Originally Posted by
JimL
The fact is that I do not understand the mindset; if he had to reset the autopilot three times, why did he then engage the GA mode (a four axis mode). Having engaged the GA, why did he not trust it until it was established that it was not doing what it was expected to do. All this given that there were issues compounding the situation - including an aircraft (which is not the best performer in any case) that weighed more than the documentation indicated.
My guess would be that this serious incident once again shows that the level of understand of a pilot for what is a very complex piece of equipment (and algorithm) is indicative of general knowledge among the pilot work-force. In my view that is not solely the fault of the pilots but of a system of training and operations which has hardly changed since the introduction of these very complex systems in the mid 2000s.
Jim
I don't think we can blame it all on training. Each and every one of us has a responsibility to self-challenge, self-critique, and self-improve. When this burden is constantly passed off to someone else, errors like this are the result.
I personally see it as indicative of a mindset, a malaise, that is common all over the industry. Moreso in the multi-whatever and IFR environments which I'll clarify later.
As long as the 'plan' is followed, then 99.9% of the crews out there manage just fine. As long as the [CRM jargon def'n] errors have been predicted and a response promulgated then we happily fix it and carry on. The problem is when fluid, unpredicted adaptability is needed. This is where the system produced "Children of the Magenta" fall apart. They will continue to (blindly in my opinion) revert back to the way they have 'always' done it. It is not a concious decision, it is a conditioned response that they have allowed themselves to develop by getting comfortable with the barrage of limits, regulations, SOP's, etc that endeavour to take away our ability to think.
The more constraining the 'rules' (sum total of reg's, limits, SOP's, etc) are then the less likely it is that we are actually thinking about the job. We are just pushing round pegs into round holes and square pegs into square holes. It is a personality thing, IMHO, that determines how an individual responds to this. Some can't stand it and leave, some accept it. I know pilots who try to prevent this malaise by reviewing EOP's each day, or something similar. Well done!
I have my own way to fight my own complacency that has shown me just how deep the ruts in the road are! There are so many things that we do that are standard (little s) that they almost seem to take on a new life as a Standard (big S). Something as simple briefing that I will decouple at altitude in VMC rather than descend to 500' coupled, or to cruise at 6500' versus the 'standard' 2000', can have the other pilot in a state for ages. It is the worst with pilot who came up in the IFR system as cadets and have never had to figure it out themselves. Many can't believe that no SOP prohibits my indiscriminate activities. It has certainly proven to me how many of my fellows don't actually listen to anything in my brief!
Those crews who have spent real time working in the VFR, single, no support environment have had to develop those self-improvement skills because noone was going to hand hold them along. They also pay more attention. I think we need to put more pressure on ourselves (and each other) in the IFR world.