PPRuNe Forums - View Single Post - Report on 1999 B757 crash at Girona finally published
Old 9th Sep 2004, 23:56
  #46 (permalink)  
fireflybob
 
Join Date: Jun 2001
Location: UK
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The purpose of accident investigation is to find out what happened and why - NOT to apportion blame.

Pilots are human beings and by definition are capable of "error" but to blame any accident on the pilot is far too simplistic. Accidents are a product of the entire "system". Error chains can start anywhere and with this one it might be argued that such a chain started with the (permitted) FTL schemes that exist (this is no criticism of Britannia) or with a fuel policy which promotes "economy" rather than "safety".

I recall on one CRM course I attended the facilitator talked about the "poor judgement chain" - once one poor judgement is made then the probability is that more will follow at an ever increasing rate. I am not criticising the aircraft commander (there but fot the grace of God go I etc) but once the decision had been made to take only an extra 15 minutes holding then the odds were beginning to be stacked in the wrong direction. Poor judgements chains can only be broken by questioning their starting point and acting accordingly.

My experience is that crews are rarely given any training and guidance as to how much extra fuel to take when appropriate. As a training captain some years ago who often operated to GRO and the like I taught crews to look critically at the destination and alternate forecasts especially when either were close to minima and if there was any doubt to load more rather than less. I know that excess fuel carriage can be a contentious issue in some companies but such policies are, I repeat, part of the potential error chain. It is also important that crews understand the ramifications of terms such as TEMPO etc.

This type of accident could have happened to virtually any operator but we have to ask ourselves, as professional pilots, how WE as individual crew members in whatever role can prevent a similar accident in the future.
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