Philipat;
Your inputs are always informative, intellegent and pragmatic and I have nothing but respect. I will stand corrected as necessary. I think I actually made my point in the earlier referenced post, but to summarise, the issues I saw were as follows:
- It is taking far too long to reach a sensible conclusion, balancing the consequences of being too quick or too slow.
- Boeing should ensure that all operators of MD8X aircraft are compliant with TOCW check requirements ahead of EVERY TO in the light of this and several prior incidents. Has this been done and, if not, why not?
- Boeing should ensure that the MMEL addresses the relay issues involving the RAT probe. Has this been done and, if not, why not?
I understand that there are legal issues and that these these issues have already, largely, been communicated to lines. However, it still seems to me that the set of circumstances involved would justify repetition for the sake of clarity and the possible saving of lives in future.
Wise (Retired) pilots such as yourself have already concluded that, as good airmanship, a final check of the "Killer items" whilst lining up for TO, whilst not required as an official check, makes very good sense. If I were a pilot I would have learned from this thread that this can save your own life and those of passengers. Why is this not a formal final check? Many lines also now mandate that Flaps be deployed after push back and before taxi commences. Why nor ALL lines?
Those are my only issues and, as I said, I am learning from this and stand ready to be corrected.
I think we're on the same page here - I did read your earlier post as well and agree with, "fix it" - in my view (as with many), this thread is, with a number of rabbit trails, some worth it many not, about how to fix it. I think the thread is emminently worthwhile reading through and learning from. I disagree with bubbers44 who states that the thread is a long winded recital and that the accident is "as simple as that", and have said so asking for a clarifying response. I'm not so sure we're on different pages but have merely misconnected.
BOAC:
PJ2 - "If that's all there was to this accident, the thread could have finished on page 1" - I strongly disagree!
No problem - disagreement is more productive than agreement of course, but help me out a bit - why and how do you disagree?
Just to be clear, I was referring to statements made which conclude that the crew screwed up and that's all there is to this long-winded narrative. I strongly disagree with such a statement, as my posts on these matters (safety systems, SMS, data collection and human factors) clearly indicate. I know some posters here eschew such approaches because they consider their operation perfect and do it right every time so they don't need these programs, assorted rexalls and prophylactics against accidents but many others either cannot or do not meet that herculian standard in aviation. So not sure if we've got a disconnect here or what.
The whole point of 2400 posts goes to the heart of human error, system and SOP/MEL design. The entreaty that we just need to ramp up professionalism, expectations and so on is hollow because nobody sets out to be unprofessional let alone have an accident, (obvious and trite). The key in the long-windedness of this remarkable thread is the acknowledgement that while human error can never be eradicated, a sustaining safety culture where high standards of professionalism are expected (and enforced where needed), can help reduce such and that focussing just on the crew or the maintenance people will not prevent the next accident of this type.
A culture which recognizes human error as real encourages "error-checking" behaviours which are essentially "recursive" - not in the sense of second-guessing one's every action or decision, but constantly reviewing what was just done with a view to catching mistakes, is a culture that has embraced the notion that it is possible to be wrong. While there are obvious signs of lack of cockpit discipline here (and in other accidents), why does such continue to occur?
Why do these kinds of accidents happen in the rail industry, medicine and the nuclear industry? People screw up is the reason but such a conclusion, (there is no analysis) is tautological and not informative.
As the point has been made many times here the latest of which is justme69's post above, the TOCWS is a secondary warning system at best - it isn't a "mission-critical part where failure of same will cause loss of the vehicle and crew", so to speak. In fact, if all crews did their job with absolute strict adherence to the SOPs, a TOCWS wouldn't be required, (and that point has been discussed).
Many posts make comments regarding safety cultures, commercial priorities, absence of informed leadership from the CEO and his/her executive team and from my own quarter, lack of belief in or use of safety data and the total absence of CEO comprehension, support or even interest. Sorry, have we misconnected here or have I misunderstood these statements as dismissing these broader notions as trying to convey something else, because it seems to me that the thing to do is go far, far beyond stating that the crew messed up into discovering why -that is what SMS is truly about, (even though it has yet to be done properly in my view).