PPRuNe Forums - View Single Post - TAM A320 crash at Congonhas, Brazil
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Old 7th Oct 2007, 07:58
  #2715 (permalink)  
PBL
 
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A thoughtful post from 3Ten.

3Ten, allow me to summarise what I think are your criteria for prioritisation. In terms of the Lockhart River categories, you are prioritising Occurrence Events (OE) and Individual Actions (IA) over Local Conditions (LC) and Organisational Influences (OI). I am not sure where you would put Risk Controls (RC).

The reasons you give is that, as a pilot, you have most immediate control over IA and then OE, and less over LC and OI.

I suspect alf5071h would argue that that leaves RC, and pilots have considerable control over RC. For example, the FSF slides presentation "Managing the Threats..." which was referenced early in this thread, spends a lot of time on how pilots can manage the risks of landing.

At Congonhas, for example, the pilots had information about the runway condition, besides what they knew themselves about the runway; they knew they had one INOP reverser; and they planned to land shorter than usual. But they were also working in conditions in which there did not appear to be SOPs that were adhered to rigorously on how to handle thrust on landing with one reverser INOP.

And, maybe needless to say, various different groups have various different interests and thereby select various different causal factors for emphasis. I prefer to have them all out there, and to make it clear that the emphasis on one set of factors rather than others is a choice independent of determining the causality. It can be made, as DingerX suggests, because there are more chances for prophylaxis; or it can be made, as you suggest, because you are an agent and those are the factors under which you have the most control; or it can be made, as others have noted, in order to attempt to avoid deleterious consequences for one's organisation (financial or political liabilities, for example).

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