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Old 26th Aug 2009, 12:03
  #2555 (permalink)  
captplaystation
 
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To quote from the report taken from CVR

14:12:08 After start list was initiated.
Before reading the last item , flaps/slats the Capt told the co-pilot to request taxi.
Before the list was read there was no record on the CVR of the Capt mentioning flaps
14:15:56 They read the taxi checklist, when they reached the last point (take off briefing ) the co-pilot read it but no reply was heard from the Capt on the CVR
14:22:06 The co-pilot did the final items on the list saying" final items we have, sorry eight eleven stowed eleven stowed". He immediately started talking about the possibility of engaging the autopilot as soon as they took off.

From all of this, while I agree that legally speaking the crew have to be given the benefit of the doubt, it seems clear that the Capt does not appear to have been asked by the Copilot ,or indeed to have volunteered the fact ,that it was clear outside so the flaps could be lowered. The Capt interrupted the copilot from reading this item to ask for taxy clearance (bull in a china shop ? ) and the copilot either didn't think, or didn't feel able to bring up the issue but just did as he was told. The Capt then became agitated and two mins later asked ATC how long would be the delay.
The copilot did not appear to receive a reply to his challenge "take off briefing", so he was at this stage operating single crew with no crosscheck/participation from the Capt, who seems to have become fixated on getting airborne to the exclusion of everything else.
The copilot appears to have been drawn into this rush rush rush mentality as he wanted to shorten the checklist correct response to "final items we have" then corrected himself by saying "sorry 8, 11 stowed (I guess he meant 8 flap rather than the 11flap they planned) 11 stowed". This to me sounds like paying lip service to it in an effort to rush and appease the Capt ,rather than physically checking the position of the handle and the amount of flap displayed on the indicator. It appears also that the crew were slightly fixated on the need to manually set thrust, and the copilot preoccupied with engaging the autopilot, to the exclusion of normal checklist completion.

Finally :

Robust SOP's can help you to do the job.

Actually doing/checking the items you have verbalised on the checklist will also be better.

A functioning TOWS may help as a last line of defence.

If you adopt (as many suggested hundreds of pages ago ) a personal "killer items" checklist it may save your ass even if all the foregoing didn't.

If you still screw up and you react to a synthesised voice telling you "stall" by taking stall recovery action, rather than musing over engine failure and how to shut the warning up, maybe, just maybe you could still retreive the situation.

This crew has done none of this, and have allowed themselves to become fixated on getting airborne, to the exclusion of everything else, including their primary role of assuring a safe operation.
They are not the first, nor will they be the last, it still happens in companies (particularly those whose modus operandi is "rush rush rush" ) and I personally know of a few times where disaster has been avoided in the last 2 years only by the timely intervention of the TOWS ( & amazingly the Crew sometimes chose to continue the T/O and configure on the roll even though the most junior crew member didn't wish to).
This happened even after the manufacture changed the checklist to stipulate putting the flaps down before taxying, giving several opportunities to catch it, IF the checklist was ACTIONED not just READ, and yet, resourceful humans that we are ,we still find ways to screw it up

Last edited by captplaystation; 26th Aug 2009 at 12:17.
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