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Old 5th May 2017, 08:56   #1681 (permalink)
 
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I'd be very surprised if inappropriate use of automation finds its way close to the top of the causes of this accident.

Either you as an operator or you as a crew know that a 10mile cruise at 200ft in bad weather downwind to a fixed land base is a bad idea or you don't. How you then handle that cruise is a bit of a secondary issue.

I wonder how many other lessons need to be relearned the hard way ?
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Old 5th May 2017, 10:32   #1682 (permalink)
 
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Crab,

I agree with all that but your penultimate paragraph identifies a problem.....the individual Pilot and Crew Member along with everyone in the process....and Operator and Authority must also see that there are no pauses, detours, or stays to that journey towards improvement.

I would suggest we might be seeing some systemic failure on display here that caught some folks out one dark night that caused them to pay a terrible price for that.

Formula One cars fail to win races unless all the bits and pieces come together to provide the driver a Ride that will afford him a chance to win if his performance is up to the task.
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Old 5th May 2017, 12:24   #1683 (permalink)
 
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Quote:
I'd be very surprised if inappropriate use of automation finds its way close to the top of the causes of this accident.
no, but the slavish following of the FMS to the detriment of basic airmanship might.
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Old 5th May 2017, 12:59   #1684 (permalink)
 
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Absolutely, that was my point.

Although to be fair, the slavish following of the FMS wasn't nearly as damaging as the decision to do it at 200ft.
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Old 6th May 2017, 21:47   #1685 (permalink)
 
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Back to basics!

As i have been freighting tourists and Hen-parties across Europe the last week, I have just read and not posted on this thread.

I must say the latest comments has been more productive, safety vise.

I compare this one to the FMS Cali accident and the New Zealand DC10 Antartic CFIT.

Basically modern equipment trusted and directly drilling a hole into the Swiss cheese.

I fly with the children of the magenta line and I am there to remind them that the basics are King , Always !

There is many contributing factors as in most CFIT, but some of the modern Duhikkies are at times counter productive.

I was just out fishing and a Norwegian SeaKing passed over my row boat.
The best SAR crew in the world the RNoAF , soon getting new and modern equipment.
I am going to miss that distinct sound.

Anyway, I hope they keep a healthy combination of old , trusted procedures and new and helpful ones. I am trust they will.

This Company and Crew has indeed shown us not to blindly trust modern equipment and at the same time disregard basics .
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Old 9th May 2017, 17:51   #1686 (permalink)
 
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Royal Navy Crewman airlifted to Hospital from Submarine

Great result by Rescue 118 who carried out the rescue while Rescue 115 flew top cover


Irish Coast Guard helicopter airlifts injured sailor from British Navy submarine | BreakingNews.ie
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Old 9th May 2017, 19:40   #1687 (permalink)
 
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Quote:
Originally Posted by BluSdUp View Post
...
I was just out fishing and a Norwegian SeaKing passed over my row boat.
The best SAR crew in the world the RNoAF , soon getting new and modern equipment.
I am going to miss that distinct sound.

Anyway, I hope they keep a healthy combination of old , trusted procedures and new and helpful ones. I am trust they will.
...
I am sure 330 SKV have the expertise to make the most of their new aircraft with all its latest technology.
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Old 12th May 2017, 22:53   #1688 (permalink)
 
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Just a personal note. If there is to be a memorial service I would be much obliged if someone would PM me details as I may miss any announcement as I'm no longer in the ROI. I worked with a couple of the crew some years ago and would very much like to pay my respects.
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Old 16th May 2017, 04:00   #1689 (permalink)
 
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Irish S-92 Accident Report Paints Picture of Confusion | Business Aviation News: Aviation International News

AIN on-line article by Mark Huber misleadingly titled "Irish S-92 Accident Report Paints Picture of Confusion". There was no confusion. Every crew member thought the aircraft flightpath was following the absolute correct procedure, nothing was challenged. Even the rear crew penultimate suggestion to "come right" was met with deliberate and paced response from both pilots.
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Old 16th May 2017, 11:05   #1690 (permalink)
 
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Irish S-92 Accident Report Paints Picture of Confusion | Business Aviation News: Aviation International News

AIN on-line article by Mark Huber misleadingly titled "Irish S-92 Accident Report Paints Picture of Confusion". There was no confusion. Every crew member thought the aircraft flightpath was following the absolute correct procedure, nothing was challenged. Even the rear crew penultimate suggestion to "come right" was met with deliberate and paced response from both pilots.
I think the confusion is exactly HOW they thought they were absolutely correct...
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Old 16th May 2017, 12:09   #1691 (permalink)
 
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A lot of pilots here, presumably with various degrees of experience in various roles, have read the CVR transcript and have arrived at various understandings of what was meant by what was said. This is the problem. I recall very early in the discussion here, it was reported, I think in the context of what is good CRM, that an ex-military pilot was overheard to say, when I press the mic I just want everybody to understand what I say.
I think @helicrazi has made an astute observation that confusion is exactly how they thought they were absolutely correct.
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Old 16th May 2017, 12:46   #1692 (permalink)
 
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Is there a difference between "Why" and "How" when it comes to the "confused" situational awareness?
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Old 16th May 2017, 14:54   #1693 (permalink)
 
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How do you overcome the "incorrect certainty" about a situation?

Potentially, an experienced pilot says something like "nothing higher than 30' here" (after misreading a 300' spot height)

I've been in many situations where something like this has been accepted as fact, and everything is predicated/explained based on an "incorrect certainty" (many not in aviation)

It might seem a farcical/extreme example but I can easily imagine the "certainty" of there being "nothing higher than 30'" resulting in a comment to "write up the faulty rad alt" when it trips unexpectedly for e.g.

Sure in hindsight it's obvious, but at the time, it can be anything but.

In a two crew situation, I feel it's not viable to check/question every statement.

Trying to explain myself:

After start, for a mission requiring 100% fuel. Add in nighttime and a little perceived time pressure.

"We have full fuel right?"
"I topped it to the bottom of the filler, dribbled it in until another drop wouldn't fit, waited for it to settle, dribbled a few drops more till it over flowed. It's full!"

The fuel status might now be beyond doubt, and any anomalies explained away as indication problems.

A fuel leak, or fueling WEX, and now sitting in WXE, are mentally discounted (especially if WXE is coincidentally filled to 90%)

How do we combat this type of error?
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Old 16th May 2017, 15:59   #1694 (permalink)
 
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I think it's important to make a distinction between confusion and incorrect SA.

Confusion is a lack of understanding or lack of confidence in the information presented. This crew showed no sign of questioning that accompanies confusion. Compare this with the transcript of AF447, where everyone is trying to grasp what is going on.

I am convinced that this crew started the last phase of the flight with a clear, albeit incorrect, mental picture of what was ahead and how they would deal with it. Nothing in that aircraft, crew, training, procedure or technology was compelling enough to cause a re-assessment of that mental picture. In fact, it appears that most cues were readily incorporated into the existing SA. Until the moment that something untoward was seen on the electroptics.
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Old 17th May 2017, 05:53   #1695 (permalink)
 
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Yes, it's like making the ground fit the map in the early stages of getting lost and until something so obviously wrong appears, it is too easy to convince yourself all is well and just as you planned it.
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Old 17th May 2017, 13:50   #1696 (permalink)
 
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Quote:
Originally Posted by dClbydalpha View Post
I think it's important to make a distinction between confusion and incorrect SA.

Confusion is a lack of understanding or lack of confidence in the information presented. This crew showed no sign of questioning that accompanies confusion. Compare this with the transcript of AF447, where everyone is trying to grasp what is going on.

I am convinced that this crew started the last phase of the flight with a clear, albeit incorrect, mental picture of what was ahead and how they would deal with it. Nothing in that aircraft, crew, training, procedure or technology was compelling enough to cause a re-assessment of that mental picture. In fact, it appears that most cues were readily incorporated into the existing SA. Until the moment that something untoward was seen on the electroptics.
This is on the money. Easy to remain confident in the SA now as generally it is very good. Unfortunately, mistakes are only really identified after they have caused major damage.
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Old 17th May 2017, 20:04   #1697 (permalink)
 
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This gets back to my question about "How" and "Why".

"How" is the triggering event....and "Why" is what set it all up for the "How" to happen.....as I see it.
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Old 18th May 2017, 02:17   #1698 (permalink)
 
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The how is easy, the aircraft was flying below MSA for the area.

The why, is because the crew hadn't got a clue they were below MSA due to inadequacies in the charts they were using.

They knew perfectly well where they were, the chart displayed just didn't show them to be in any danger. That led to confusion when an obstruction was identified ahead, because the chart would be expected to show anything large or tall enough to cause danger to the aircraft.

It really doesn't have to be any more complicated than that.
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Old 18th May 2017, 02:22   #1699 (permalink)
 
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Originally Posted by G0ULI View Post
The how is easy, the aircraft was flying below MSA for the area.

The why, is because the crew hadn't got a clue they were below MSA due to inadequacies in the charts they were using.

They knew perfectly well where they were, the chart displayed just didn't show them to be in any danger. That led to confusion when an obstruction was identified ahead, because the chart would be expected to show anything large or tall enough to cause danger to the aircraft.

It really doesn't have to be any more complicated than that.
You're no fun.
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Old 18th May 2017, 08:47   #1700 (permalink)
 
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MSA

Gouli,
at 200ft you know you are below msa!
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