Aviate, SOP, Navigate, Communicate

[RatherBeFlying]

Rostov, Singapore and Dubai (along with many less recent examples) lead me to propose an amendment to our major priority list.

It appears to me that SA and flying the airplane have become eroded by SOP doctrines such that attention to aircraft control in the x y z axes has become compromised at critical times.

SIA deserves inclusion because it seems (pending AAIB report) attention to checklists overtook cockpit attention to a major fire threat – that most thankfully remained under control.

Normally Tech Log would be the proper forum, but the recent occurrences and active discussion of them lead me to start this discussion in R&N

[dontdoit]

Wasn't that also where the guys on Swissair 111 came unstuck faced with a serious airborne fire? A desire to get checklists completed at the expense of sticking the jet on the ground at the earliest opportunity - and at least one of the crew was a fairly senior instructor at the airline too. RIP, there but for the grace of ... etc.

[Lonewolf_50]

Don't let them bully you into it.
Aviate, Navigate, Communicate. If the SOP isn't written to support that priority, then the SOP is part of the problem.

[Piltdown Man]

The navigational element has always been continue, divert or return. To my knowledge, no checklist has ever said "Do not land now". The problem that pilots face is which bits of the checklist do we ignore due to lack of time. Too many want to achieve perfect checklist execution. My preference is to land and complain about the rubbish in the checklists and the fact it could not be completed before landing.

PM

[hoss183]

Lets not forget that Capt Sullenberger forgot some checklist items when landing (Outflow valves). Personally i would rather fly with him than a SOP obsessed captain who continues to circle in a burning plane.

[RexBanner]

In Sullenberger's case it wasn't that the outflow valve was forgotten, they just didn't have the luxury of time. The ditching checklist is a long one.

[flydive1]

In my aircraft the ditch switch is the first item on the check list, and is a memory item.

At which point of the check list is in the Airbus?

[Chronic Snoozer]

Whats that saying 'guidance of wise men, blind obedience of fools'?

[albatross]

Flydive 1
Perhaps that checklist came out after Sully's yatching event in the river?
Just asking.

[Juan Tugoh]

Whats that saying 'guidance of wise men, blind obedience of fools'?

The trouble is there are far too many fools that think they are wise men and will use this trite little phrase to justify their deviation from well and hard won rule sets, thinking that they know better because they are "wise men"

[flydive1]

Flydive 1
Perhaps that checklist came out after Sully's yatching event in the river?
Just asking.

"Well, looks like we are going into the water"

Memory item, push the ditch switch.

1 second, done.

Just saying

[AerocatS2A]

"Well, looks like we are going into the water"

Memory item, push the ditch switch.

1 second, done.

Just saying
Yeah but, was that checklist like that prior to Sully's event?

I know our completely unrelated type had a new set of memory items in response to Sully's ditching. We now have a "Loss of all engines at low altitude" set of memory items that was in direct response to the A320 ditching.

[compressor stall]

The entire A320 ditching checklist was changed after Sully's accident.

[Yaw String]

Ditching in a Boeing..777/787..OPO U30..FA...that's it,not difficult to learn!
Having seen those flocks of geese around Dubai,in the evenings....Off 30L,not much time to go for the checklist..however,with the island building going on,it may be difficult to find the water..!!!!!

[Double Back]

The comment about the "forgotten" outflow valves is outrageous, I hope commenters will never have to face a comparable situation.
From the failure they initially decided to return, that became impossible so they changed that into Teterboro, and when that did not proved feasible, it became the Hudson. Writing these sentences took me longer.
Three major decisions in a short time span under super high stress.

That crew got everyone safe down in an extreme emergency in a scenario even the meanest sim instructor would never have dared to present to a crew.

They did not "forget" is, they skipped it because they concentrated on the main elements of the emergency. And that saved the day for all, the fact that it sunk a bit faster afterwards is comment from armchair and hobbysim pilots.

I had a few moments in my career during which I probably would not have been able to recall my first name.

[flydive1]

:rolleyes::rolleyes:

[Ian W]

The comment about the "forgotten" outflow valves is outrageous, I hope commenters will never have to face a comparable situation.
From the failure they initially decided to return, that became impossible so they changed that into Teterboro, and when that did not proved feasible, it became the Hudson. Writing these sentences took me longer.
Three major decisions in a short time span under super high stress.

That crew got everyone safe down in an extreme emergency in a scenario even the meanest sim instructor would never have dared to present to a crew.

They did not "forget" is, they skipped it because they concentrated on the main elements of the emergency. And that saved the day for all, the fact that it sunk a bit faster afterwards is comment from armchair and hobbysim pilots.

I had a few moments in my career during which I probably would not have been able to recall my first name.

It sunk a little faster afterwards due to a passenger opening one of the rear doors which was close to underwater - against the instructions from the crew.

Sounds familiar from another thread here - it was obviously a 'no brainer'.

[sheppey]

I notice in various syllabus of type rating and recurrent training in jet transport simulators, that loss of thrust on both engines is included. It is a QRH item. The checklist always assumes one engine comes good and its a happy ending. Box ticked.. Next sequence please.

But what if either engine cannot be restarted? It has happened. Then you have no choice but (force) land at the nearest airport/flat ground/ocean. That being so, how come airline pilot simulator training does not include a practice dead stick landing (say) from 25,000 feet? After all it has happened over the years. We spend endless simulator hours on LOFT exercises as well as probably 90 percent of simulator training being on automatics. Repeat ad nauseum each cyclic training.

In fact, unless you have experienced this event (dead stick forced landing) in a simulator several times (there is considerable judgement skill required) the chances of crashing are high. Indeed very high. Granted, simulator time is not a revenue generator. But what training is allotted needs to be prioritised. Automation practice is fine. But a pilot gets that in line flying for 95 percent of his career. The weak link in the chain is invariably the crew as we have seen countless times. No pilot can reasonably claim he can successfully force land a jet or turboprop airliner at first go. It requires manual flying at its most skilful. Yet no priority is allotted for crews to practice a dead stick approach and landing from altitude.

[JW411]

I used to do that regularly in the sim whenever we had 10 minutes or so to spare at the end of a slot. 10,000 feet or so above somewhere like Geneva; good weather, engines (four) not recoverable.

Most crews made a reasonable job of it and got down to the extent that they would have walked away from the aeroplane.

The biggest surprise was how late they had to leave lowering the gear (bearing in mind emergency lowering). I well remember one captain who was continually pestered by the F/O to lower the gear, got it just right and obtained three greens about 10 seconds before touch down! They made a perfect flapless landing.

[hoss183]

@ Double back - That was exactly my point, he made a heroic ditch saving all lives, who cares the SOP or checklists werent perfect.

[Double Back]

Sheppey.
We had things like that once in a while, however planes like a 747 are not really supposed to fly the whole envelope at N-4.... If I remember correctly, the windmilling engines would not generate enough hydraulic power during speeds below 250 kts after extending flaps (electrically), so one could or would run out of control.
As an APU was not always available to get the hydraulics going.

The one time I did it, the SIM lost it shortly before "landing". Programming was just not sufficient in that region.

One can exaggerate SIM training into scenarios that are so remote, that one could end up in "negative" training, so it would backfire and scare people into psychological problems. Nobody wants a result like that. Training is a delicate business, not as easy as some think. Parallel to increasing skills, self confidence should grow in harmony. But the last one can easily be damaged trying to max out the first one.

That is the reason why SIM instructors have their hands at "freeze" button, when things are likely to run into a crash scenario. I have never witnessed it, but those who did say the last seconds were horrendous realistic.

In my GA flying I once got a student whose previous instructor had him drop into a spin with a Cub, during training stalls. Not briefed before, not warned, nothing.
He learned to fly in the end but never really got rid of that anxiety.

[Schnowzer]

What a ludicrous thread! Crews screw up SOPs when not under pressure, what makes anyone think that putting SOPs into ANC will save startled crew members, under extreme circumstances, that are simply not processing information? Their brains have shut down and they need to get thinking again; they are not screwing the SOPs up because they are thinking...

The biggest problem in the aviation industry is cultural. All the HF guys and girls tell us it is a human trait to make mistakes. We can't f...ing help it; we are all, human. All the pilots accept that tenet and even talk about it to their mates. We then tell crews to avoid errors if they can, trap them if possible and if not to mitigate the effects of the error.

Then the real world intervenes and it is just not good enough. A crew screws-up, makes a mistake and then does exactly what we want them to and make the very best of the circumstances they now find themselves in.
What do we do? Congratulate them? Nope we say "you shouldn't gave made that 'human' error, you need (select your airline):

A. A low grade
B. more training
C. a punishment
D. firing

Until the industry and all the hindsight Harry's on PPrune wise up and accept that we need to really accept that errors will happen; train people to have the basic competencies to do well in trying circumstances, SOP be damned; nothing will change.

[Arewerunning]

Problem is, the new generations of pilots " a la MPL dct to AIRBUS" -British educated- are starting to be a majority...and they believe the **** they have been fed during training and normal line flying. They are already starting to be in flight ops management positions: there is no way you will be able to change their views...

1-SOPs SOPs SOPs
2- ap on at 200ft
3- ap off at 200ft.
4- visual? It is dangerous!!!!!!!!!!!
5- you are freezing in the cockpit because of trim air malfunction? We have to txt to company before switching off pack number one....
6- I go pee? Let me confirm ATC clearance when you are back...
7- manual thrust? Is not SOP
8- airbus design? The best in the world...( they don't even understand what happen in open descent mode)
9- before aligning IRS let me confirm the position coordinates with u...
10- are you sure you want to use manual braking?

It's just crazy....

[Discorde]

As an instructor (now retired) it always troubled me that the B757/767 QRH did not cover the dead stick landing case. As with other posters on this thread, if time allowed I would include it in sim sessions. Some guidance was published in the paper 'How To Do Well In The Sim' (http://steemrok.com/howtodowellv4) but this guidance was 'unofficial'.

[Zaphod Beblebrox]

I have to weigh in on the Sullenberger case. I fly for the former US Airways, on the 320, and have flown with Sully. He abandoned the checklist all together because he knew that he could never get through it. I am looking at the A320 QRH, it has been amended since Jan of 2009, but "start the APU" is way down the second page of a two page procedure. Sully jumped right to that and the NTSB report lauded him for it.

Accident Report
NTSB/AAR-10/03
PB2010-910403

"Although the flight crew was only able to complete about one-third of the Engine Dual Failure checklist, immediately after the bird strike, the captain did accomplish one critical item that the flight crew did not reach in the checklist: starting the APU. Starting the APU early in the accident sequence proved to be critical because it improved the outcome of the ditching by ensuring that electrical power was available to the airplane. Further, if the captain had not started the APU, the airplane would not have remained in normal law mode. This critical step would not have been completed if the flight crew had simply followed the order of the items in the checklist."

The NTSB also noted that the checklist itself was not designed for the scenario of flight 1549:

1.17.1.2 US Airways Engine Dual Failure Checklist
According to Airbus, the Engine Dual Failure checklist was originally developed “based on the highest probability in time of exposure that a dual engine failure would occur.” Because Airbus airplanes spend much more time at higher altitudes and, therefore, a dual-engine failure had the highest probability of occurring at a high rather than a low altitude, Airbus designed the Engine Dual Failure checklist for the occurrence of a dual-engine failure above 20,000 feet. Airbus indicated that it had not considered developing a dual-engine failure checklist for use at a low altitude.

Sully, a former F-4 pilot, had the fighter pilot mentality and history of a lot of "Bold Face" memory items. When you are the only person in a really fast airplane that glides like a brick you will not have a lot of time to read stuff about what to do. You need to have the the major items memorized so you can do what you need to do while you "Aviate, Navigate and Communicate."

You don't allow the checklist to get in the way of that.

[HamishMcBush]

You need to have the the major items memorized so you can do what you need to do while you "Aviate, Navigate and Communicate."

You don't allow the checklist to get in the way of that.

Amen to that

[PLovett]

Problem is, the new generations of pilots " a la MPL dct to AIRBUS" -British educated- are starting to be a majority...and they believe the **** they have been fed during training and normal line flying. They are already starting to be in flight ops management positions: there is no way you will be able to change their views...

1-SOPs SOPs SOPs
2- ap on at 200ft
3- ap off at 200ft.
4- visual? It is dangerous!!!!!!!!!!!
5- you are freezing in the cockpit because of trim air malfunction? We have to txt to company before switching off pack number one....
6- I go pee? Let me confirm ATC clearance when you are back...
7- manual thrust? Is not SOP
8- airbus design? The best in the world...( they don't even understand what happen in open descent mode)
9- before aligning IRS let me confirm the position coordinates with u...
10- are you sure you want to use manual braking?

It's just crazy....

Your scaring me now. It just seems so bleedin' obvious that that approach is a spiral dive to industrial level homicide.

Having just done my company's HF refresher units for the year, it made the point that SOPs' were good for those occasions when time was critical but that they couldn't cover every eventuality or indeed need to when there was time to consider options.

With Sully and flight 1549 he recognised that time was limited but not critical and SOPs' could not apply. He used his aviation knowledge to achieve a best outcome. I doubt that there are many cadet trained airline pilots who could reach that level of aviation knowledge ever as their training would appear to cover the usual but not the unusual.

[crablab]

I doubt that there are many cadet trained airline pilots who could reach that level of aviation knowledge ever as their training would appear to cover the usual but not the unusual.

Might this be another reason modular is better than integrated! :E

[Double Back]

During my airline life I used to go walking in many cities, no plan, just see where my feet would bring me.
It is at least 30 years ago, forgot the city where it was, but I got to a freighter harbour. Dirty, smelly, noisy, rusty ships, almost eerie and a bit scary as it had gotten dark. An odd guy passing by, not interested in any human contact. The picture is still vivid as I write this.
Aviation was still in its heydays, good salaries on most carriers, fancy hotels, lots of good training where cost was not an issue (my company FLEW hundreds, if not thousands of dedicated training hours at that time.)

I never forgot the thing that crossed my mind then. Shipping was a top industry once also, why it had slid down to this level? Will aviation descend to this sorrow level also in the future? I laughed at myself, thinking: naah, can't, impossible. Walked back happy.

Sigh...

[mrdeux]

Re Sully and the ditch switch....

Going by the images of the recovered aircraft's aft fuselage, I doubt that the outflow valves would have made the slightest difference one way or the other.

[Double Back]

TA

I used to refer to the 744 as a big C172. Meaning, all basics are there. You can fly it with just the IAS working. I loved to fly it manual when conditions allowed it, but not to all expense.
If conditions were right, I did it from 15000' or so, anyway with large speed and configuration changes included. Then You really feel how the plane behaves. A "manual" landing with a disconnect from 500' and a full configured, trimmed plane is just barely adding to one's skills.

There are a few points to be taken into consideration however. When the PF decides he/she likes to fly manual, the workload for the PNF dramatically increases, now all settings, even turning the heading bug, he/she needs to do per command, plus checklists, R/T. So You loose partly Yr buddy, and with it his/her backup.
In a busy environment like LAX, ORD or JFK that is not always wise especially during peak hours. However if those are Your homebases, it might be different.
PAX paid their tickets to get there the safest way. That too much automated flying erodes pilot skills is not their problem.

Tired after a long flight, marginal weather during the approach, are valid enough to make a wise decision and skip yr "training" to the next opportunity.

Using GA flying as a surrogate not completely replaces manually flying an airliner. And it is not w/o danger, each year airline pilots loose their life in GA planes. In about 40 years of commercial flying I lost at least five friends/colleagues in GA related accidents, "only" one to an airline accident.

[LLuCCiFeR]

Of course something needed to be done about the wild gung-ho cowboy days of the past, but what we currently see is the sad product of office/management pilots (avoiding fatigue and avoiding having to make real decisions in real life line flying, by escaping into a cozy 9-5 job :rolleyes:) who need to justify their pathetic postholder positions by constantly reinventing the wheel and wanting to rule out any eventuality by churning out new or different SOP's on a daily/weekly basis. :=

Unfortunately the current strict SOP "Befehl ist Befehl" ("orders are orders") mentality has gone way too far, but this 'blindly-following-orders' mentality has turned out very useful when it comes to renegotiating contracts. :suspect:

Isn't it a coincidence that the increase in CRM and blindly sticking to SOP's are inversely related to the deterioration of T&C's in our industry over the last 20-30 years? Is safety compromised by introducing and brainwashing an entire generation of pilots that "being nice" and "sticking to SOP's" is good for safety?

When I fly with some older colleagues I notice that they are much more relaxed, a bit more casual (but definitely not unsafe!) with SOP's and not necessarily true CRM miracles, yet when it comes to the company trying to screw us over they usually don't take any sh!t either and are not afraid to slam their fist on the table.
The younger and friendlier "nice guys" (CRM champions) on the other hand are shaking like a leaf on a tree and will sign any lousy contract in order to avoid a confrontation with management. :ugh:

[aguadalte]

PM: The navigational element has always been continue, divert or return.

That's a wrong/simplistic view of the Navigational element of the major priority list. It means (among other things) know where you are, avoid CFIT, keep your SA regarding terrain awareness while you decide to continue, divert or return.

[Piltdown Man]

Aguadalte - You are absolutely correct. But that is what we are paid to do. All the time.

PM

[RealUlli]

Using GA flying as a surrogate not completely replaces manually flying an airliner. And it is not w/o danger, each year airline pilots loose their life in GA planes. In about 40 years of commercial flying I lost at least five friends/colleagues in GA related accidents, "only" one to an airline accident.
(SLF here)

However, from what I've read, both Sully and the Gimli Glider Pilot had been flying gliders in their spare time and put that training to good use.

I don't know about other incidents/accidents/crashes where this might have played a role, but I think I see a pattern - a pilot of a GA plane is required to do ANC because there are not that many SOPs...

What do you think?

[Sicofit]

All this business with checklists and completing them reminds me of the saying; the operation was a success but the patient died. When are we going to remember that we should just fly the aircraft and safely.

[LLuCCiFeR]

All this business with checklists and completing them reminds me of the saying; the operation was a success but the patient died. When are we going to remember that we should just fly the aircraft and safely.Perhaps because the CFO, CEO and shareholders have no clue about safety, and instead prefer cheap and docile pilots who are easily scared into signing constantly degrading T&C's? :rolleyes:

A hull loss once in a while is merely a convenient reminder for all the other pilots to study those SOP's and be even more scared for their job, the flight data department and line checks. :E

[crablab]

Just on the topic of Sully and his ditching, it appears there is a film coming September 9th - Trailer Here (https://www.youtube.com/watch?v=kODNqB64nMI&feature=youtu.be)

[LLuCCiFeR]

Problem is, the new generations of pilots " a la MPL dct to AIRBUS" -British educated- are starting to be a majority...and they believe the **** they have been fed during training and normal line flying. They are already starting to be in flight ops management positions: there is no way you will be able to change their views...

1-SOPs SOPs SOPs
2- ap on at 200ft
3- ap off at 200ft.
4- visual? It is dangerous!!!!!!!!!!!
5- you are freezing in the cockpit because of trim air malfunction? We have to txt to company before switching off pack number one....
6- I go pee? Let me confirm ATC clearance when you are back...
7- manual thrust? Is not SOP
8- airbus design? The best in the world...( they don't even understand what happen in open descent mode)
9- before aligning IRS let me confirm the position coordinates with u...
10- are you sure you want to use manual braking?

It's just crazy....
Hahaha! Spot on! (and sounds awfully familiar :\ )