PPRuNe Forums - View Single Post - Erebus 25 years on
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Old 18th Jul 2016, 02:16
  #1211 (permalink)  
megan
 
Join Date: Mar 2005
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megan seems to think Colins and crew should be absolved of any responsibility because 'well, other crews did it
Don't you dare verbal me, not said that at all. Unlike yourself, and others, I'm interested in answering the question, "why did he do that?" Is that not the lesson we should all be seeking? ampans argument that,
he was an idiot and thick. Couldn’t even pass School C. As to what was going on inside the head of Captain Collins, the answer is: Very little.
in no way addresses the issue, and only shows what lack of understanding he has.

With regard to CFIT, ANZ had a near event where a 767 with 176 souls descended to 340 ft PA (384 ft RA) 5½ miles short of the runway prior to an overshoot being carried out. Unlike the airlines handling of the Erebus event, in this case their after the event actions were impeccable, in fact exemplary. They undertook a world wide education program, I've never seen the like of it since by any operator.

In the report they said,
While acknowledging the role that operational personnel play in the incidents, the analysis looks for deficiencies that can be eliminated and system defences that can be strengthened. In general terms, there are three levels of action that may be taken when mitigating hazards:

Level 1 - eliminate the hazard. These are the safest decisions but may not be the most efficient.

Level 2 - accept the hazard and adjust the system to tolerate human error and reduce the possibility of an occurrence.

Level 3 - accept that the hazard can neither be eliminated nor controlled and train operational personnel to be aware of the potential hazard.

Third level actions should not be taken in preference to first or second level actions, since it is impossible to anticipate all future kinds of human error. The system should be designed to tolerate the entire range of normal human behaviour; that is, it must be ‘error tolerant’.
Take a moment to consider what it says, and apply it to the Erebus event, particularly the three points.
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