This one was directly a pilot problem.
Why, you may ask, when the stab jackscrew failed?
It completely failed after the crew attempted many maneuvers, both flaps up and flaps down, to check handling.
-411A circa dark ages
So, since we warm fuzzied the aerospace scene with CRM etc, we set up the process for activity beyond the checklist. While there are times tht this is appropriate, there are as many or more when that is not the case.
I do not argue that 411's doesn't have some point on this one, I just suspect it is a case of "shootin' the messenger". Is it not of interest that the system set this program up, through the auspices of
AC120-51 (orig, A thru E),
JAA-OPS TGL No5 & 6 etc. The line between correct action and correct inaction is blurred, as the basic premise of CRM is to give better outcomes, which often is misrepresented as being the perfect outcome. As a lowly 22,000 pilot and air safety investigator off and on for the last 30 years, and a past CRM facilitator, I find myself rather reserved in the benefits of teaching perfect outcomes in a dynamic environment. (well, when I taught...). As a pilot, I think that an adeqate solution that removes my airborne problem to a ground management problem is usually a good thing, satisficing my requirements of minimal disruption to my operation, minimum interference by external intrusions and hopefully least risk to me, which is what I get paid for by the passenger.
I have watched too many relatively competent crews loose SA while running evermore complicted scenarios of their own making, (both in simulations, and in investigations after whacky outcomes occur in 12" to 1' scale, HiDef etc), to be overly enamoured with our current philosophy in opertions and training.
Operationally, the driver (which is professionally where we have allowed ouselves to be re-categoried as... thanks AI...) is torn between the basic tasks as written, and the desires of the passenger (percieved) and the companies overt and subjective demands. Out of all that, he/she is damned if he does (
AS261), and damned if he doesn't (
SR111).
It is far easier to be perfect after reading the crash comics.
I recall a small vignette from a prior life; where in beginning of the '80's, flying with tin hat on, I had a jammed elevator system in flight. Oddly the cause was immediately obvious and the emergency checklist was considered to be catastrophically detrimental to the actual problem (shifting hyd boost on > off)... jury rigged a solution, and landed. The subsequent investigation found I had acted correctly in light of my diagnosis being correct, "but the NNCL (NATOPS) had not been actioned as written". A week later the writer of the comments (an experimental TP...) had a similar jam of his ailerons, and followed the same actions I had for the same reasons. No comments made on his report.... Easy to have the solution on the ground, and after the reports published.
Crew disregarding an approved procedure is a matter of some gravity, yet, notwithstanding the vignette above, external agencies such as Maintenance and Ops Control suggesting the crew don't action a fire checklist, MEL etc, is hardly sound risk management, but crosses the line to being interference in the operation. If the PIC is compelled by his knowledge to act in some way, then he will take responsibility for that at all times without question. The dispatcher or maintainer don't. And by law, nor does the FAA ATC controller. After a crew have actioned the NNCL and the situation has not improved will always call for careful and thoughtful consideration of the relative risks involved, classic decision making under conditions of uncertainty.
As far as Alaskan goes, I think the greatest learning point missed was the fabrication of records, and the absolutely disgraceful treatment of the insider who blew the whistle to the FAA and was pilloried for his efforts at attempting to preserve life, while of course little substantive action was taken by the regulator to do same.
. As is often the case, the company fails to see that their behavior when it goes feral due to commercial factors makes them the enemy of both the pasenger and the company itself, whereas the whistle blower is perceived to be the threat.
All depends on your point of view.
411A, I think the issue of operation risk management is far more complex than it appears on the surface, and that simplistic observations are often just that, simplistic.
happy new year.
Warm Springs