare. Took down piece of a fence and did some supposed damage to some farmers property with the jet blast. So now, knowing Atlas the way I do, all of the pilots will get to take some kind of online test about it. And that will make the FAA happy.
    In your experience, how many times in 100 would the verification step catch an error?

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    • #17
      Thank you BB for the detailed explanation.

      --- 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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      • #18
        Originally posted by TeeVee View Post
        pilots' version of the blue wall of silence?
        No, more like common decency and courtesy. There are people whose job it is to release the wash, and BB is not one of them.

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        • #19
          Originally posted by ATLcrew View Post
          No, more like common decency and courtesy. There are people whose job it is to release the wash, and BB is not one of them.

          Like I said, just the facts Mam, just the facts, no names.

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          • #20
            Originally posted by ATLcrew View Post
            No, more like common decency and courtesy. There are people whose job it is to release the wash, and BB is not one of them.
            like i suspected, blue wall stuff. you do realize that this helps no one? and further, the names were omitted to "protect" the not so innocent. and of course, i'm being sarcastic here, as it's not about innocence or guilt. this was very very likely pilots' error. as an alleged pilot yourself, you should be grateful for the lesson learned.

            i'm not advocating anyone getting canned over this, since i'm not in the position to judge whether this was the kind of mistake that absolutely should never have been made. and i rarely, if ever, rejoice in anyone losing their job. but you've gotta think of it this way: being in charge of an enormously dangerous instrumentality carries with it an enormous burden not to eff up, and if you do, you're gone.

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            • #21
              Originally posted by TeeVee View Post
              like i suspected, blue wall stuff. you do realize that this helps no one? and further, the names were omitted to "protect" the not so innocent. and of course, i'm being sarcastic here, as it's not about innocence or guilt. this was very very likely pilots' error. as an alleged pilot yourself, you should be grateful for the lesson learned.

              i'm not advocating anyone getting canned over this, since i'm not in the position to judge whether this was the kind of mistake that absolutely should never have been made. and i rarely, if ever, rejoice in anyone losing their job. but you've gotta think of it this way: being in charge of an enormously dangerous instrumentality carries with it an enormous burden not to eff up, and if you do, you're gone.

              I know Atlas, NO ONE is going to loose their job over this. There will be a come to Jesus meeting at the training center in MIA, and more than likely a sim ride or two.

              Comment


              • #22
                Originally posted by Schwartz View Post
                In your experience, how many times in 100 would the verification step catch an error?
                Human beings have an inherent flaw, they make mistakes. This is one of the reasons for the verification process. Is it perfect? Nothing ever is!

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                • #23
                  Originally posted by Evan View Post
                  TOPMSFMSNOTAMTCASOBWBSFMSTOPMS
                  Indeed.
                  Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                  Comment


                  • #24
                    Originally posted by BoeingBobby View Post
                    Human beings have an inherent flaw, they make mistakes. This is one of the reasons for the verification process. Is it perfect? Nothing ever is!
                    Any value in an electronic system sort of monitoring/overseeing any of this stuff...speaking broadly?
                    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

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                    • #25
                      Ya know...ANOTHER reason for the 'line of scilence' is that blabbing can open the employer up to 'defamation' lawsuits from the ALLEDGED stupid pilots (suits aided by someone's coworkers.) I know I'm a dumbass at times, but y'all continue to say the funniest things.
                      Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                      Comment


                      • #26
                        Originally posted by BoeingBobby View Post
                        Human beings have an inherent flaw, they make mistakes. This is one of the reasons for the verification process. Is it perfect? Nothing ever is!
                        For sure, I know that is absolutely true. The reason I ask is it is very easy to have a false sense of feeling secure bypassing the normal procedure of double checking if the number of mistakes was very low. If let's say, an error was made and caught 3 times in 100, then the odds of getting away with skipping the double check procedure this mistake is 97%. I imagine a good pilot who makes the odd exception of bypassing the double check would never likely have an incident like this in their career even if they skipped procedure once a year.

                        It's also really easy for 2 pilots in the same environment to make the same mistake at the same time (see recent Air Canada incident).

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                        • #27
                          Originally posted by 3WE View Post
                          Indeed.
                          LOL

                          Comment


                          • #28
                            Originally posted by Schwartz View Post
                            ...would never likely have an incident...
                            Aviation accidents mostly involve the unlikely. Thus, the unlikeliness of an event is no excuse for not doing something to prevent it.

                            The more important word is 'foreseeable".

                            Comment


                            • #29
                              To Schwartz and TeeVee and Evan's point... I made this exercise before and was not taken seriously because, they said, it is not realistic. it is not, and it is not meant to be. It is an oversimplified reality to make a point. Reality is much more complex (and worse).

                              Say that all pilots are alike, they have exactly the same training, same skills, same strength and weakness regardless of their experience (they all have enough experience to have their ATP license and that's enough, additional experience doesn't make them any different).

                              Now, that doesn't mean that there is no randomness. You can have identical dice and they will not yield identical values every time. But, ON AVERAGE, even if they are biased (but in the same way) they WILL produce the same fraction of 1, 2, 3, etc... among them.

                              In the same way, these pilots don't touch down always with the same vertical speed, but the average vertical speed and the distribution of vertical speeds around that average is the same for all of them. (just used the touchdown vertical speed as an example, but it can be anything).

                              Now say that there is a mistake (like wrong take-off computation) that this universe of pilots make, as a combined crew, at a rate of once per million flights. And say that this mistake ends up being an accident one out of 100 times that it is made. Since these pilots fly, on average, 10,000 flights along all their career. The vast majority of these pilots are never involved in such a mistake. Only 1 in 100. And only 1 in 10,000 have an accident as a result of this mistake. Yet, with 40 million flights per year, we have on average 40 such incidents per year and an accident every 2.5 years.

                              When this accident happens it is very tempting to say "pilot error, they were irresponsible, they didn't do their job, after all most of the pilots never make this error in their whole career". And yet, that's not the case. With the current system and process, this accident is bound to happen every 2.5 years on average. And blaming, disciplining and firing the pilots who make it will not help an inch to improve the situation. Not only it can happen to any pilot, but it can happen to any pilot with the same probability. It is something that WILL happen to some of them, any of them, at any time, every once and then.

                              Now, full disclosure is something that can lead to improve the situation. It can make the pilots more aware. It can help make the pilots realize that that can happen to them too. The poor unlucky pilots that made the mistake can explain how this mistake happens, what factors were involved, and this information can be used to take actions reduce the likelihood of occurrence.

                              And yes, I realize that these pilots, in the Atlas case, didn't follow the procedure. Every time there is a PILOT ERROR there is something that was not done correctly. But, even then, there is a fine and fuzzy line (but there IS a line) between a real mistake and reckless negligence.

                              Giving any kind of disciplinary action to this crew makes no sense to me. Giving THEM remedial training either. These pilots will not make the same mistake with or without remedial training. They learnt the lesson the hard way. Improving procedures, improving the training program, adding software aids, adding TOMPS, maybe adding or changing regulations, etc works much better. I mean, can work at all.

                              --- 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


                              • #30
                                Originally posted by Gabriel View Post
                                And yes, I realize that these pilots, in the Atlas case, didn't follow the procedure. Every time there is a PILOT ERROR there is something that was not done correctly. But, even then, there is a fine and fuzzy line (but there IS a line) between a real mistake and reckless negligence.
                                Gabriel, this is what I've been saying all along, about everything from Turkish 1951 to this incident. In most of these cases, there is a fuzziness between negligence and mistake, but we have to allow pilots to make occasional mistakes. That's what redundancy is there for. And we have to allow both pilots to make the mistakes on rare occasions. That's what protective systems are there for.

                                The only obvious negligence I see here is the continued resistance by both the industry and its pilots to making TOPMS a standard requirement. Since it is a relatively simply, relatively cheap, relatively maintenance-free and relatively harmless addition to the cockpit, I see no excuse for this.

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