Air Nelson Dash Noeswheel Report

[blah blah blah]

Crash pilots ignored cockpit warning alerts - report - National - NZ Herald News (http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10844375)

Interesting arguments put forward...

[Bongo Bus Driver]

I had a TCAS descend on the taxiway at Auckland once. I suppose TAIC expected me to react to that as well!

[remoak]

I think TAIC's point is "don't allow strict adherence to procedure - whether correct or not - get in the way of common sense". This is otherwise known as "better to be safe than sorry". A low approach and overshoot is not going to break the bank in a Dash, and if it does reveal an issue, will have been worthwhile. If not, you delayed the flight by two minutes and used a few kilos of fuel, hardly a sack-able offence. Any airline that would discipline a skipper for that should have it's AOC pulled.

Mr Stringer is being somewhat precious with his "crew did everything by the book" line. Whatever happened to airmanship?

It also makes you wonder how DHC could get the procedure so badly wrong. What is it with Dash 8s and undercarriages?

Having said all that - the reporting is somewhat sensationalist and, well, crap. They didn't ignore the warning, they did everything they were required to. I just think that airmanship took a back seat to procedure.

[haughtney1]

The use of the low level fly past or “fly-by” by an aircraft with landing gear, or other condition, for the purpose of ground observation / confirmation does not provide meaningful additional information etc etc etc. Such operations are prohibited.

Remoak old chum, this is straight out of a JAR Ops 1 and I'm assuming EASA compliant OMA. The etc etc etc is my edit to keep the post to one page...
I wonder if the TAIC chap had any relevant access/experience with respect to the legalese that we have to deal with?:}

[Flt.Lt Zed]

The DASH 8 diverted from Nelson 50 miles away due weather.Maybe the cloudbase and visibility were too low for a fly by ?

[aerostatic]

Personally I am disappointed with this TAIC report. The QRH clearly stated that if either of the gear indicating systems showed the gear to be down and locked then it was down and locked. Given that that is what the manufacturer had to say on the matter, in writing, in a critical operational document (the QRH) it should have been good enough to hang your hat on. I'm all for applying common sense when there is genuine ambiguity but I don't see it applying in this case.

[Roger Greendeck]

So TAIC believes that the pilots should have ignored the manufacturer's advice about the technical performance of their system?

What about if they ignored advice and that caused an incident?

This looks like a classic case of being wise after the event. Maybe, if they had the fuel, they would have been been better off holding and contacting TAIC to ascertain the correct course of action from the investigator.

Come to think of it, I might start adding some margin fuel for accident/incident investigation in the future.

[blah blah blah]

It wasn't necessarily the manufacturers advice.

They had fuel to think about things.

There was a lack of airmanship displayed.

I was surprised that the report was so generous.

[AerocatS2A]

It wasn't necessarily the manufacturers advice.

Yes it is the manufacturers advice. The Dash 8 QRH says that if the gear indicates unsafe, you should check the alternate indicating system, if that indicates down and locked then the gear is down and locked*. Obviously that advice is now known to be wrong on this occasion, but the pilots didn't have any reason to suspect that at the time. They did exactly what they should have done and were let down by both the aeroplane and the TAIC.

*From memory, I don't have it to hand and haven't flown the Dash for 18 months.

[haughtney1]

Gosh Blah, I wish I had your outstanding airmanship qualities, I find the conclusions of the report contradictory at best.
On the one hand..
3.1.5. The landing gear selector lever was left in the DOWN position and the captain directed the first officer to begin the “Landing gear fails to extend” checklist in the operator’s customised QRH (see Appendix 1).

Which is chapter and verse what I would hope we all would do

Followed further on by..
4.17. When the pilots moved the landing gear selector lever to DOWN on the approach to Woodbourne, the “Landing ear Inop” caution light did not illuminate, but the indicators on the landing gear panel told them that the nose landing gear was in an unsafe condition. The use of the “Landing gear fails to extend” procedure in the Air Nelson QRH was the appropriate action for the pilots to take. The procedure stated that if either the advisory indicator on the forward panel or the verification light under the alternate extension flap was green, the corresponding landing gear leg was down and locked. The 2 indication systems were independent of each other.
4.18. The text of the QRH removed any doubt for the pilots. It clearly stated that if either light was green, the relevant landing gear leg was down and locked. When the pilots saw the green verification light for all 3 landing gears, including the nose landing gear, the pilots had every right to believe the verification light, and halt the “Landing gear fails to extend” procedure.
4.19. The captain said that in his capacity as the airline’s flight operations representative at Bombardier customer seminars, he had heard the saying “a green is a green” used to emphasise the dependability of the verification system. His comment that “a green is a green”, made when he declined the first officer’s suggestion to fly past the control tower and have the nose landing gear position checked by the controller, reflected his confidence in the verification system. Most other pilots would have concluded at that point that all of the landing gear was down. Notwithstanding that confidence, shortly afterwards he requested a second check of the verification light, and both pilots confirmed that it was still green.

At this point there has been no reference to the operators operations manual as to whether a flypast is recommended or even allowable in this circumstance (please don't hit me with the airmanship argument...these days it's about avoiding culpability...which is why even QRH's are written the way the are)

Followed by the key findings in all of this..

Findings
With the nose landing gear stuck in a partially extended position, light from the taxi light was likely detected by the sensor for the down-lock verification system, causing it to give a false green light.
The false green light on the verification system misled the pilots of ZK-NEB into believing that the nose landing gear was fully down and locked.
The verification system for checking if the landing gear is down and locked on the Dash 8 series of aircraft is not reliable enough for pilots to place total trust in it when
trying to establish the status of the landing gear.


Quite simply the manufacturers recommendations hung these guys out to dry, yes they COULD have flown past the tower..but there is no guarantee of a successful outcome.
Then a further kick in the nuts for the crew..A none too subtle reference to the investigators opinion..as well as the standard get out clause..just in case it could be hung on him in a later incident...
4.40. A fly-by cannot confirm absolutely that a landing gear leg is locked down, especially at night, but an observer can report the landing gear appearance. In the case of the nose landing gear on the Q300, if the wheels appear down and the forward doors are closed, that is useful information, because the Proximity Switch Electronics Unit must sense that the landing gear is down and locked before it will signal the doors to close.
Followed by..A bit of 20/20 hindsight that supposes all that previously happened..didn't in fact happen and that the crew should have ignored the QRH...
4.41. The pilots could have sought technical advice from the operator and likely would have done so had they gone around in response to the aural warnings. If it had been confirmed that the nose landing gear was not locked down, the checklist would have led the pilots to silence the potentially distracting warnings and they would have instructed the flight attendant to prepare the cabin for an emergency landing.
And lastly....a statement indicative of an operator with potentially a few more deficiencies in its Ops spec....why the need to clarify? shouldn't the course of action be clear for all to see?
4.42. The operator later clarified the action it expected its pilots to take, including making use of an external observer, when there was a disagreement between landing gear position indications.

I wholly agree with the CRM aspects of the report, but these aspects in their isolation had no real bearing on the outcome.
The reality IMHO based on the report is that the Q300 concerned had a defective system that was deficient for the task with which it was designed to do..namely alert the crew as to the state of their landing gear...the fact that this system was given credence over and above the various other warning systems speaks volumes about the manufacturer, their "green is green philosophy"and its poorly concieved design.
The crew did everything that could be reasonably expected of them, notwithstanding the CRM issues...and the now "clarified" company procedure.
The manufacturer and operator however appear to have escaped any censure..other than a couple of recommendations

[remoak]

rmcdonal

Interestingly the message being pushed by CASA (I realise this is a NZ incident) is exactly the opposite, CAR215 would hold the AOC holder accountable for not enforcing a strict adherence to the approved manual.

Does any approved manual over there explicitly prohibit a low-level flypast for the purpose of inspecting an undercarriage?

Haughtney1

Remoak old chum, this is straight out of a JAR Ops 1 and I'm assuming EASA compliant OMA.

Yes mate but we don't live in EASA land, we live in NZ and over here it is actively encouraged, at least by Airways...

At this point there has been no reference to the operators operations manual as to whether a flypast is recommended or even allowable in this circumstance (please don't hit me with the airmanship argument...these days it's about avoiding culpability...which is why even QRH's are written the way the are)

Well... please explain the difference between an approach followed by a missed approach, and a low approach and overshoot? it's the same thing, the only difference is what you call it. Declare that you are carrying out the appropriate approach and go around at DA/MDA... you achieve the same thing and nobody can criticise you, far less prosecute you. However you CAN be blamed (and prosecuted) if you do not take all steps available to you to resolve any ambiguity in what your aircraft is telling you, when the next thing that happens is an accident. It's called "duty of care" and is something all aircraft commanders should be intimately acquianted with. Just think for a minute... what would have happened if the Dash had unexpectedly veered off the runway following a nose gear indication issue, and people had been hurt? Which is exactly what happened to an ATP a few years back in Edinburgh. I'll think you'll find the captain would have been in a world of hurt, irrespective of what the manual might say.

I might be old-school, but airmanship rules and culpability can take a hike... ;)

Flt.Lt Zed

The DASH 8 diverted from Nelson 50 miles away due weather.Maybe the cloudbase and visibility were too low for a fly by ?

If the weather is too bad for a low approach/overshoot, it's also too bad to make an approach... in any case, I was inbound to WB at the time this was happening and the wx wasn't that bad.

[haughtney1]

I might be old-school, but airmanship rules and culpability can take a hike...

Can you imagine how much time in Jail I'd get if I did that.....:E

Fair points BTW, but it's telling to me the TAIC guy noted that they had to get clarification...and it's also worth noting that the crew whilst uneasy felt that the warnings were nuisance...so in essence, not ambigious..spurious, an easily argued point my Lud given the system faults..and the manufacturers own (most likely attributable) statements...
See its the lawyers...

[AerocatS2A]

Remoak, what's your go-around performance with the landing gear down?

[remoak]

Adequate... why?

You aren't asymmetric... you know your main gear is working fine... you are VMC and can remain so... please explain, using small words and a crayon, what the danger is...

Haughtney old bean...

the crew whilst uneasy felt that the warnings were nuisance...so in essence, not ambigious..spuriousAnd that's the whole point... if you are not absolutely 100% certain that there is no issue, you ALWAYS err on the side of caution and do whatever you have to do to become 100% certain and 0% uneasy... which is why you use ALL the avenues available to you... including observation from the ground. Which, by the way, has often clarified whether an emergency exists or not in the past.

Oh, and I forgot to mention...

The use of the low level fly past or “fly-by” by an aircraft with landing gear, or other condition, for the purpose of ground observation / confirmation does not provide meaningful additional information etc etc etc. Such operations are prohibited.

In an emergency, as you know, the rule book goes out the window. There is nothing to stop you doing a low pass if you deem it necessary during an emergency. Just don't forget to declare an emergency!

One day, young Skywalker... ;)

[blah blah blah]

It wasn't necessarily the manufacturers advice.

Yes it is the manufacturers advice.

The manufacturers advice, in terms of their QRH, and what the company did, in terms of THEIR QRH were two different things when this event happened.

Gosh Blah, I wish I had your outstanding airmanship qualities

My outstanding airmanship qualities were exactly the same as all the pilots at Air Nelson who also questioned why the Captain didn't take the hint from the FO and why they didn't take the time to have a think about the problem. The EGPWS going off should have been a hint.

[HF3000]

And if something happened while attempting to troubleshoot a problem that their QRH told them didn't exist?

Crew are not generally encouraged to troubleshoot beyond the guidelines in the manual unless a greater emergency exists.

Didn't someone die doing that a while ago?

Oh yes: United Airlines Flight 173 - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/United_Airlines_Flight_173)

[AerocatS2A]

The manufacturers advice, in terms of their QRH, and what the company did, in terms of THEIR QRH were two different things when this event happened.

Did they differ in any meaningful way? I'm not familiar with Air Nelson's QRH, but it doesn't seem like it was saying anything different than Bombardier's.

Edit: Just read the Air Nelson QRH from the report, although laid out differently it is functionally the same as Bombardier's, so the crew were following the manufacturers instructions.

[AerocatS2A]

And now having read the Bombardier QRH, I see where they differ. The Bombardier QRH would have directed you to check the alternate verification system if only a green gear down and locked light had failed to illuminate, but if a green light was out and you had other indications of a failure to extend such as gear door open lights on and the gear unsafe light on, you would carry out the alternate extension procedure. I agree that if they'd followed the OEM QRH rather than the Air Nelson one, the incident would not have happened.

[framer]

The pilots said that they had had enough fuel to go around again. Had they done so, one would expect that they would have asked the controller to report the nose landing gear position, as the first officer had earlier suggested they do.

4.39. Had the controller said that the nose landing gear did not appear to be down, the pilots would have realised that the aural warnings were genuine. It would then have been logical for them to disregard the (false) green verification lights and go back to the “Landing gear fails to extend” checklist. This would have directed them to perform the alternate extension procedure. However, as mentioned above, that procedure would have been unlikely to succeed in this case, because the actuator was jammed.
It seems to me this investigator is giving his opinion of how he might have liked the situation to play out. An opinion formed from a comfy chair with months to assess. I could do the exact same thing....in fact I think I will;

"Had the manufacturer run a thorough risk analysis procedure when relocating the taxi light from the external nose cone to the landing gear strut, they most likely would have determined that the light sensing verification system was no long appropriate. Having realised that the system was no longer appropriate, it would have been logical for the manufacturer to re design the verification system or alternatively, reconsider the relocation of the taxi light.
ZK-NEB had been investigated for landing gear malfunctions twice in the 5 weeks preceding the accident flight. No fault was found on either occasion and the aircraft was returned to service. Had the airlines maintenance system been capable of identifying trends of unresolved malfunctions it is logical to presume that further analysis of ZK-NEB would have resulted in the faulty actuator being replaced."

I'm not suggesting that what I've just written is better than the report, I am suggesting that it is the same as what the Investigator has done. Had X happened, then Y would logically follow, and Z would be the outcome.

[601]

TAIC lead investigator Peter Williams said the actions of the pilots were "understandable'' in terms of the information they had.

On the information presented to the pilots, this statement should read;

TAIC lead investigator Peter Williams said the actions of the pilots were "correct and in accordance with the published procedures'' in terms of the information they had. However, we shall recommend that the CAA require the manufacturer to amend the procedures to prevent conflicting information being presented to the flight crew

[framer]

....Spot on...

[Roger Greendeck]

The report spends a lot of time on the associated warnings from the original unsafe gear indication (horn and EGPWS) and is critcal that the crew ignored those warnings. Suggesting they should have gone around and sought further advice. What would that advice have been?

The report does not state if the horn or EGPWS receives indications from both gear indicating systems or just the primary. If it only receives it from the primary then the crew were correct in their assessment of what they expected to hear. If it gets it from both and the horn and EGPWS were an additional bit of important information then why weren't they in the QRH?

The whole point of OEM documents such as the AFM and QRH are so that you don't have to ring the OEM and ask for advice when it is time critical.

My aircraft type has multiple undercarriage indications but the OEM is very clear that only one of them has to indicate a green to be certain that it is down and locked. Nevertheless I would have a sense of unease during the approach, just like these guys did. So the fact they were uneasy should not be miscontrued to mean that they thought that needed more advice.

[Daysleeper]

I wonder if this problem goes through to the later Dash models. The Q400 checklist says if any gear indicators fail to illuminate (or come up red) then check the alternate lights. If they are all green then the gear is safe for a normal landing.

[AerocatS2A]

I wonder if this problem goes through to the later Dash models. The Q400 checklist says if any gear indicators fail to illuminate (or come up red) then check the alternate lights. If they are all green then the gear is safe for a normal landing.

Are you sure about the bold bit? My Dash 8 300 QRH basically has three landing gear checklists. One for the alternate gear extension, one for a failure of a green down and locked light, and one for a door advisory light.

If you have a green light out and no other indications then you would use the LANDING GEAR INDICATOR MALFUNCTION checklist. But if you have other associated warnings such as the red gear unsafe light, and the light in the handle indicating gear not in the position selected, and the gear door open advisory, the only applicable checklist is the ALTERNATE LANDING GEAR EXTENSION checklist. The situation is not covered by either of the other two checklists.

Where Air Nelson differed is that they had their own QRH with an additional checklist for any gear unsafe indication. It first directs you to check the alternate indicators, and if they are green no other action is required. This is not part of Bombardier's QRH and ultimately led the crew to landing with an unsafe nose wheel.

[Bongo Bus Driver]

Aerocat

I understand that Air NSNs QRH must be checked and approved by Bombardier prior to CAA allowing it to be used.

[AerocatS2A]

Fair enough. My view on it is that crew did things by the book. The argument is then between Bombardier and Air Nelson to decide who was responsible for the book.

[framer]

I agree. There seems to be a return to the "pilot error" mindset from our esteemed aviation leaders. Did anyone see the head of the nzcaa on 60 minutes completely denying that there were any systemic failures from the regulator re Fox glacier crash and blaming it solely on the pilot?

[nike]

Also worth following the PelAir westwing story.

Seems the modern investigator pool isn't as independant as one would expect.

[Daysleeper]

Are you sure about the bold bit? My Dash 8 300 QRH basically has three landing gear checklists. One for the alternate gear extension, one for a failure of a green down and locked light, and one for a door advisory light.

Yeah my bad for not being precise, there are a variety of checklists so you could find a crew following this list...


Landing Gear Fail to Indicate Locked Down
(gear lever selected down)
Note > amber and/or red advisory lights may be illuminated.
If any of the instrument panel green gear locked down advisory lights fail to illuminate:

Gear alternate extension door - open
Gear locked down indicator - on / check / off
gear alternate extension door - close

If all three alternate extension green gear locked down advisory lights illuminate

normal landing can be made
end


original bold

[heated ice detector]

If any one is interested ATSB report 9601590. DHC-8 VH-JSI.
possible procedure and check list similarities.

[aluminium hail]

To add some clarification to the system on the -300, the normal gear indication system is controled by the PSEU (proximity switch electronic unit) and it also provides info the EGPWS to provide "Too Low Gear" callout. The alternate system illuminates the alternate gear verification lights and nothing else.

If the PSEU has a fault then you should get a LDG GEAR INOP caution light and will be required to do an alternate gear extension.

In this case there was no caution light but the evidence suggested that the PSEU was not sensing that the nose gear was down. (the evidence being that the alternate lights indicated down and locked but the normal lights were not)

The Capt knew that if the alternate lights were green the gear was down and locked.

Based on the knowledge that the PSEU must have had some sought of fault that had not illuminated the associated caution light the Capt would not have been surprised to hear the EGPWS warning because it gets its info from the same system, therefore he elected to continue the approach.

Now you can debate that decision till the cows come home but if the PSEU was at fault you would get the same callout every approach until you pulled its circuit breaker so how many times should he have gone around?

[framer]

I wouldn't have expected them to do anything other than what they did because both the Manufacturer and Air Nelson told them ( through the QRH and verbally ) that the gear was down and locked. The manufacturer was adamant that that the gear was down and locked if three greens showed on the backup system, they designed the system, they tested the system, they have monitored the systems performance through many incidents and accidents while sitting at desks with no fuel induced time pressure. If I was the Capt of that flight I would have felt confident that they were correct.
I fly 737 classics and NG's, in the classic we don't have a back up light system but in the NG'S we do. The NG QRH says
: If a green landing gear indicator light is illuminated on either the centre main panel or the overhead panel, the related landing gear is down and locked. Our company also actively discourages tower fly-bys as well. Can I trust that Boeing has done a better job of testing it's systems? Shall I do a fly by if I have three greens on the standby system? Knowing the "Pilot -Error " mentality of NZ accident investigators I think I will if I'm in Auckland.

[remoak]

[Asbestos suit on]

I wouldn't have expected them to do anything other than what they did because both the Manufacturer and Air Nelson told them ( through the QRH and verbally ) that the gear was down and locked. The manufacturer was adamant that that the gear was down and locked if three greens showed on the backup system, they designed the system, they tested the system, they have monitored the systems performance through many incidents and accidents while sitting at desks with no fuel induced time pressure. If I was the Capt of that flight I would have felt confident that they were correct.

And manufacturers are NEVER wrong... :rolleyes:

It's pretty scary to see so many pilots utterly incapable of thinking outside the box. SOPs are great and all, but there have been (and always will be) many scenarios that are not necessarily solvable by slavish obedience to checklists and procedures. As a wise person once said, "rules are for the obedience of fools and the guidance of wise men".

By all means fly by the SOPs and use all the checklists appropriately - I do. However, I have been in situations where strict obedience to the procedures would have had us in a fatal crash scenario. You are allowed to think - a prerequisite for a pilot's licence is not a lobotomy.

As we can see from the incident in question - and many others - the crew should have been able to rely on the information they had, and draw the correct conclusions. But - guess what? There were errors in the systems designed to protect the aircraft and the crew. And I'm not even slightly surprised.

Airmanship used to be about a pilot making a correct decision based on all the available evidence, including such things as taking account of any uneasiness about what the pilot is looking at or sensing. Far better that than slavish obedience to "procedure".

And I don't buy the culpability argument. If you do everything by the book but still crash and kill people, you are just as likely to be hung on the "duty of care" provisions as anything else. There's a lot more to it than "by the book".

I don't think the Air Nelson incident(s) is/are a big deal in themselves, but they do illustrate (in my opinion) a worrying trend towards slavish obedience to procedures by pilots, and a somewhat typical arrogance in NZ aviation circles towards manufacturer's SOPs.

[owen meaney]

Airmanship used to be about a pilot making a correct decision based on all the available evidence, including such things as taking account of any
uneasiness about what the pilot is looking at or sensing. Far better that than
slavish obedience to "procedure".Same problem in Norfolk "misadventure" - it's all the procedure manual' fault

[AerocatS2A]

Remoak, I agree in principle with what you are saying. My only question is, at what point do you decide that you need to act beyond or in addition to the supplied checklist? Of course a checklist can't be provided for every circumstance and if your situation doesn't match the checklist then you have to use your knowledge and experience to make the best of a bad situation. VH-JSI, which took a large bird through the wing root, is a good example of this. These Air Nelson guys, however, seemed to have a checklist that adequately covered their situation and it seemed to them at the time that there was no reason to look further into it. In fact if the alternate indication system was as robust as they'd been lead to believe the checklist they'd followed would have worked fine, but neither Bombardier, Air Nelson, nor the crew, had the vital piece of information that the alternate system was flawed and should only be used to confirm an alternate gear extension or as an alternate to a single green advisory not illuminating. Whether by design or accident, this is actually how the OEM checklist is written, but whoever approved Air Nelson's variation to it didn't seem to see the benefit in the original layout.

[remoak]

AerocatS2A

My only question is, at what point do you decide that you need to act beyond or in addition to the supplied checklist? For me... after I have completed the abnormal/non normal/emergency checklist, I mentally sit back for a moment and ask myself "am I absolutely certain that I know what's going on, and am I absolutely satisfied that I have done everything that I possibly can to mitigate risk?" If the answer to both is "yes", then job done and let's land this sucker (or whatever). But if there is the slightest doubt - and that can be just an uneasy feeling from either pilot - then it's time to dig a little deeper.

I can recall one incident where we would have shut down an engine out over the North Sea on a stormy night if we had followed the checklist religiously. However, the application of a little lateral thinking led us to the conclusion that what we were looking at (indication-wise) wasn't what was actually happening. The engine continued to run just fine for the rest of the flight...

As I mentioned, I have no difficulty with the crew's actions in this case - although I'm sure the skipper might have second thoughts next time! No, what discourages me is the attitude that "if the book says it, it must be the truth". That is a fallacy that has cropped time and time again in accident investigations. The other is the idea that if you do everything by the book, sit back with a self-satisfied smile on your face and subsequently crash and hurt people, you are automatically immune from blame because you followed the procedure. Anyone who believes that should watch the investigation into the CTV building collapse during the Christchurch earthquake. Plenty of people are being ripped to shreds for not helping as much as they could have, even though they can truthfully say it wasn't their job at the time. The point being made by the investigators is simple - "you were there, it doesn't matter whether it was your job or not, you were in a position to help and you didn't do so to the best of your ability". Duty of care.

When I was doing my F27 and 146 type ratings in the early '90s, our instructors would throw us curve balls constantly to see how we would react. They wanted to see us use the checklists correctly and follow SOPs... but what they REALLY wanted to see is whether we could think outside the box and come up with a solution that wasn't written down anywhere. They wanted to know if there was a mind at work in the pilot's head, as opposed to an automatic procedure-following piece of wetware.

Going back to the incident at hand, could somebody please explain why a) Air Nelson felt it necessary to re-write the checklist; and b) if the re-write was better than the original, why didn't DHC adopt it?

I already know the answer, but I'd be interested to know if anyone else does... ;)

[pakeha-boy]

Remaok...

I'll wholeheartedly agree with you that we take too much for granted. I'd say that our knowledge, as pilots, about our steed doesn't go very far and deep, which needs not be as bad as this phrase suggests. I consider the trick to a long operational life is to know just enough (and recall it promptly) to get one safely out of any conceivable airborne situation - even if the exit is not effected in a neat, elegant or economical manner. I found out that I best remember not the lessons picked up in operating manuals but anecdotes from other pilots, safety publications,(quote)

I would suggest that one reads the NTSB report of the Jetblue incident in KLAX,and take note of the "resources" that the crew used to take care of this issue......at the end of the day,you as the Capt,and F/O.....will be required to prove that you used "all" avenues to deal with the issue at hand...

[haughtney1]

I don't think for one second that anyone would disagree with your comments Remoak, particularly the on-going assessment of an issue, the thing is, you and I both know that there is a company culture here at work in the background, and I don't mean with respect to guys on the day.
Rightly or wrongly, most operators train us to rely on the QRH, and for better or worse they tend to be reliable documents....but they contain the usual caveats..this is straight out my 777 QRH, and note the trouble shooting comment.

While every attempt is made to supply needed non–normal checklists, it is not possible to develop checklists for all conceivable situations. In some smoke, fire, or fumes situations, the flight crew may need to move between the Smoke, Fire or Fumes checklist and the Smoke or Fumes Removal checklist. In some multiple failure situations, the flight crew may need to combine the elements of more than one checklist. In all situations, the captain must assess the situation and use good judgment to determine the safest course of action.
It should be noted that, in determining the safest course of action, troubleshooting, i.e. taking steps beyond published non-normal checklist steps, may cause further loss of system function or system failure. Troubleshooting should only be considered when completion of the published non-normal checklist results in an unacceptable situation.

Damned if you do damned if you don't :ok:

[HF3000]

I think that is pretty clear.

Their QRH clearly told them they did not have a problem.

Further troubleshooting in this situation would have been clearly outside the guidelines of the manufacturer and the operator.

This crew did the right thing.

[AerocatS2A]

Remoak, I agree with what you are saying.

As for this:

Going back to the incident at hand, could somebody please explain why a) Air Nelson felt it necessary to re-write the checklist; and b) if the re-write was better than the original, why didn't DHC adopt it?

I don't know anything about Air Nelson but assume that, as has been alluded to here, there is some cultural thing going on. Perhaps they have a tendency to try and reinvent the wheel? As for B, it wasn't better.

[remoak]

Damned if you do damned if you don't

Depends on the outcome...

It should be noted that, in determining the safest course of action, troubleshooting, i.e. taking steps beyond published non-normal checklist steps, may cause further loss of system function or system failure. Troubleshooting should only be considered when completion of the published non-normal checklist results in an unacceptable situation.

I don't necessarily disagree, although this is clearly a legal boilerplate. Please define "an unacceptable situation"... a deliberately vague term.

HF3000

I think that is pretty clear.

Their QRH clearly told them they did not have a problem.

All good except that they DID have a problem, as it turns out... :ugh:

Further troubleshooting in this situation would have been clearly outside the guidelines of the manufacturer and the operator.


Does the DHC QRH and/or the Air Nelson Ops Manual specifically prohibit any further consideration of a problem? Not talking about "guidelines" as they wouldn't be limiting in any case.

Cheers AeroCat

[HF3000]

Yes they did have a problem. And it turned out to be a design flaw, not a flaw in the actions of the pilots.

What are you suggesting? In future suspect that the documentation is always wrong? Suppose I have an increase in vibration on one engine and I go to the QRH and it tells me that it's ok to continue unless other engine indications are abnormal. I know better than the manufacturer so I elect to shut the engine down anyway and then I have to land at the nearest available airport. When an engineer is ferried out there and the passengers have spent the night sleeping on the floor of the terminal it turns out to be a gauge malfunction and I am looking for another job.

[remoak]

What are you suggesting? In future suspect that the documentation is always wrong?

No... but definitely suspect that the documentation COULD be wrong... as it was in this case. In 99.9% of cases, it will be fine... but if it just doesn't make sense to you and you aren't sure, dig deeper. That's the difference between a good commander and a competent one.

I'd much rather that than what you are suggesting, which is to always trust the documentation, no matter what.

[pakeha-boy]

Quote HF 3000

.....I know better than the manufacturer so I elect to shut the engine down anyway and then I have to land at the nearest available airport. When an engineer is ferried out there and the passengers have spent the night sleeping on the floor of the terminal it turns out to be a gauge malfunction and I am looking for another job

Well HF 3000 ...Welcome to the world of being a Captain,if your not up to making those types of decisions then you shouldnt be in the seat.....nothing personal,

Hindsight...20/20...monday morning halfbacking....very easy to do in this situation....Most operating manuals have a disclaimer that "all" situations cannot be accounted for and that the "PIC" HAS THE FINAL AUTHORITY to the operation of that A/C...................preaching to the choir???

Could this crew have done more??? I believe so...the outcome might not have been different,,,,,,Ive flown the Dash series...100/200/Dash 7.....never had a lot of issues with this A/C except for the D7........and just about always flew around on 3 ENGINES,because of "gauge malfunctions"........which I might add,...according to the engineer,on the ground...."COULD NOT BE DUPLICATED"..........

I hate the idea of "hanging" pilots....some deserve it.......I have crashed 3 A/C(all in alaska)...207/402/twin otter..........all FAA/NTSB investigated,and all situations I was exonerated,due to their particular circumstances........so I feel I,m in a position to comment.......the C-402 was a landing gear issue,similar to the DH-8........MY POINT?????..... from every one of these situations ...after the fact .....and in consultation with the feds,NTSB and more experienced pilots.........I COULD HAVE DONE MORE.........That is something I learned and valued....and it still holds true today........

I do know what its like to bang one up,be dragged through the mud by the company and Authorities.......and have to be held accountable......and reading this report,indicates to me that the crew had time to investigate this issue further.......but that decision ultimately lies with the PIC.......if the crew "did the right thing" as some have alluded...they will now surely learn from this outcome

......do not confine yr thinking and flying of an A/C to just that of the Ops manual/QRH/Company culture........their are always other avenues

[slamer.]

LOL PB, copied this in then saw you had already used it.... thought some here may still benefit from a discription.


Monday morning quarterback American football: A person who criticizes or passes judgement with benefit of hindsight. Monday morning refers to the games played or broadcast on weekends, with criticisms leveled by a spectator the following week.

[remoak]

Ah yes but the problem these days is that you now have Sunday Night Football, Monday Night Football and Thursday Night Football, so you could also have Tuesday Morning Quarterbacking and Friday Morning Quarterbacking... :ok: