Inspired by this thread, I've just re-read the ATSB report (
Investigation: 199403038 - Boeing 747-312, VH-INH, Sydney NSW, 19 October 1994). An awful "read", it certainly was a classic "Swiss Cheese" accident. Despite my readily admitted admiration of the PIC, it's undeniable that the ultimate responsibility for this accident lies with him.
By George:
Had I have thought this, then I would have realized that you'd have known and flown with both of the other "players". I knew the FE to talk to, but never flew with him. I was saddened to read about the FO giving up flying after the peer treatment he received - we do (did) work in an unforgiving industry, don't (didn't) we?
Trail Boss:
Aren't your comments just a little trite and super-critical?
"A three engine approach followed by either a gear or flap failure is a well practiced simulator exercise, something an experienced 747 captain would have been exposed to on numerous occasions."
An experienced captain would also know that extension of the gear, using only the hydraulic ADP takes longer than when the EDP is operating."
So you're telling me that, placed in the same situation where the operator (rushed introduction/different operating culture), the owner declining to modify the aircraft and a unhelpful crew all combined to "set you up", there's no possibility that you'd have been led into the same error? And, by the way, he DIDN'T have the ADP functioning!
"And yes, the gear lights on the F/Es panel can be viewed from the captain’s position; it just requires the F/E to position his seat accordingly."
Well I don't claim to have eagle vision, and I always had to stare very hard indeed to see the gear lights at the rear of the panel. That I'm not alone in this is shown by how these lights where subsequently outlined by at least 3 B747 operators I know of.
Notwithstanding where the final responsibility lies, I've always thought the PIC was in particular poorly served by the FE. This gent had spent his previous few years as an FE on the B767, a truly brain-atrophying job if ever there was one, and then he's on his post-training first line trip manning what was a decidedly complex panel. It's easy to imagine him being overloaded and perhaps overwhelmed - this is implied in the report.
One contributing issue was the failure of the ADP to operate as it should have; the possible reasons for this are discussed on p.53 of the report. The only logical conclusion I can reach here is, that despite what the FE subsequently claimed, the ADP was
never switched to either AUTO or CONTINUOUS. And, given the way it's laid out, I suspect this is what the ATSB are insinuating too...
There would also be an important cultural issue here - I flew the B727 with Ansett; when I got to Cathay (where BJ spent most of his airline career) it was apparent how much better integrated into the entire operation the FE's were there. They were regarded, and expected to be, an equal third member of the crew (e.g. they monitored all approaches and were expected to call out of tolerance deviations) whereas in Ansett there was an imaginary "chalk line" at the aft end of the pedestal and the FE was expected to stay aft of this, man his panel and leave the rest of the operation to the pilots. Hopefully this changed subsequently; I'd be interested to hear from By George how it was done on the Ansett (and SQ) B743's. I just can't imagine any up-to-speed FE letting the PIC go ahead and land with only "4 greens" displayed and not speaking up assertively.
By George, PM sent....