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Old 8th February 2011 | 09:09
  #2803 (permalink)  
lederhosen
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: ATPL
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From: Germany
I find Dekker's report most informative but cannot agree with all his conclusions.

For example he maintains that the crew were not rushed although they were vectored in above the glide, descended with gear down flaps 15 to 1000 and then configured straight to flaps 40 and then apparently only at the prompt of the training captain.

The trainee, who is pilot flying, leaves the autopilot in till 400 feet and is obviously behind the aircraft as he fails completely to notice the drop in speed.

Dekker plays down the concept of gates and appears to be saying that unstabilised approaches are quite a regular event. I did however like the idea of safety pilots rewarding crews for performing go-arounds with a bottle of wine or something similar.

He provides a balanced view but one which is extremely, some might say excessively fair to Turkish Airlines. He stresses many positive aspects about their training for example, but plays down that they are regularly well down the safety rankings. He lists the facts; very experienced captain, new copilot who is transitioning from fighters and safety pilot with 700 hours on the 737. The captain is refered to by an honorific. But then he concludes there is no evidence that CRM is a factor.

I really like the idea of no blame culture and there is no question that there were a number of contributory factors, not least poor vectoring, a technical glitch and an inexperienced pilot flying. But I think this really was avoidable. There were at least four points where the crew could have regained the initiative.

On the intercept heading they could have pointed out to the controller that they would prefer a less agressive heading, particularly given the visibility.

Once established they could have slowed down and full configured giving themselves more time, before capturing from above.

At 1000 feet in imc they should have performed a mandatory go-around due to not being fully configured, spooled up or anywhere near vref.

At 400 feet and stall warning more precise actions which we practice regularly in the sim should have prevented ground contact.

I find the report well written and thought provoking. But to me this accident is like Handy's frog anecdote. If you throw a frog in boiling water it will jump out. If you put it in cold water and slowly heat it up the frog will boil to death. In other words an insidious trail of small factors added up to a major and very avoidable accident.
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