QANTAS Pilots Distracted

[Ken Russell]

Qantas pilots 'too distracted' to put down landing gear | thetelegraph.com.au (http://www.dailytelegraph.com.au/news/sydney-nsw/qantas-pilots-forgot-to-pull-down-landing-gear-in-aborted-landing/story-e6freuzi-1226169720738)

Seems as if high-tech needs to be higher to protect us from humans error :sad:

[Akali Dal]

Must be a red herring; this could never ever happen!!! Are you trying to besmirch the reputation of the great Qantas pilots?:=

[Groundloop]

Seems as if high-tech needs to be higher to protect us from humans error

Why? The landing gear warning horn sounded and they did a go-around. The existing system worked.

[RATpin]

"There but for the grace of God go I"
I think most of us that have been in this industry for a while have thought this or something similar on these occasions.
There have been times when I have been grateful for a third pair of eyes on the flight deck to catch an error missed due to fatigue or multiple ATC changes etc.
We can all have a "Bad Day" and make mistakes,fortunately,we have benefitted
from the sacrifices of those the that went before us(If your new to this industry for a starter try "Fate is the hunter"-google it gen y}.
I believe that most real aviators take no satisfaction from the mistakes of others and use these opportunities to re-examine and critique their own standards.

[Busty Nerd]

Spot on, RATpin, just another lesson at someone else's expense.

Having said that, I like to think that I own my errors. The PF reported the transfer to the tower frequency at 8nm was late?! Sounds like that SA didn't improve much once their feet hit the ground. But the save-your-ass-by-slinging-mud-at-anyone-else-you-can-think-of defence mechanism sure kicked in!

[TBM-Legend]

How about using a check list???

[Keg]

That's probably when they discovered. It approaching 500' a lot of us do an airliner equivalent of a PUFF check that includes check list complete. Probably realised they hadn't done the check and then worked out why.

Been in similar circumstances myself into BNE in crappy weather. ATC advised a bunch of information on hand over- just prior to 2000', quick back and forward between F/O and myself, change of procedures, ATC again with more info, clarification from me, etc, etc. Lots going on and sometimes stuff gets missed. Picked it up at 1700' when I looked across to call F30 and realised that I'd missed the previous step. I kicked myself very, very hard for that one after the fact. Not one of my better days. Twas a red eye so no doubt that played a part but still dirty on myself.

The report on this one says that 'fatigue wasn't a factor' but I'd like to know the pattern. Either way it's either an 0500 report or an 0515 report. If they were on an overnight in MEL then wake up time is somewhere between 0355 and 0410. Possibly earlier if they were MEL based and starting the day's work. Was it first day, second day, third day of early starts?

I wonder if they had something anything to eat as well. Probably didn't eat the crew snack- does anyone?- and I wonder if they were appropriately nourished? (You're a little high there John. Wasn't that one due in part to blood sugar levels?).

I like this quote too:
The radio traffic on all frequencies during the descent and approach into Sydney was not unusual fort hat time of day.

That means it was going flat stick most probably. Monday morning too.

Not excusing it, just pointing out some things that can make those holes in the swiss cheese significantly bigger than they may be at other times. A timely reminder to work hard on avoiding those errors folks- particularly in these sensitive times.

[towerboy]

Long shift, early start, long run, " (not) appropriately nourished"...ATC providing information. "The fatigue wasn't a factor" but I was on the "red eye".

What about, I didn't do what I should have done...I was wrong....................................never!!!

[sheppey]

But what about the complex and dare I say superfluous amount of "SOP guff" that is foisted upon the Qantas crew as revealed in the lengthy ATSB report. Heads Free/ Heads down and all that bewildering amount of calls and switching of roles to remember on the approach. Has not QANTAS heard of the KISS principle?

[Wally Mk2]

Good to see that humans can learn from their mistakes. A pilot induced mistake is usually an end result of errors or poor judgment made by others before hand such as ATC trying to squeeze us all in with min delay.

I believe in a 2 crew environment that the PF ought to have a smaller picture of what's going on round him/her than the PNF. That way the PF can concentrate on the 'minding the shop' philosophy where as the PNF can look at the big picture all around them. PF fly's the plane inc it's configuration, looking ahead (if VMC) towards the rwy (if aligned)forming that part of the picture of where he's going and limit what you try to comprehend with regards to what's going on around you as the human brain is a finite peace of equipment with a break down point.
SOP's are a good thing, there to make us all do the same thing at the same time to reduce errors but they can also be just a guide at times. You can make 10 airframes identical but you will never make 10 pilots the same.

Procedures & A/C design/equip are just a back up which worked in this case.




Wmk2

[Keg]

Tower boy. I did say I was wrong but those with a confirmation bias to bag out others tend not to see that.

Of course those with even a basic understanding of CRM know that there can often be other things that lead to being 'wrong'. Those that don't understand those issues, and are therefore unable to work to mitigate them, are the real danger. So which are you?

[easily_confused]

And what would CASA of had to say if this was Tiger? Or will they just sweep this one under the carpet for the untouchables?

[Wedcue]

If it were Tiger they would have received the same treatment as Qantas.

It sounds like you're easily confused.

[Capt Kremin]

Can someone point out to me a post from a bona-fide QF pilot that states they never make errors?

Qantas has a safety culture. That is not the same as saying they never make errors. Every pilot in every airline makes errors from time to time. What makes a safety culture is how those errors are addressed.

I'd bet my fourth stripe that this crew self reported. We already know they went around as they discovered their error. We all know airlines that would have done neither.

I personally came within a few hundred feet of doing the same thing a few years ago. I went around even though the GPWS hadn't gone off and I self reported. The circumstances; distractions and weather, were very similiar. Does that make me an unsafe pilot?

The level of immaturity displayed by some of these posts is disturbing. Are you really professional pilots?

[DutchRoll]

It's too easy to say "well you just screwed up".

It takes a bit more thought and application to assess the contributing factors as to why that screwup might have occurred. It's not like they didn't put the gear down because they couldn't be bothered that day.

[Wally Mk2]

'P Dub' I didn't actually say ATC made errors of judgment with ref to this particular event, the words 'such' and 'or' where added to avoid any actual blame of anyone agency or individual in this case. It was of a generic nature in the opening of my post. ATC make errors & poor judgment just like the rest of us, 'tis human to err inc ATC. The stupidity of Pollies & their curfew crap are to blame a lot in these cases.


Wmk2

[Busty Nerd]

There's a difference between finding the contributing factors to a safety incident and defensive blameshifting. ATC have already been mentioned in this thread half a dozen times, when I can't see one single aspect about this particular incident that warrants their mention. In 15 odd years of operating at Sydney I could count on the fingers of one hand the number of times I've been transferred to the tower frequency EARLIER than 2500' (excluding those silly PRM thingies). I'm not saying they don't make mistakes like the rest of us do, but why did the PF see the need to make the point to an ATSB investigator that this was a late transfer and cause of distraction?

As someone interested in CRM and wider human factors in aviation I see James Reason's model increasingly and incorrectly used to fling crap at as many factors as someone's mind can grasp so that they can lessen their own feelings of guilt. In the end, no-one 'owns' anything because we can dish off 2% here, 5% there etc. "It's always someone else's fault." And it's not just aviation...

[sheppey]

That way the PF can concentrate on the 'minding the shop' philosophy where as the PNF can look at the big picture all around them.

Both pilots should already have `the big picture` at all times. It is called Situational Awareness.

[framer]

In 15 odd years of operating at Sydney I could count on the fingers of one hand the number of times I've been transferred to the tower frequency EARLIER than 2500' (excluding those silly PRM thingies).
Nothing to do with this incident but if we're giving personal experiences, I had SY ATC chat away about how he wanted us to take exit A3 instead of the high speed and give reasons why etc when we were at 200agl only about a month ago. I have to admit it was hard not to divert my attention from airspeed etc to look at my 10-9.

What about, I didn't do what I should have done...I was wrong
If the industry had had that attitude for the last 40 years we wouldn't have made headroads into why accidents actually ocurr. I'm not saying ATC had anything to do with this incident but unless you were there dealing with the distractions yourself it's a bit rich to bag the crew (or ATC for that matter).

[V-Jet]

At least pilots are only distracted for a few seconds.

Geoff Dixon has stated that management was so distracted they didn't really do their jobs for more than six months. And (unlike the company) pilots didn't wreck the jet!

We don't get paid Wirth's $1m, but that shouldn't stop us having a go. Full page ad in the Tele stating same??

The only things the pilots didn't achieve was a massive bonus for a job well done!

[Keg]

The reality is that both ATC and pilots don't spend enough time observing each other at work to fully comprehend workload and other issues that are going on. Familiarisation flights should be mandatory each year for an ATCO and an hour each in the TWR, APP, DEP should be mandatory for pilots each year also.

[Mozzie75]

Keg...couldn't agree more with the joint famil concept. Unfortunately it is one of those things which gets left behind when rosters are tightened and rostering holes need filling. I still make the effort every 12 months or so to complete a famil flight (Emirates and Virgin in the last few years). Hopefully Qantas (including all "Qantas-Group" airlines) will revise their policy to allow ATC to re-join a famil program. There are plenty of times when I have been sitting down the back wondering why the travel time couldn't have been spent doing some famil up the front.

[framer]

That instruction at 200 FT AGL as you have described it is ridiculous. As PIC I would have been ignoring it as best I could, but left wondering afterwards if the controller had any concept of what is going on in the cockpit for the last 500-1000 FT.

That sums up my reaction perfectly. I contemplated giving him a friendly call to explain how I felt but by the time I got to the hotel was ready for bed and didn't, I probably should have. The interesting thing for me was that my initial reaction was to asses my chart and discuss it etc before I realised that the real priorities were actually elsewhere.Famils should be the norm.

[amos2]

Excuses, excuses, excuses!!...

you lot really are giving professional aviation a super bad name!

Wot' say we go back to basics:

Lesson 1: Aviate..Navigate..Communicate.

There, that wasn't too hard was it? :ugh:

[maui]

Does anyone know when the GA was initiated? I am loathe to go on the assertions of a journo, but if the report has any accuracy I relation to the initiation of the GA, something is seriously out of kilter.

The report suggests that the GA was initiated at about 500 feet in response to an aural warning. The two possible aural warnings are, landing flap selection with gear up or GPS " too low gear".

Bearing in mind that the checklist cannot be completed before the final flap is in position, do the Qantas sops allow selection of final flap at altitudes below 1000 feet, and/or landing checks to be completed below 1000 feet.

If so have these been approved by CASA? Inept as CASA may be, I'd bet my leftie that they would not countenance such a late procedure.

So I must assume ( hope) the report is factually incorrect.

Maui

[amos2]

Err! Hang on, I forgot to allow for you Gen X & Gen Y's. ( Is that really what you call yourselves?)

So, Lets make that: Aviate, Navigate, Communicate, mitigate and add a bit of crm? :ugh::ugh:

[nomorecatering]

A non-pilot friend of mine has just read this thread, her comment was "what a lot of self righteous gits........pilots occasionally make mistakes, but the system caught it. Learn from it and get over it".

Quoted word for word.

A pretty cluey lady i must say.

[kellykelpie]

Uh Oh, Amos2 has forgotten his pills again:ooh:

[ohallen]

NMC,

Is that friend of yours going to the RAT AGM...she may be good value and make a lot more sense than what is likely to occur other than Mrs Austen.

[BP2197]

A good operator learns from their mistakes, a true professional learns from thier mistakes and those of others. I think this discussion has merit.

[framer]

heh heh, Amos cracks me up :) I like flying with guys like you Amos (there aren't many of them ) cause when you f#ck it up it's kinda satisfying to pick you up on your errors:D

[RATpin]

Framer,In my experience,just stay quiet-they always dig a hole for themselves and need "saving"

[Lookleft]

Just to nitpick the report itself it is suggesting that the PIC had a total of 16500 hours of which 15000 were as PIC and 594 total time on type. Since when has QF offered DEC to non-type rated pilots?

[Sunny Boyle]

Ya, Akali I can't believed that it indeed happened! Gremlins in the works?

[Jack Ranga]

I had SY ATC chat away about how he wanted us to take exit A3 instead of the high speed and give reasons why etc when we were at 200agl only about a month ago.


You are within your rights to ignore this. Most of us wouldn't attempt instructions of this sort at this time.

The reality is that both ATC and pilots don't spend enough time observing each other at work to fully comprehend workload and other issues that are going on. Familiarisation flights should be mandatory each year for an ATCO and an hour each in the TWR, APP, DEP should be mandatory for pilots each year also.

You would need to staff both organisations to allow this to happen. I haven't been on a famil flight for over 10 years now. Unfortunately the empire builders in our organisation would see this as an ATC having a bludge day.

Back in 'the good ole days' a trainee ATC would spend a week or two on airline attachment. That means getting up at 4am and doing full days with the flight crew. And when you fellas come in they pick a nice cosy time for you to have a look not when it's flat knacker. Apparently we aren't mature enough to have you plug in beside us while we are working the peak traffic.

It's not hard to organise or run this, it just takes commitment and unfortunately costs a bit of coin. Coin that would come out of a bonus.