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Old 18th Nov 2020, 11:10
  #29 (permalink)  
alf5071h
 
Join Date: Jul 2003
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This event is an example of a hazard of misapplication - misunderstanding the concept of SOPs; an extreme SOP culture where all events are expected to follow the rules. Life is far from that perfection; training should concentrate more on process, understanding, thinking about an appropriate course of action, opposed to placing events into neat training boxes to be ticked off.

Also a reminder of how the industry forgets, mislays knowledge, most of which applies today but is put aside because of rarity of events; a weakness from improving safety standards.

From many years ago, and dusted off in the 90s for the PSM+ICR studies, a long lost example of Engine Malfunction Analysis - for crew.
https://www.dropbox.com/s/f18gotbmjs...lysis.pdf?dl=0

PSM+ICR page 2 https://www.skybrary.aero/bookshelf/books/1623.pdf
'The simulator propulsion system malfunction models in many cases are inaccurate and/or do not have key cues of vibration and/or noise. There is also no robust process that ensures the quality and realism of simulator propulsion system malfunction models or that the malfunctions which are used in the training process are those most frequently encountered in service or those most commonly leading to inappropriate crew response. This shortfall leads, in some cases, to negative training.

While current training programs concentrate appropriately on pilot handling of engine failure (single engine loss of thrust and resulting thrust asymmetry) at the most critical point in flight, they do not address the malfunction characteristics (auditory and vibratory cues) most likely to result in inappropriate response.

The changing pilot population, coupled with reduced exposure to in-service events from increased propulsion system reliability, is resulting in large numbers of flight crews who have little or no prior experience with actual propulsion system failures.'
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