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Old 14th Aug 2007, 09:53
  #1622 (permalink)  
teropa
 
Join Date: Dec 2001
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The more I think about this accident, and the likeliness of a human mistake, the more clear it becomes.

The psych expert described one possible chain of events from the POV of human mind tendencies of reaction during the landing.

If you think about it. The previous landing was OK. The TLs were not an issue. The FO managed to idle both TLs and everything was just fine. Then comes the second flight, with the capt as PF. They are engaged in thinking about a slippery and short runway, with TR2 inop. Very little energy (I think) is contributed in both of the pilots' minds to what to do when TR2 is inop. But probably more is directed towards: slippery rwy, short rwy, flying the app 1 dot low, getting the plane to STOP.

Now imagine this. With all the precautions and preparations done to enable a safe landing in these less than ideal conditions, and then you hear "No spoilers" after touchdown. Right at this moment you are facing a brutal slap in the face against your plans. As the seconds fly by, you are faced with the inability to decelerate. Nothing happens even though your operable TR is reversing, and you know it since you pulled it back yourself. Speed is not decelerating, and just a couple of seconds later you know that this time tea and bisquits at the Chief's office is not going to save the plane. Something far worse is going to happen, but you are not thinking about crashing into a building at 100kts just yet. What do you do? There's only one answer to this. You will try to manipulate ALL the controls that instinctively would allow you to STOP the plane, make the speed come down and prevent a complete disaster. You will stand on the brakes. Allow me to speculate that IF the plane had had some sort of facility to A) WARN the pilots of the situation where one ENG brakes, and the other pushes forward and B) ALLOW the Ground Spoilers to be extended and possibly C) WARN the pilots more clearly that there are NO Ground Spoilers and NO Autobraking, then this crash would have been prevented.

To put a long story short: In a catastrophic situation, where you have to make decisions in a SPLIT second, the human mind can and will lock up just too often to just ignore this in the operation of the aircraft. There is no way in hell that the crew could have detected the misplaced TL during the situation where all they were concerned over was the fact that the plane is NOT decelerating.

What to do?

A) is already covered (partly) by AB by issuing the new ECAM msg and the CRC for this situation.

B) is absolutely shameful, that the pilots have no manual control over the GS whatsoever. Just amazing. On a Boeing plane all you had to do was pull the SB all the way back.

C) The "No spoilers" on ECAM I think is not enough to communicate such a critical shortness in the braking ability of the aircraft. Especially so that this shortness also meant that the autobrakes did nothing. In the heat of the action the pilots didn't realize that there was no deceleration. The LEAST the thing could do would be to say "No spoilers" together with "No autobrakes" with proper warning chimes so that the PNF could call these items immediately upon touchdown and the PF could then slam the brakes.

What I see here is an airplane built so tightly around desired logical chain of events, where there is not enough communication towards pilots to let them know that THIS time we have departed from the desired chain of events, and we are NOT stopping at all. So do something. It's simply not enough to expect a human mind to "COMPLETE" an unfinished input map to enable the desired output in a situation where each second matters. In that kind of case the pilot would need to be told CLEARLY and concisely what is NOT happening that he expects to happen, AND allow him all the manual control needed to get the most out from the airplane systems (manually) to try to make it right. And forget about the logic maps at that split second.

If the investigation reveals the mistake of the PF of leaving the TL in the CLB detent, then so be it. Humans err. But the airplane in question did almost NOTHING to help the human in the situation. Especially AFTER the mistake had already been done. And I will also add that people should forget about the mumbojumbo of what is or isn't expected of a pilot at each phase of the flight. The simple fact is that IF a mistake can be done, someone will make it someday. And the machine better help the person then to overcome the mistake with the least negative results. Not like this. As was said before in this thread, IF the mistake happens... the system should "fail gracefully". The Airbus did not do this, and 200 people lost their lives as a result. Think about that.

Tero
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