Judge not lest ye be judged
The judgment of a company’s or crew’s actions during an in-flight non-normal event is probably foolish and definitely inappropriate without full knowledge of the facts. However this event does raise some issues to be considered and perhaps learnt from.
But first some facts:
Status messages are in fact part of the EICAS system. Status messages are available full time when powered. The “Status Cue” which alerts the crew that there are in fact status messages on the status page is inhibited for 30 minutes after engine start. This is because status messages are essentially related to dispatch. Once engines are started the idea is that the flight is essentially dispatched with regard to status messages only and the crew does not need to and should not be concerned with the message. This falls away however if an EICAS Alert (Warning, Caution or Advisory) message occurs before takeoff. Some of these messages are actually there to prevent a takeoff and only appear on the ground. These messages in themselves are often accompanied by a status message and these combinations may therefore prevent takeoff. The MEL will decide. If EICAS displays an Alert (warning, caution or advisory), between engine start and takeoff then crews would then take notice of the status message having done whatever checklists are required. In some instances an EICAS caution can even resolve itself but the underlying and remaining status message should be considered prior to takeoff. E.g. Flap problems that are temporarily resolved when in commanded postion despite FSEU status messages - Probably not a great idea to commence the takeoff.
Multiple status messages affecting the same system are beyond the scope of the MEL. Its intention is to cover each fault in isolation. Multiple status messages on the same system generally indicate a larger problem that cannot always be dealt with by simply looking at each message as a single issue and applying the MEL.
In flight a status message on its own should not dictate a course of action. In some events the status message can simply be cleared without further action as the fault was transient. It would be a pity to jettison fuel and return on the assumption that the fault may prevent dispatch at the next station according to MEL. This has been done before and the engineer simply walked in, cleared the fault and said “off you go”. A few red faces I imagine. Multiple Status messages (possibly with EICAS Alert messages) in flight occurring simultaneously and related to the same general system should be some cause for concern. Clearly an event has occurred. Maintenance looking at downlinked data may be able to shed more light on the subject. When this event is accompanied by visual, tactile or aural feedback, it leaves little to doubt; the only question remains is “how bad?” In this particular instance the messages are all related to the engine and/or sensors deriving information off it. A bang and a number of sensors being lost or related systems being affected is almost conclusive of damage of a more serious nature.
To look at each status then in isolation and assume this is simply a redundant feature being lost and therefore inconsequential, somewhat defeats the purpose and design of the system. It was never intended to be used like that, either on the ground or in the air. Clearly this event was not enough reason for an engine shutdown if it continued to run without loss of power or parameters exceeded but the event should be considered as a possible reason to land the aircraft and investigate.
Who knows what actually happened on the day. I’m fairly confident any EK crew would have contacted maintenance before taking hasty unilateral decisions but here is where it gets a little sticky.
The commercial dictate would argue that the engine was running normally and the status messages each in isolation did not warrant a return. After all, the engine is turning and burning quite happily for now. On the other hand one would hope the engineering side would have been heavily prompted to come to the conclusion that a fairly significant engine event had taken place. So would have the crew who then had to face a route without an abundance of friendly airports and some significant terrain.
My guess is that the crew and some engineers were concerned that if they jettisoned fuel and landed, and it transpired that there was not much wrong with the engine itself that they then would have the book thrown at them. The one that says you don’t need to land for status messages or shutdown engines that are running without parameters exceeded and if both engines are running normally you carry on. I suspect this was going through a few minds. Had they landed and the damage been proved they would have been let off the hook. Who knows, perhaps even commended but even still possibly queried if they ignored engineering advice and took the decision upon themselves.
Now the engineering advice in itself is a minefield. It comes with a disclaimer that they are not ultimately responsible despite them probably often being better informed on a system than the crew. An easy way out indeed. I wish I could use the same umbrella sometimes!
I don’t envy the crew. They could have been damned either way. And I don’t know what transpired after they became aware of the problem. It’s interesting to muse what the decisions might have been taken if some senior post holder had been aware of the problem and his family was on board.
What I do know from a number of discussions and incidents is this:
In many cases the crew is more concerned with what the company may do to them if they get something wrong rather than the actual consequences to the flight of getting it wrong. They are not the same thing. If one errs on the side of safety but it subsequently appears as overcautious then this can be a cause for a nasty letter or worse. Look at what happens if a bit extra fuel is carried despite the reasons.
We make mistakes. The CRM department tells us that all the time. But if a mistake puts the crew in a jam which they recognize as of their own making then they become panicked, not by the situation but by the recriminations. It’s somewhat akin to having an in flight problem and then compounding it by telling the crew they may lose their whole livelihood. This is exacerbated by the expat existence. It’s not just the job at stake but the home they live in, the friends they see, the schools the kids attend etc. A panicked crew is unlikely to perform well. Show them threats from an in-flight situation and they often perform wonderfully as trained; throw in the threat to livelihood and family and they can come to pieces.
Unfortunately the price for costing a company a bit of cash or negative publicity can be a hugely punitive reaction despite the mistake being unintentional or even well meaning. An interview panel, time and thousands of pages of manuals can and will often be used to demonstrate the failures. Its also not difficult to make an argument that safety has been compromised. But face it this happens to some small degree on every flight. There will always be some degree of error. I dont know how many times I've seen a crew make a bigger error in a simulator because they are worried about the instructor noticing a small one. This is exacerbated in flight with recorders that miss nothing and are now used to hang crews rather than the original intention of anonymously monitoring trends.
Pilots are acutely aware of all this. We have moved to a new era in aviation. The corporately motivated pilot is superseding the safety motivated pilot. The two should go hand in hand but sometimes do not. And by this I don’t mean corporately motivated in a positive manner – huge bonuses for obvious good performance. No - they have been left with the final responsibility thereby providing a useful scapegoat for others if anything goes wrong and this feature is being used more and more frequently. And when did you last see a crew get an SVP type bonus when they made decisions that ultimately saved a lot of lives, money, or the company itself. No that’s their job – they are trained to do it. But doesn’t the same apply to any SVP?
Not a lot when a crew gets it right - maybe a pat and a star. Personal calamity if they get it wrong, even if no one is hurt. On the other hand there are huge bonuses for not so obvious performance for other senior post holders and no accountability for some obviously appalling decisions. This is the corporate way and is not only confined to airlines. The crux is aviation plays for high stakes, not just the profits of the shareholders; hence responsibility from all should be of the highest order and leaning towards the conservative.
The crew are the last defense against silly decisions motivated by economic gain but worldwide they are being manipulated into a situation where making a stand may be career suicide. Did this phenomenon influence this particular case? Who knows? But it is happening and the pressure is mounting. The tools and options for pilots to stand against commercial pressure are being slowly dismantled. This should be of great concern to the flying public.
Today’s pilots are often so afraid of being in front of a wooden desk that they make choices that could result in a lot of wooden boxes.
Last edited by Pixy; 2nd Sep 2011 at 19:12.