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Old 29th Mar 2012, 02:02
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Turbine D
 
Join Date: Dec 2010
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Lyman,

You are still concentrating on the examination at 10,000X magnification.

Does it really make a difference who was piloting the aircraft between 2 hr 11 min 00 and 2.hr 11 min 45 and which seat they were seated in? The BEA made it clear on Page 20 of IR#3 the AoA was not directly displayed to the pilots. Further, if you read Pages 29-31 you will see some of the data you say was not presented to the pilots that was presented as they referenced it in their conversations. I will let it up to you to decide which ones, although it is pretty clear.

PJ2 & RR_NDB,

You both have hit on some very important aspects of this event IMHO. The question of "Why?" is of paramount importance in problem solving any situation or event that is out of the ordinary. The machine - human interface is always an important aspect to look at and review. There is a technique to be applied when asking "Why" to get at a root cause. It is a matter of asking it five times, giving a response between each "Why". At level five is generally found to be the root cause from which corrective action can be taken. It is a process that works. However, it is more complicated when you can't interview a key person in the problem loop. When this happen, you have to make a list and go through the process. So PJ2, lets take your first question and explore: "Why, when the autopilot disconnected, and manual flying was demanded did the PF pull the sidestick back commanding a continuing climb, Why? Well, there can't be an interview, so we have to provide multiple answers for consideration:

a. He was shocked it happened, the "Startle Factor".
b. He responded based on his training and SIM experiences
c. He responded based on his recollection of the "Memory List".
d. He --- --- --- ---

For each of these you ask "Why" four more times and what you will come up with is a rather concise short list, sometimes, one item that defines the root cause. Now I can't contribute to this as only experienced personnel intimately familiar with the aircraft (the pilots) need to compile the list and ask "Why". Once you have determined (or think you have) the root cause, you can then turn the root cause over to experts to begin the process of providing the solution, along with your input as to the quality of the solution decided as being best.

A simplified example would be this:

The power failed on climb out at 1,700 feet on a Boeing 767, Delta's Flight 810 from Los Angeles to Cincinnati on June 30, 1987.
The Captain with 29 years of commercial flying experience failed to coordinate with the First Officer and reacting to an amber light, warning him of a fuel-flow problem, pulled two round knobs cutting off fuel to the plane's two engines instead of pushing square buttons two inches away that would have corrected the problem.
"Why"?
To make a long story short, he had flown the B-727 for years and had transferred to the then, new B-767. When this event occurred shortly after liftoff, he applied from his "experience and memory", without looking, exactly what was required on the B-727 but not the B-767. The initial fix was to cover the knobs and square buttons with a plastic cover that you had to "look at" to open, but the real solution was to move the engine control panel to the overhead console. Training was also found to be defective at the time at Delta regarding entry into the B-767 which was corrected.
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