Flight Safety
Incidents or accidents are not just isolated incidents IMHO, unless of course it is a deliberate or willful act. That is certainly not the case here.
When an incident/accident happens the Flight Ops department should be looking at itself first and foremost. Flight Ops management have a duty and a responsibility to protect its employees and to give them all the help guidance and instruction within their control. Did they do enough to prevent such a situation from occurring?
What is an aircraft with an inop thrust reverser doing going to ‘marginal’ airfield, more so when wet – because it is legal – is that a good enough answer. Certainly not especially since it has had several incidents and near ‘misses’ in the past.
How many times in the simulator and for real has the thrust lever of an engine with a locked out thrust reverser been left in the climb detent on landing. I would imagine enough times and how many times has this been demonstrated in the simulator, probably not enough times.
The human brain is so complex that no one really understands it, only a thousand and one theories. I remember in the sim the instructor leaning forward and in a real western drawl said ‘Do you like that noise’. A warning horn was going off but both of us (pilots) had blanked it out during the emergency procedure. Of course it was driving the instructor nuts.
Here we have a situation where there are 2 Capts operating with one on a line check, the weather is not good, the runway is wet and by all accounts slippery, thrust reverser locked out, long duty day. These are some of the factors we know about. What about the human factors? Rosters and duty times plus a hundred and one other questions that need to be answered; all of which could have played a part in this tragic event.
I would not think for a minute that the pilots even heard the continuous retard retard – ASSUMING that the TL was above idle. Again getting back to the organizational responsibility – has this situation been demonstrated in the simulator, has a notice to aircrew been raised over this very possibility. The managers should be examining every aspect here and asking ‘did I do enough’ what more can be done.
Airbus have issued a 'Notice'. Had the airline issued such a notice in the past, I would hope they have done now.
The MEL states that ‘It is recommended not to select reverse thrust on the affected engine’ is it an SOP to brief for this. If not should there be one?
The report on ‘how good pilots make bad decisions’ mentioned earlier is worthy of mention again. This should not only be compulsory reading but also part of CRM training. How many times have pilots continued without being stabilized. Is there a stabilized Call? If not why not. On the airbus the call is – decel, spoilers, reverse green. Often just said and not monitored. But is a fault regularly practiced in the sim, not enough I would think.
Next in line is the Airport.
Enough has been said about the airport conditions which almost certainly played a factor in this accident.
As BOAC mentioned earlier the holes all matched up. Everything seemed to be against them.
What I am afraid of though is that this may go down as another pilot error, which would be grossly unfair on the pilots and aviation.
The flight ops management has a duty to protect and care for the pilots, I just hope that they have the resolve to do so here. They must stand up for their employees. It was not JUST their fault.
All factors should be considered and a thorough examination of every aspect of this accident. This should then be fully published so we can all learn from mistakes made.
Anyone can make a mistake and we all do. Sometimes we get away with them others are not so lucky. 4HP; would you have got away with it here, unlikely. What if the r/w was properly drained – possibly? We should give support to those involved and everyone can learn.
Flight Safety is for everyone and is not for those who want to castigate.
Jim