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Old 23rd July 2012 | 23:53
  #673 (permalink)  
PJ2
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Joined: Mar 2003
: ATPL
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From: BC
Every part of this Godforsaken industry hides behind the pilot. No matter what, the pilot is legally responsible, which leads to manufacturers making statements to the effect that pilots are expected to follow procedure and understand situation before they act.
We need to think about that statement.

First, as pilots we all know that the captain is legally responsible; that is ancient maritime and aviation law.

That said, I think it is entirely reasonable that manufacturers expect pilots to follow procedures and understand the situation before they act. That is what we do. However I believe what you may be saying is that the manufacturer may possibly hand the pilot a situation which is completely confusing for which there is no training, no information in the FCTM, poor indications of what is wrong or no industry experience with the abnormal and the crew has to make up a response. I don't think that is the case here. The failure and the correct response was well understood by June 2009, the industry had had many such events and information was out as early as 2006 on how to treat the failure when the aircraft is not at immediate risk. The question within this context is, Why didn't this crew know this and why did they respond the way they did prior to the stall?, (all bets are off once the airplane was stalled).

The notion of the "organizational accident" has been around since Perrow's work in 1984. I'm not exactly sure what is meant by the term, "industry", but despite what some corporate lawyers may argue and want because we're seen as their 50,000A fuse, many organizations in this industry cannot duck responsibility for design, process, structure, priorities etc., any more. Pick up Diane Vaughn's, "The Challenger Launch Decision" or anything by Chick Perrow or Sidney Dekker. From airline managements to airframers to systems engineers, the legal net is cast broadly in many countries though there are notable exceptions.

There are very few abnormals or even emergencies which require you, as the pilot, to deal with "in seconds". The rejected takeoff, an engine fire/failure/severe damage, rapid depressurization/emergency descent, runaway stab, aircraft stall indications, TCAS & EGPWS warnings, (by design, both require moderate, not extreme responses), loss of airspeed/altitude information at/right after takeoff and perhaps some go-arounds, (from CATII/III) all require immediate and accurate responses. Right after these, smoke of unknown origin requires an urgent but measured response using checklist/QRH. Hydraulic, electrical, landing gear and flight controls require attention but not as rapidly as the two former emergencies. Then there are numerous abnormalities associated with aircraft systems which are type-specific and may, though likely not, require an immediate response.

I wrote in June 2009 that the loss of airspeed information at cruise altitude is not an emergency and does not require immediate action. What is required immediately is calm, then a collection of thoughts to ensure cockpit discipline which means launching into standard procedures. Ensure control and stability of the flight path and navigation, call for the drill or checklist while taking the radios (if necessary) and as per training, confirm any non-reversible items before actioning them.

Nowhere is there a call for the actions that took place here. If the crew does not maintain the standard required cockpit discipline, there is no system or aircraft design that can overcome the unpredictable outcomes that may, and here did, follow.

The business is not going to hell in a handbasket, but there are indications that in specific quarters, all is not well. This accident among a few others, is in my view an indication of that fact, especially when thirty-odd other crews dealt to varying degrees of perception and action with a similar loss without major incident.

My views on automation and the industry are expressed but I am an enthusiastic supporter of automation providing we don't forget who we are or permit others to define who we are when in the cockpit and flying their airplanes. Skills, knowledge, readiness and discipline are our responsibility alone and where we deem them threatened we have to speak up, just as we are doing here, at conferences and in management meetings. Hopefully we're paying attention to our safety reporting system and FOQA data as well.

Last edited by PJ2; 23rd July 2012 at 23:59.
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