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Old 5th Apr 2007, 01:12
  #307 (permalink)  
alf5071h
 
Join Date: Jul 2003
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theamrad we are thinking along similar lines, but with differences in detail.
“… public perceptions should be the last consideration when a GA is appropriate – of course passenger comfort is another ideal – but safety is paramount,”
I agree, but do we make these considerations on every flight – some would argue yes, but other evidence suggests that the judgments made in everyday operations are flawed and thus might become the norm (LOSA report - 11% of all approaches are unstable). Thus, the need for an ‘unsafe act’ becomes the ‘latent factor’; it just has to wait for the particular situation and failure to perceive/act to complete the accident path.

“… cultural issues – my thinking is always going to be down the line of training in best CRM practice – and the insistence on its use.”
I agree, but when viewed in conjunction with “what is the point of having someone in the right-hand seat” (Centaurus), then the value of CRM is questionable and the difficulties of training, at least behavioral shaping, are significant – see the link about ‘asking for help’ below, and the difficulties of encouraging teamwork … “after repeatedly trained in school at every level … to "do your own work", by adulthood the socialization is deeply embedded, … ” – failure to work together.

“P1 not receptive” … surely culture only shapes the human factor, it isn’t the human factor?

As for systems, particularly EGPWS, I ride a high hobby horse. See the addendum to ‘Celebrating TAWS Saves’ (via ICAO) and ‘Last line of defence’ (via FSF).
GPWS, the computer, did not suffer ‘false alerts’. The design was limited and overall system had weaknesses, which EGPWS has overcome and is very reliable – it does not have false alerts. Every alert must be respected; only hindsight / subsequent investigation will determine the validity of the event. The associated systems (FMS, Rad Alt, etc) and the human remain the weak links. Some similarities with organizational systems and their components ?
Automation and system reliability is matter of trust; we trust an automatic GA, which is not necessarily a fail active system. The technology exists to couple EGPWS to the autopilot GA mode. If the auto pilot (or FD) changed to GA, I suggest that few pilots would override the action – it triggers the necessary change in thought – situation assessment – realization of the need for alternative action. People are already working on coding the parameters of the stabilized approach into a warning system, automation is next. An approach warning system (deviation from a stabilized approach) would be threat and error awareness system, much the same as EGPWS is when considered as a constant display of the margins from terrain.

Centaurus We too are in agreement.
I have been there, done a little type conversion training, and made no progress with culture – perhaps leading to the desire to understand what could be done from their viewpoint as opposed to mine. The summary of my visit was that there were pilots who could operate the aircraft and those who could not – a disturbing, but dated observation. There was little evidence of the Western ‘social’ CRM, together with many weaknesses in the basics - airmanship, situation awareness, rules and procedures, and aviation knowledge.

Re "Real Men Don't Go Around”. I note the thread.
See ‘asking for help’ in the blog at – cscwteam - ******** - .com at archive 2006 08 27 (Sept 1, High reliability asking for help – after Comair) Sorry no link available – couple the bits together or Google.
There are also some interesting follow on links ‘System blindness, safety culture, and accidents’ and ‘Secrets of High-Reliability Organization’.

Also see:-
Archive 2006 09 05 (TEM Sept 5) “It tries to change the way we think in the cockpit by taking more of a big picture outlook on what is going on, slowing down what we do, and communicating concerns to find threats and errors before they cause a violation, incident, or accident”.

and
“For pilots, there is no "fog caused accident" exemption (car). There is only "the pilot in command continued operations into conditions beyond his skill and experience, …” (Drivers Aug 27)

Last edited by alf5071h; 5th Apr 2007 at 01:36.
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