PPRuNe Forums - View Single Post - Report on 1999 B757 crash at Girona finally published
Old 19th Sep 2004, 17:04
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Rananim
 
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Any crew can screw up.The last hundred years has surely taught us that much.More interesting than the actual error chain that night are the set of conditions that made that error chain possible,if not inevitable.
Something led that commander to load only 15 minutes of extra fuel when thunderstorms were forecast.Company pressure has already been rejected,so what was it?A genuine oversight?A belief that European weather is generally benign(which it is)?Was the co-pilot happy with the 15 minutes?Would he have dared speak up if he wasn't,considering his relatively junior status?The report's matter-of-fact statement that the crew "discussed" fuel requirements is frankly bizarre.Dispatch is not involved in the fuel decision in Europe as I understand it.It is fair to say that crews generally dislike sticking out like a sore thumb.Would dispatch involvement("Bad weather forecast in Gerona,we suggest an extra 45 mins,subject to your approval?")not give an automatic company seal of approval?
The fuel,or lack of it,dictated the mindset on that second approach,something which Bally Heck fails to recognize.The psychological benefit of carrying enough gas settles the mind,ensuring that judgement is never clouded by diminishing options.
Steep cockpit gradients do exist and can work.But there is a heavy burden on the Captain.Checks and balances from the right seat might be non-existent or inappropiate("1000 down" instead of "GO AROUND").Failure of the lights was unfortunate but must not be used as an excuse.Go-arounds can and often do involve main-gear touchdown.
Blaming dogbox design is a misnomer.If you dont crash the thing,the dogbox is just fine.
Fatigue might have played a role but there is less evidence for this.Loss of motor skills,induced by heavy reliance on automation day in day out,was not addressed either.The Captain was reported to be in a state of mental shock.Thats unfortunate because it takes but a second to check a -4.5 pitch attitude.Reliance on automatic height call-outs for flare is also an indication of automation over-reliance.This was addressed by the report but not in the correct context,I believe."I didnt flare because there were no call-outs"
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