JQ Incorrect Config report

[Buckshot]

The ATSB report released this week makes some interesting observations regarding fatigue, training, workload and situational awareness.

http://www.atsb.gov.au/media/5199980/AO-2014-129%20Final.pdf

[Mach E Avelli]

Maybe I missed it, but nowhere do I see a recommendation to ditch the term 'set' in relation to flap setting and instead require both crew members to respond with the actual number. Perhaps their SOP picks this up somewhere else?
IMHO the word 'set' should be banned from terminology for critical items. It is only OK for variables of a minor nature such as lights and certain automated systems that can't readily be mis-handled.
I bet there is not a pilot out there who has not at least once selected the wrong flap for take off; hopefully with the error detected by the other crew member.

[Bankstown]

The response isn't 'set' in the before takeoff checklist, it's 'CONFIG (number)'.

[Mach E Avelli]

Thanks Bankstown. Do both pilots call it?

[bdcer]

Mach,

The trick is when PNF calls "Flap setting...." during the before take off checklist, the PF can call "Config....", naming the flap setting with reference to:

1. E/WD (engine warning display) to show actual flaps position,
2. TOLD (data card) to show planned/calculated flaps position,
3. MCDU to show flap position entered into the "box",
4. Flap lever to show flap position selected.

I can't find this flow written anywhere, but someone kindly passed it on to me, & it could pick up several potential problems. Having said that, it is hard to stay disciplined on cumulative multi sector days, as energy levels are impacted.

[Sue Ridgepipe]

When setting flaps in after start scans, I always refer to the MCDU Perf page (which the PF should have set on his MCDU).
Likewise, when doing the before take-off checklist, don't respond until you've checked the EWD flap setting agrees with the MCDU perf page setting.

[Metro man]

I check the flap selector position as well giving me three items.

[Mach E Avelli]

Some operators don't allow flaps to be set in the after start or taxi scans until the Capt (or PF) calls for it. The aim (I suppose) being to prevent any pre-emptive moves.
One manufacturer had (and may still have) a rather bizarre SOP whereby after take-off the PF simply called for "climb sequence" and PNF reduced thrust, set speed bugs and retracted flaps with no verbiage whatsoever. That makes for a nice quiet cockpit, but goes a bit too far in the other direction, with the potential to turn to fertilizer when there is an engine failure or some other distraction.
When I did my training on that type at Flight Safety in the USA, they had wisely modified their version of the FCOM to require all flap moves to be called by PF and responded to by PNF as the lever was moved. PNF's hand had to stay on the lever until flaps were in position and were again called by PNF. By requiring three calls at every selection there was far less chance of a SNAFU (though of course still not impossible - nothing is impossible).

[Lookleft]

The sample checklist in the report is in fact the PF, PNF After Start flow pattern. As Bankstown stated, the checklist list response to "Flaps" is "CONFIG...".

Crews need to remain aware of the vigilance decrements that can
occur when they detect tiredness within themselves during the final sector of a busy duty day. Many research papers on fatigue, sleep and the circadian cycle are available to provide pilots and operators with further insights into the complex interaction of variables which may contribute to how a crew member performs their tasks if tired or fatigued.

How about not rostering multiple early starts with 4 sector days! How about a proactive airline introducing a proper FRMS rostering system and not waiting until 2016 when they will have to have one?

Sorry I forgot the crew were working for Jetstar, in which case the above questions are rhetorical and bear no resemblance to sound safety practices.

[framer]

A new automatic terminal information service (ATIS) was issued around the time of pushback. After the engine start the PM conducted his after start scan, but still retained a mental image of a 16L departure, leading to the selection of CONFIG 2 instead of CONFIG 1 + F. The PF did not monitor the PM or notice this error.
I am certainly not judging this particular crew as I have made a similar mistake myself after a change in conditions ( I was an F/O at the the time and the Capt picked it up on the taxi so I was lucky) , but, I do think the above highlights the importance of monitoring your mates selections/flows . Why would you not monitor them? ....because you are rushing.
If the F/O is selecting flap or other critical items like packs or anti-ice etc, we need to take the time to watch and think about what they are doing rather than looking out the window giving the thumbs up to the Engineer or ( heaven forbid) fiddling with our phones. It will take an extra 4 seconds to get moving....who cares?
Ps I agree with Lookleft above.

[The Green Goblin]

Could have been worse. Could have been config two figures with config one.

It happens occasionally. Usually picked up in checklist.

[Capn Rex Havoc]

Don't know what they use to calculate the Take off performance, i.e. an EFB or not, but not withstanding, our company has an SOP that if you are doing a runway change, when you calculate the new performance figures you are meant to force the config to the original flap setting.
That would have prevented this incident.
:ok:

[Snakecharma]

Mach, climb sequence on the Embraer works a treat.

We, as a general statement, speak far too much for the sake of saying words.

I often see instances where the pm calls "speed checked flap x" as soon as the pf calls for flap x when they are supposed to check the speed, select the flap and read the flap selection off the ewd.

Similarly on other aeroplanes we were forced to call spoilers when the manufacturer had no such call. The spoilers were automatically controlled, were not armed on approach and moving the lever backwards and forwards did nothing when on the ground in the landing config, so even if they didn't deploy the crew could no nothing about it. The focus should have been on where the aeroplane landed, how much runway remains and is it about to become an issue with undeployed spoilers.

Same applies to long briefings, they are a waste of time in my opinion..

[AerocatS2A]

Snakecharma, I agree in general, however the PM/PNF should be anticipating the call for flap and should have enough situational awareness that they already know the speed is good, it shouldn't need checking again. I expect to call for flap and get it (or get called on "speed" if I've stuffed up) what I don't expect is to call for flap and then have the PNF piss around for 20 seconds checking the ASI against the speed card etc. To me the mental process of the PNF should be, "speed is now good for the next flap setting, I expect the PF to call for the next flap soon." Then when the flap is called for the PNF has already checked the speed and can select the flap.

[morno]

So what happens if while the PM (not PNF) is doing something else, the speed goes back past the flap extension speed?

I disagree with your idea. The idea of the PM saying "Speed checked" is that the speed has indeed been checked at that time and it is not trending up past the extension speed.

morno

[framer]

I'm with Aerocat on this one.
On the last few thousand flights I've done I can't remember one time when the PM was 'doing something else' . There is too much talking as it is.

[Mach E Avelli]

"speed checked" is one of those gratuitous calls in the same camp as "inbound, no flags".
But one pilot commanding and the other acknowledging configuration changes is sound airmanship.

[morno]

And what's not to say the PF made an incorrect call to extend the flaps above VFE?

You're in a multi-crew aircraft, that means there's 2 people to check things before they're selected.

morno

[noclue]

FFS the flight deck is going to get pretty full if the PM/PNF/whatever can't do more than 1 thing at a time.
20s to check speed is below flap limit, give me a break!

[Mach E Avelli]

Extending flaps above VFE is unlikely to cause a crash. Not selecting them to the correct takeoff configuration could, and has, caused a crash (or several). But, to avoid the 'boy who cried wolf' scenario, we need to limit calls to the essentials.

On a related subject, I once flew for an airline which embraced 'fly-by-mouth'. If we were not yapping away constantly it was simply not good enough for the astronauts who controlled flight standards. So...as an experiment, on several pilots I tried reading the completely wrong checklist e.g. after takeoff checks before landing. The automated responses were generally exactly as per the wrong checklist being read. It was best to do this on the 4th sector of a busy day as the result was almost guaranteed. Which just went to show how programmed pilots had become to saying the words regardless, and how multiple sector days not only induce fatigue, but complacency.

[AerocatS2A]

Morno, I don't think you are getting what I'm saying. The PNF should have enough SA so that the speed really is checked, it was checked the moment before flap was called for and it was checked the moment after. The PNF should have constant awareness of the aircraft state and shouldn't have to take 5secs to check a speed.

I'll allow that if their attention is diverted then yes they should recheck the speed, but that is not what I see, I see guys sitting back fat dumb and happy and only once flap is called for do they check the speed. That bothers me. They should already know the speed of the aircraft, it shouldn't normally require a specific pause to check it again.

Another related thing I see is the airspeed gets passed a flap related bug, you call for the appropriate flap and they make a show of checking the bug against the speed card - dude, the bug's been sitting there staring at you since takeoff, could you not have checked its accuracy earlier? Even 5 knots before we got there would be fine.