PPRuNe Forums - View Single Post - Bmi Airbus lands with park brake on (Report)
Old 13th Sep 2007, 17:53
  #7 (permalink)  
old,not bold
 
Join Date: Apr 2006
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Whoops.....I slipped up asking about the HF angle had been looked at, based on the BBC report, before reading the AAIB report.

The operator even called in a psychologist to help them with this aspect. So it was a silly question.

But I am doubtful about what then happened. The report picks up a number of issues that could be described as contributory, but the eventual single recommendation only concerns changing SOPs to include a look at the lower right quadrant of the ECAM screen in the pre-landing checks.

With respect to AAIB, this is only going to capture the error if, or when it's made again, and does nothing to prevent it happening in the first place.

In the engineering world, a Boeing MEDA investigation, now in common use, systematically analyses ALL contributory factors, and then derives from that analysis recommendations to prevent a re-occurrence of the error, not just to improve its capture. Most events are found to be the culmination of a number of contributory factors leading to errors and, perhaps, violations.

The AAIB report, and /or the psychologist's report, quite rightly mentions the lever design and location, cockpit workload, and the commander's focus on the weather, as contributory factors. But it was not a systematic analysis, and the recommendation ignored most of the contributory factors it did find. I'll bet there were some more, too.

It's not the AAIB's job only to make recommendations with little financial impact. For example; was the design issue irrelevant? Not according to the report; "The ability to grasp the parking brake handle in a similar manner to the flap selector......may.. have prevented the commander from obtaining initial tactile feedback...". It's what we old folk call a "Murphy" and they need to be fixed when found, not left to entrap the next poor sod (This was No 5, wasn't it?).

The sentence
He was not the first one and will for sure not be the last one
may well be a realistic take on our approach to safety today, but it makes me weep. Simply rewriting the pre-landing check to improve the probability of capturing the error is totally inadequate.
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