PPRuNe Forums - View Single Post - Report on 1999 B757 crash at Girona finally published
Old 15th Sep 2004, 19:06
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atse
 
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Well, was it Fuel, Weather, Fatigue, Cockpit Gradient, CRM, Planning or what?

Most accidents can be analysed from different perspectives and, depending upon that perspective (or hobby horse, or bias if you will) a version of events - and how those events could have been interrupted - can be easily re-created in retrospect. Those strongly holding to a particular point of view will invariably find suggestive evidence that just seems “obvious” to them.

The problem is that for each notion as to what factor was critical - e.g fuel, weather, fatigue, cockpit gradient, CRM, etc. - a version of events can be constructed which differs as to the crucial aspects. Working out which version is “correct” can rapidly become a fruitless exercise, since very notion of “correct” becomes part of the problem of analysing the events.

It is, just to take one example, clear that Tartan Giant is somewhat horrified by the fuel decision of the commander/crew. In the absence of knowing the outcome, or the commander’s reasons when he made the decision, the amount of fuel has to be considered sufficient (read that again carefully if you think it is nonsense. Otherwise you are forced to make the claim that the flight dispatch decision was itself demonstrably wrong, at the time of dispatch. I don’t think the evidence is there to make any such statement). The fuel carried may look insufficient IN RETROSPECT, given a particular perspective and the way events unfolded.

But how many times have pilots found themselves in situations that looked much worse, or better, than expected on arriving at destination? Consider it this way: if the crew had carried 45 minutes extra fuel, but arrived at the airfield 30 minutes earlier, held because of CB avoidance and then found themselves in an absolutely identical situation, would we now be hearing anything about fuel? I think not. I think the focus would be elsewhere. My point is that it is not the amount of fuel that is at issue here, but the reasonableness of the decisions made AT THE TIME THEY WERE MADE.

Surely the real point, so well outlined in the Flight Editorial, is that this was an ordinary flight that suddenly, and for various unpredictable reasons went awry. The big problem is that this was indeed an ordinary flight and the path to the dreadful outcome is only clear in retrospect. In my opinion we should be talking about why the Flight Editorial is so important, as well as it’s significant for all professional pilots.

If you think about this event in real time, as it unfolded for the crew concerned, I think there is a lot to be learned about how each of us might wish to approach analogous situations in the future. Surely that is the benefit of having a discussion about accidents?
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