OK465, everyone will have their own view of what is important depending on training, experience, etc; this is human and to be expected, and welcome in safety debates. However, my attempt is to view this accident (via the report) without bias (probably impossible), and by considering human centred factors, each with equal importance.
If, as in some modern views of accident causation these factors are all required to generate the event, it may be useful to understand how and from where the factors originated, and then how they came together at that time. After the event it is much easier to identify one (or more) factors which would have prevented the accident – hindsight bias, yet the crew had to work in real time. Now our responsibility (the industry) is to work with this knowledge to provide foresight, or at least identify mitigating factors to help avoid such situations – the factors and the timings of an occurrence.
Attempting to understand the points raised, consider what happens every day;
- Do we always know the height at which we cross the threshold? +10ft probably not. +20ft possibly yes; particularly with experience, but then explain how we know. Qualify this with the conditions of the accident where there may have been greater focus on aircraft control following the late hdg change, then perhaps it’s more likely that neither pilot noticed the height difference in the demanding conditions.
- Do we always know where we touchdown? + 100ft probably not, + xxx probably yes, but according to conditions, etc, … as above .... We might have a good understanding of a situation after an event with the aid of the FDR, but this tells us little about the understanding at the time of an event.
Also, a pet peeve about defining touchdown zone; the airport / runway manuals give definitions and values, the operator provides a policy for the landing zone, but on the day, it’s the crew who have to identify an acceptable zone. The first 3000ft might be OK for a 9000ft runway, less so on a 6000ft runway (50%), yet on a 9000ft runway with marginal performance based on ‘actual distance’ +15%, then the touchdown has to be close to 1000ft (QRH assumption). How might we ensure that we will touch down at 1000ft, particularly with an unnoticed +20ft TCH, and weak awareness of the hazards of a tailwind?
Every approach and landing warrants consideration of the intended touchdown point, an acceptable zone varies with runway length, wt, speed, etc, etc, and particularly runway condition for which there may be little accurate information. That’s the judgement and airmanship we strive for.
Yes, there can be two or more views of accidents (
Safety 1, Safety2). Also consider that both crew had apparently similar understandings of the situation at the time; thus this involves more than one person, or even the crew, but also the operator and regulator, who’s understandings might be based on what they expected from their regulations, procedures, and training opposed to what actually happens in operations – we don’t ask them to put their hands up.
Hands up everyone who has made a night landing from an offset LOC, with a recently increased tailwind limit, at max landing wt, on a limiting wet runway with questionable braking action.