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Old 22nd Apr 2009, 18:07
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PEI_3721
 
Join Date: Mar 2006
Location: England
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Re “Captain was fired after this incident”.
If this is true then the action does little to further the cause of aviation safety.
The incident is an example of a threat (TEM terminology) which was not, or could not be detected. This is typical of the hazards associated with visual misidentification / illusion, and similar to several of the incidents described "here".

In these instances, both crew members can simultaneously suffer a failure in situation awareness, which does not enable or contribute to good cross monitoring.

Whilst the VOR could have been monitored more closely - SOPs were not followed, the report fails to identify why such a ‘failure’ (crew procedural violation) occurred. Similarly there is harsh wording about the crew’s failure to “comply” with the approach procedure – the crew did not check that the aircraft was following the procedure, … but why? Something we all might do when ‘visual’?

The report concludes the ‘probable cause’ as a crew decision failure with contributory factors; one of which was poor CRM. The report earlier defines CRM and crew responsibilities, and discusses error, but perhaps fails to support the conclusion of poor CRM, which IMHO together with the probable cause leaves the blame option open.

Was this aircraft fitted with EGPWS?
If so, at what altitude during this approach should an amber alert ‘Caution Terrain’ be given, together with the amber ND/radar display?

Was the EGPWS obstacle mode enabled?
Did the company SOP specify displaying the EGPWS map during the approach?
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