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Old 1st Jul 2013, 06:49
  #22 (permalink)  
lederhosen
 
Join Date: Jul 2007
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The report provides an excellent example of how accidents happen and the sequence of events is pretty clear. To write it off as pilot error because they were idiots is however a bit too simplistic.

There is a whole chain of causal factors. The crew composition and training would be a good place to start. Both pilots were experienced on type, but the co-pilot was 50 with 3600 hours of which 3000 were on type. The commander was 45 with 8000 hours / 5000 on type. So they had been flying the aircraft for many years without killing themselves. However it is an unusual pattern of experience. The co-pilot seems to have started straight on this widebody at a pretty advanced age and it is unclear how much help he was.

The flight was scheduled in the middle of the night to a tricky airfield experiencing difficult weather conditions. It is clear that the circle to land with some airfield lighting defective would be stressful. To be fair this is not an everyday maneuver, although I sense 411A rolling over in his grave at that comment. With hindsight it is clear that these guys needed a lot more training to be able to perform one safely.

Things went wrong early with an unexpected and apparently unbriefed approach. The real problem occurred when in a high stress moment in the middle of the night on downwind the pilot flying apparently mistook the altitude for the heading bug. When the aircraft responded unexpectedly the crew became confused and lost control of the aircraft. The large pitch power changes and mode confusion at low level over a dark sea clearly overwhelmed the crew.

I would suggest that a significant portion of blame rests with the airline in setting up this situation.
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