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Old 29th Apr 2019, 14:19
  #4569 (permalink)  
737 Driver
 
Join Date: Apr 2019
Location: USA
Posts: 217
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Okay, a lot of ink got spilt yesterday, and I'll also offer my apologies to anyone offended by my admittedly passionate approach. But is has been passion with a purpose. In the interest of moving the conversation along, I would like to more explicitly address a subject that I've only touched on so far.

There are those among us who believe that, when presented with sufficient novelty and distraction, it is completely understandable for an aviator to misdiagnosis a problem and not apply the proper corrective action. After all, we are only human, and all humans are fallible. I really don't have a problem with this general concept, but I strongly disagree that it is a problem beyond remediation.

Let me start with an observation. When the stick shaker went off, the Ethiopian Captain did not turn into a formless lump of clay. He actually did fly the aircraft after a fashion. He manipulated certain controls and he provided directions to the First Officer. I think it is worth looking carefully at what he actually did - rotate, climb to 400', engage the autopilot, continue climb to 1000', retract the flaps, contact ATC, request a vector. If I presented this sequence of actions to you without any preamble as to place or time or aircraft condition, what does this look like? If you said a normal takeoff profile, go to the head of the class. I humbly submit that, when all was going to shit and the Captain was uncertain as to what was going on, he defaulted to his training. Unfortunately, he defaulted to the wrong training.

Let's consider for a moment aircraft reject procedures. Everything is fine up to V1, continue the takeoff. Certain things happen prior to V1, not only reject the takeoff, but reject the takeoff with a set of aircraft-specific actions that must be accomplished in a timely manner. Please read that sentence again. There are at least two "default modes" of operation present in any takeoff (more if you wish to count emergency specific actions like Engine Failure). Which default mode the pilot selects makes all the difference in the outcome.

Just as the "continue the takeoff" mode would be inappropriate with an Engine Fire light prior to V1, the "reject the takeoff" mode would be inappropriate with a Master Caution/Anti-ice light once above 80 KIAS (at least it would be on the 737). For a pilot transitioning from single-engine to multi-engine operations, this is a whole new realm of experience that does not come naturally. (Those of you who have screwed this up in the sim, please raise your hands. ) The key to successfully training for this maneuver depends on repetitive practice (procedural memory) with a particular focus on the appropriate triggers.

What I am suggesting is that one of the ways out of the conundrum presented by the Ethiopian and Lion Air accidents is to first acknowledge that there really was a "default mode", a set of aircraft-specific set of actions that if accomplished in a timely manner, would have changed the outcome. Please read that sentence again. The default mode to which I refer is the simply the one that I have been repeating ad nauseam: Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude.

Perhaps some of our gentle readers are starting to clue in why I keep repeating this phrase. It is because when you go to bed at night, I want you to be thinking the words, "Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude." I want you to be thinking about these words when you get up in the morning, when you have a cup of coffee, when you are taking a dump, when you are driving your automobile. I want you to think about these words when you are in the sim or when you are "chair flying" a scenario. I want these words to become your mantra. Most importantly, I want you to be thinking these words for every takeoff, every landing, and truly, for every flight operation. Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude. Repetition, repetition, repetition.

Once we've committed these actions to procedural memory, then all we need to do is work out the trigger. We have triggers for rejects, we have triggers for engine failures, we have triggers for emergency descents, we have triggers for all sorts of emergencies. When that trigger presents itself, then a certain set of default actions follow.

Let me suggest an appropriate trigger here. When presented with an unexpected warning, an undesired aircraft state, or a loss of situational awareness and you are unclear as to what you should do next: Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude.

Keep repeating this set of actions until you arrive at a stabilized condition where you can better assess what is going on. This procedure is basically the Swiss Army Knife of our non-normals. When you have no clue as to what to do next, Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude. Given what we know of Ethiopian 302, Lion Air 610, Air France 447, and a host of other aircraft accidents, I think it is reasonable to say if the crews had applied this procedure, then there would be a few hundred more people alive today.

Easy to say, hard to do you might respond. Yes, you're right. Hard to do, but not impossible to do.

There was a time in my aviation career when one would be subjected to the whims of a sadistic simulator instructor whose only job was to present you with a host of malfunctions and upsets for which there was only one correct initial response: Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude. You did this again and again and again until it was impressed upon you that there will come a time when you really have no clue what is going on and that the only safe harbor was, Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude. After some passage of time without sufficient evidence that this was a "cost-effective" use of sim time, this type of relatively unstructured training was replaced with what has largely become a set of scripts consisting of known problems and known answers.

I am suggesting that in the aftermath of these accidents there should be a strong reemphasis at every level of training and operations that, despite all efforts to the contrary, the professional pilot can still be faced with novel and potentially hazardous circumstances that exceed all malfunction-specific training. In those circumstances, when there is no other obvious solution, Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude.

Specifically, our training needs to intentionally incorporate surprise, uncertainty, and ambiguity because that is one of the hazards we are likely to face. Some of us have had the opportunity to train in an altitude chamber where we learned first-hand our hypoxia symptoms so that we could better respond to those symptoms in a timely manner. In the same vein, what is needed is a type of training that repetitively introduces us to our startle reflex so we can better recognize it and respond appropriately. And what is that appropriate response? In the absence of any other clear guidance, Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude. I humbly submit if that if the Ethiopian and Lion Air crews had been offered this type of training, then we would not be having this conversation today.

I fully realize that some of us are at airlines that are not going to take this message to heart and will not substantially change their training regimen. In those cases, it falls to the individual pilot to do whatever he can to train himself. Repeat the mantra, chair fly some scenarios, and know that at some future point, you may be presented with the unknown and have no clue what to do. In those cases,Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude. This will not fix every possible set of malfunctions, and there will be situations which are truly unrecoverable. Fate is Still the Hunter, but I am hoping we may have learned a thing or two since Ernie Gann penned those words. You can only do what you can do with what you have. However, as long as you have an aircraft that is flyable, you will rarely be wrong if you:
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Turn off the magic, set the pitch, set the power, monitor the performance, trim the aircraft, move to a safe altitude.

Last edited by 737 Driver; 29th Apr 2019 at 17:59.
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