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Old 2nd Aug 2007, 14:41
  #923 (permalink)  
wileydog3
 
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The -330 crash with Nick Warner was a terrible thing and it happened with one of the world's premier test pilots in the left seat. I flew with Nick a few times and when I returned to the States, I checked around with some other test pilots I knew. Without reservation, each said that Nick could get more data from a test card quicker than just about anyone. I was told he was a consummate test pilot. Still, the accident occurred. It was a long day. Multiple flights in the aircraft and sim as I remember and then the fatal accident.

At times, even the best find themselves in a situation where there is insufficient time to solve the problem.

But an earlier post is correct about looking beyond the NTSB 'x happened'. And the quote about Sidney Dekker is also correct. No one makes mistakes on purpose. And no one intends to crash when they climb into the cockpit.

It is about culture. Culture defines what is important. That influences what is assessed. That influences perspective and that influences what information is pertinent and what is not.. and that influences decisions which move toward outcome and outcome reinforces the culture.

The problem of culture is often only revealed by either an accident or through a FOQA program so what is really happening in the total flight environment is not confused with the supposed environment which is defined in the Ops Manual.

One lesson that may be a take-away and that is in Burbank, the 737 broke traction when the pilot tried to turn. I have read that you can turn or you can brake but often you can not do both and retain traction. Here, we see the crew trying to turn. This is not to say it was the wrong decision but there is cause for thought.

Finally, it is worth considering that there is no such thing as "Business as Usual". There are too many variables in the equation for it ever to be "Business as Usual". Granted, day after day nothing happens and there is a strong lull to accept Business as Usual. And it is hard to keep a keen perspective searching for something that is, most of the time, not there and I will admit that at times I am not as wary or vigilant as I should be. But I have to try. The consequences can be and often are disastrous.
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