Loganair 2014 Severe Icing/Mtn Wave AAIB Report

[Ted927]

AAIB has issued its report on the 2014 Loganair encounter with severe ice conditions and mountain wave. There were some crew variances from SOPs as well.

https://assets.digital.cabinet-offic...LGNM_09-15.pdf

[ewe.lander]

Read it several times, total sympathy with the Captain, fully accept what AAIB say but felt he dealt with it well given the 'cues' he had. As a Turboprop Captain on all sorts over Scotland I'm with him. Easy to be smart after the event. Maybe I'm a Dinosaur.........

[parkfell]

An important aspect of this event is to learn from it, and continue to educate the crews.
Dealing with severe icing can only be done by keeping the speed safe, and escaping from it. The difficulty is deciding when moderate icing IS CHANGING to the onset of severe. Ice deposits on the front windows and the wiper are good clues. Start escape procedure no later than IAS 160 kts.

[Tourist]

Doesn't sound like the FO liked flying with him though.....

[mockingjay]

So within the last year we have had two temporary loss of control events in Loganair. This incident whereby the incorrect technique was used and the S2000 incident which was likely due to mode error/confusion. We also have a failure of CRM in this incident due to the steep authority gradient which resulted in the airline retraining crews. A scary situation whereby the FO saw what was happening, knew how to get out of the problem yet didn't speak up. I could understand this happening in an airline laden with primadonnas or one where the culture makes it difficult, but a turboprop operator in Scotland? Is there something very wrong at Loganair or just an unfortunate set of circumstances? If this was Air France or a South East Asian airline there would be a lot more posts pointing out how unsafe they are.

[pattern_is_full]

I am curious about why any pilot, faced with deteriorating speed, would hesitate to firewall the throttles immediately (along with other procedures). Not specific to this crew, since in one of the previous events listed, the same hesitation occured.

Is there something in the Saab (or other) SOPs/training that inculcates a belief that engaging TOGA/MCP should be a last resort, rather than a first resort?

[parkfell]

WITHOUT PREJUDICE

It is often the case in airlines that the "culture" is set by the top management team. Those who adopt a policy of

" the floggings will continue until morale improves"

have only got themselves to blame when events occur.

Rule by fear is never the answer.

Get the culture right in the first place and middle management will behave in a far more appropriate way to their staff, and they will feel that they can communicate with the line managers and talk about their concerns. The fact that the FO felt inhibited from expressing their anxieties prior to the event cannot say much about an open and transparent culture?
It could be the case that the FO was an oddball in the first place? Who knows?

Blaming the crews is not the answer, or the solution. Get the training right and everything will flow from that. This is NOT an option.

A final thought ~ if you think training is expensive, wait until you have an accident.

[nacluv]

As someone whose flying these days is only as SLF, I find it staggering (and very worrying) that "Authority Gradients", egos etc still exist between the two front seats.

Seems that Staines, Tenerife et al have taught us nothing.

[Nil further]

Scarey stuff , heart goes out to F/O. Shades of Tenerife in as much as potentially catastrophic situation F/O knows a "Senior Training Capt' " has called it wrong but is unable to speak up due the CPT personality , will WE ever learn ?

[Livesinafield]

No we will never learn because we can't, our personalities and our design makes its so.

Cockpit gradients will always exist because you have someone who is more senior than the other

The FO knew what to do and why didn't he suggest it? Because he was too worried about being wrong and the captain thinking he was stupid, we have all done it at sometime in our careers and anyone who says that haven't is either lying or a cold soul...

On another note nice to see someone handle a stall recovery correctly and not just fly it into the ground

[Countrygent]

Very much agree with parkfell here. When there is a culture that is created that creates a thought process of "What must I do to avoid being hauled over the coals" rather than "What must I do for the safety of the aircraft passengers and crew" there are going to be problems. As has been noted, two serious control issues as well as an aircraft off the runway at SYY is not a good record this year.

Training and encouragement from the top down is the ideal that as an industry we should have learned. Sadly it's not always the case.

[Deep and fast]

Company culture is very important! Don't know about Loganair tho.

Embarrassment lasts a few minute or hours but death is permanent. See it say and if wrong say sorry.

The captain has a big role to play is this though, I regularly remind the FO if he's sees something or is uncomfortable about something then tell me. Normally I would refer to the manual for determining the answer so I don't sound like a dictatorial arse passage.

Once that's done its done.
The captain sets the tone and the company the culture.

Now if a company has a punitive culture then that's a different ball game.

[cats_five]

Originally Posted by parkfell

It is often the case in airlines that the "culture" is set by the top management team. Those who adopt a policy of

" the floggings will continue until morale improves"

have only got themselves to blame when events occur.

Rule by fear is never the answer.

<snip>

There are a lot of people over on the 777 Las Vegas fire thread who want to treat the SLF that way - floggings etc.