The ETTO principle & potential dangers of overreliance on "old school" flying skills

[Armchairflyer]

Just watched the ACI episode on Santa Barbara Airlines Flight 518. If the presentation of the accident is halfway correct, it is IMHO an excellent if sad example how a) the ETTO principle can bite even the best and most experienced and b) having excellent "old school" flying and navigational skills and not having to rely on the magenta line (or merely AI/DG in that case) can come with a safety penalty, too.

Air Crash Investigation: 28 Seconds To Survive (S12E12) - YouTube

[+TSRA]

I'll respond by focusing on the two topics as I see it.

I agree that it is a great example of the ETTO principle. But perhaps not in the same way you see it.

ETTO

The ETTO principle, in my opinion, is designed for experienced crews who can get into this exact situation. It allows for a balance between efficiency and thoroughness, which is what experience teaches you to do.

The crew of this accident were neither efficient or thorough. They were negligent.

If they were efficient, they would have completed their checks in enough time to complete both the checks and allow the Attitude Heading and Reference System (AHRS) time to spool up. Efficiency carries with it both time and quality, the reduction of either can cause a hole in the cheese to appear (I refer to the swiss cheese model).

If they were thorough, they would have realized during their instrument cross check (which they obviously did not do) that the attitude and heading information was not presented.

The fact that the pilots could not tell that their AHRS was not yet operational is a testament only to their lack of situational awareness and/or understanding of aircraft systems.

Old School Skills

The crew did not allow themselves to fall back on "old school" abilities. They were trying to fly using instruments which were not ready for flight.

When the crew finally did revert to "old school" techniques (the standby compass), it was way too late to prevent the accident. Had they recognized early on (say, during the climb when they should have been using their EADI to set a pitch attitude), then they may have been able to remain visual, go back to the field for landing, and spool up their instruments.

You're Right

You're right that this is a great case study. But it's a great case study for slowing down, knowing how long your instruments take to spool up, and knowing that an extra 30 seconds and a deep breath can prevent a lot of accidents.

Applying the ETTO principle to this accident suggests that the crew were too efficient. They were. They were too efficient so as to become negligent.

[safetypee]

The ETTO Principle. (www.hfes-europe.org/books/proceedings2012/Hollnagel.pdf)

Why Things That Go Right, Sometimes Go Wrong. (www.abdn.ac.uk/~wmm069/uploads/files/Aberdeen_ETTO.pdf)

Fostering successes rather than reducing failures. (www.scribd.com/doc/47279623/-Fostering-successes-rather-than-reducing-failures-Hollnagel-presentation)