PPRuNe Forums - View Single Post - Turkish airliner crashes at Schiphol
View Single Post
Old 8th Mar 2009, 15:53
  #1856 (permalink)  
andrew_wallis
 
Join Date: Jan 2008
Location: warwickshire
Age: 56
Posts: 25
Likes: 0
Received 0 Likes on 0 Posts
having read the thread.......

I don't know what caused this crash - no one does yet, maybe the investigators are close but this is a rumour network, so I think its reasonable to state some possibilities.

1. It wasn't caused by one thing - be it RA failure, pilot error, training flight. We know from life in general, and aviation in particular that a chain of events has developed - nothing broke that developing chain- not crew action, not computer, had that been possible this event would not have occurred.

2. To those who say training should not be allowed on commercial flights, ok, but think it through, the consequences of doing this include many more planes in the air, many of them empty, increased fares for pax, increased global warming for everyone - not acceptable.

3. Everything we do in life is a risk, our job as professionals is to minimize that risk. Note- I'm not suggesting we can eliminate the risk because we can't - the closest we can get to elimination of risk is to stay in bed all day, and even that poses the risk of hypostatic pneumonia.
To minimize risk we need to train (=practice) and make mistakes, remember we learn more from our mistakes than anything. The trick is to make these mistakes in a safe environment- be it simulator or real world.

4. There is a constant tension between cost and thoroughness - and we need to decide where on this continuum we place the acceptable norm. The "bean counters" will try to make us accept more risk in return for cost savings- that is their job, and they are good at it. However, they are not the ones sitting at the pointy end in the middle of a freezing dark night in the middle of nowhere - the pilot carries that burden. The "bean counters" genuinely do not understand - they understand statistics, graphs, spreadsheets, and use these tools to constantly shave off cost in the name of efficiency.
Aviation is very safe, look at the bean counters graphs that prove it. However, that 0.01% on their graphs are real victims in real accidents.
Eventually nothing more can be shaved in the name of efficiency.

5. The human/computer interface isn't quite right yet, at least not in all cases. Pilots initially learn to fly a simple plane with little in the way between the flight controls and the pilot-aviate,navigate,communicate. As we transition through complex singles to twins to jets we are taken further and further away from these basic skills, as we accept more and more help from automation, which most of the time gets it right. The real skill is in understanding how this technology can help us, and maybe more importantly what to do when it fails. If we can't do this we are in trouble, we may never know it because the holes never line up in the cheese, but when they do, the consequences are tragic.

Solutions - generally I think we need to look at increasing our understanding of systems and their failures-diagnosing them, and indeed treating them. If we don't diagnose the problem, then we can't treat it, and the problem will get bigger until it becomes fatal.
In this specific case, had the RA failure been diagnosed correctly, then someone on the flight deck should have known that the automation (AP/AT) was dependent on that RA and the likely consequence was a throttle retard for flare - diagnosis leads to treatment - do something about it - fly the plane. This link in the chain would have been broken, and the accident would have had a much greater chance of being avoided.

The workload at EHAM is a minor link in the chain, maybe lower workload and more time would have helped, but i personally doubt it.

Sadly, the investigation is likely to look for simple answers to complex problems, and the temptation is to blame the pilots-nice and neat, simple recommendations and no one has too much work to do to put the bigger links in the chain right.

I'll get my coat.
andrew_wallis is offline