BEA Flight 548: Staines

[Genghis the Engineer]

I found myself reading up on BEA Flight 548 today to prepare for a lecture I'm giving on safety.

Wikipedia: British European Airways Flight 548 - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/British_European_Airways_Flight_548#Reference-AIB)

The Lane report:http://www.aaib.gov.uk/cms_resources.cfm?file=/4-1973%20G-ARPI.pdf

I found it quite disturbing just how many current lessons are still there, and some questions that we should still be asking about new Integrated/MPL first officers, and what we've since come to call CRM. That said, we've clearly come quite a long way - in terms of crew monitoring, medical standards, use of standardised procedures, and acceptance of junior crew challenging senior crew.


40 years ago today.

G

[HEATHROW DIRECTOR]

40 years, eh? I cleared it for take-off.

[Piltdown Man]

So the question is, who has to do the learning? I'd suggest that it's the "old fogeys" like myself. The newbies, whilst often lacking in certain people skills, have a reasonable understanding of what's right and what's wrong in the flying department - even if all of their experience is based on exceptionally standard flying (which I can't argue against). Therefore, it's up to the more experienced member to create an atmosphere which is conducive for the less experienced to voice any concerns.

PM

[fireflybob]

I had recently graduated from Hamble when this accident occurred and the P2 and P3 were Hamble trained so it hit home fairly hard.

Like all accidents there were many holes in the swiss cheese which lined up that day. It was before the days of Mandatory Occurrence Reporting and BEA had had 2 previous near misses when the LE droop had been retracted at too low an airspeed but they'd got away with it. Reports had been made but at that time there was no legal requirement for CAA to be copied.

Therefore, it's up to the more experienced member to create an atmosphere which is conducive for the less experienced to voice any concerns.

Piltdown Man, agreed but it also takes two to tango! With all respect to new FOs (and I know how it feels since I joined as Second Officer when I was 20 years) there are some things which only come from "life" experience although robust SOPs can go a long way towards alleviating any conflicts.

It only goes to prove that even now with automation it's the humans that are key to safe operation and they can only do the best they can with the resources they have available to them at the time. Safety operation is a product of the overall system, just as any accident is. CRM is just one of the ingredients for safe operation.

Also remember that at that time pilots had no training for recognizing and dealing with pilot incapacitation - which was one of the recommendations of the Accident Report.

[safetypee]

G, sad but true. History reminds us that we must learn, keep on learning, and remember.
And after that we forget, or cannot recall, or misapply what we did remember; and it’s called error.

There are several new academic views of the problems of error and how human behavior is influenced by the operating environment. Views which go beyond James Reason’s excellent markers, but which require adapting for practical use, so is it time to move forward with these?
An example could be Hollnagel’s Functional Resonance model or ‘performance variability’ to replace ‘error’ by focusing attention on the factors which cause variability and not the outcome.

Now there’s a challenge for you in your forthcoming safety lecture!

https://sites.google.com/site/erikhollnagel2/coursematerials

Non Newtonian View of Accidents (http://www.scribd.com/doc/78438533/Non-Newtonian-View-of-Accidents)

From a technology (http://www.ida.liu.se/~eriho/PVM_M.htm)

Organisational Accidents Reason (http://www.scribd.com/doc/37066515/Organisational-Accidents-Reason)