QANTAS Pilots Distracted
Thread Starter
Join Date: Jan 2008
Location: Syndey AUSTRALIA
Age: 90
Posts: 4
Likes: 0
Received 0 Likes
on
0 Posts
QANTAS Pilots Distracted
Qantas pilots 'too distracted' to put down landing gear | thetelegraph.com.au
Seems as if high-tech needs to be higher to protect us from humans error
Seems as if high-tech needs to be higher to protect us from humans error
Seems as if high-tech needs to be higher to protect us from humans error
Join Date: Feb 2008
Location: PERTH,AUSTRALIA
Posts: 156
Likes: 0
Received 0 Likes
on
0 Posts
"There but for the grace of God go I"
I think most of us that have been in this industry for a while have thought this or something similar on these occasions.
There have been times when I have been grateful for a third pair of eyes on the flight deck to catch an error missed due to fatigue or multiple ATC changes etc.
We can all have a "Bad Day" and make mistakes,fortunately,we have benefitted
from the sacrifices of those the that went before us(If your new to this industry for a starter try "Fate is the hunter"-google it gen y}.
I believe that most real aviators take no satisfaction from the mistakes of others and use these opportunities to re-examine and critique their own standards.
I think most of us that have been in this industry for a while have thought this or something similar on these occasions.
There have been times when I have been grateful for a third pair of eyes on the flight deck to catch an error missed due to fatigue or multiple ATC changes etc.
We can all have a "Bad Day" and make mistakes,fortunately,we have benefitted
from the sacrifices of those the that went before us(If your new to this industry for a starter try "Fate is the hunter"-google it gen y}.
I believe that most real aviators take no satisfaction from the mistakes of others and use these opportunities to re-examine and critique their own standards.
Join Date: Oct 2011
Location: The Lab
Posts: 2
Likes: 0
Received 0 Likes
on
0 Posts
Spot on, RATpin, just another lesson at someone else's expense.
Having said that, I like to think that I own my errors. The PF reported the transfer to the tower frequency at 8nm was late?! Sounds like that SA didn't improve much once their feet hit the ground. But the save-your-ass-by-slinging-mud-at-anyone-else-you-can-think-of defence mechanism sure kicked in!
Having said that, I like to think that I own my errors. The PF reported the transfer to the tower frequency at 8nm was late?! Sounds like that SA didn't improve much once their feet hit the ground. But the save-your-ass-by-slinging-mud-at-anyone-else-you-can-think-of defence mechanism sure kicked in!
Nunc est bibendum
That's probably when they discovered. It approaching 500' a lot of us do an airliner equivalent of a PUFF check that includes check list complete. Probably realised they hadn't done the check and then worked out why.
Been in similar circumstances myself into BNE in crappy weather. ATC advised a bunch of information on hand over- just prior to 2000', quick back and forward between F/O and myself, change of procedures, ATC again with more info, clarification from me, etc, etc. Lots going on and sometimes stuff gets missed. Picked it up at 1700' when I looked across to call F30 and realised that I'd missed the previous step. I kicked myself very, very hard for that one after the fact. Not one of my better days. Twas a red eye so no doubt that played a part but still dirty on myself.
The report on this one says that 'fatigue wasn't a factor' but I'd like to know the pattern. Either way it's either an 0500 report or an 0515 report. If they were on an overnight in MEL then wake up time is somewhere between 0355 and 0410. Possibly earlier if they were MEL based and starting the day's work. Was it first day, second day, third day of early starts?
I wonder if they had something anything to eat as well. Probably didn't eat the crew snack- does anyone?- and I wonder if they were appropriately nourished? (You're a little high there John. Wasn't that one due in part to blood sugar levels?).
I like this quote too:
That means it was going flat stick most probably. Monday morning too.
Not excusing it, just pointing out some things that can make those holes in the swiss cheese significantly bigger than they may be at other times. A timely reminder to work hard on avoiding those errors folks- particularly in these sensitive times.
Been in similar circumstances myself into BNE in crappy weather. ATC advised a bunch of information on hand over- just prior to 2000', quick back and forward between F/O and myself, change of procedures, ATC again with more info, clarification from me, etc, etc. Lots going on and sometimes stuff gets missed. Picked it up at 1700' when I looked across to call F30 and realised that I'd missed the previous step. I kicked myself very, very hard for that one after the fact. Not one of my better days. Twas a red eye so no doubt that played a part but still dirty on myself.
The report on this one says that 'fatigue wasn't a factor' but I'd like to know the pattern. Either way it's either an 0500 report or an 0515 report. If they were on an overnight in MEL then wake up time is somewhere between 0355 and 0410. Possibly earlier if they were MEL based and starting the day's work. Was it first day, second day, third day of early starts?
I wonder if they had something anything to eat as well. Probably didn't eat the crew snack- does anyone?- and I wonder if they were appropriately nourished? (You're a little high there John. Wasn't that one due in part to blood sugar levels?).
I like this quote too:
The radio traffic on all frequencies during the descent and approach into Sydney was not unusual fort hat time of day.
Not excusing it, just pointing out some things that can make those holes in the swiss cheese significantly bigger than they may be at other times. A timely reminder to work hard on avoiding those errors folks- particularly in these sensitive times.
Join Date: Apr 2008
Location: Australia
Posts: 15
Likes: 0
Received 0 Likes
on
0 Posts
Long shift, early start, long run, " (not) appropriately nourished"...ATC providing information. "The fatigue wasn't a factor" but I was on the "red eye".
What about, I didn't do what I should have done...I was wrong....................................never!!!
What about, I didn't do what I should have done...I was wrong....................................never!!!
Join Date: Aug 2011
Location: Australia
Posts: 423
Likes: 0
Received 0 Likes
on
0 Posts
But what about the complex and dare I say superfluous amount of "SOP guff" that is foisted upon the Qantas crew as revealed in the lengthy ATSB report. Heads Free/ Heads down and all that bewildering amount of calls and switching of roles to remember on the approach. Has not QANTAS heard of the KISS principle?
Good to see that humans can learn from their mistakes. A pilot induced mistake is usually an end result of errors or poor judgment made by others before hand such as ATC trying to squeeze us all in with min delay.
I believe in a 2 crew environment that the PF ought to have a smaller picture of what's going on round him/her than the PNF. That way the PF can concentrate on the 'minding the shop' philosophy where as the PNF can look at the big picture all around them. PF fly's the plane inc it's configuration, looking ahead (if VMC) towards the rwy (if aligned)forming that part of the picture of where he's going and limit what you try to comprehend with regards to what's going on around you as the human brain is a finite peace of equipment with a break down point.
SOP's are a good thing, there to make us all do the same thing at the same time to reduce errors but they can also be just a guide at times. You can make 10 airframes identical but you will never make 10 pilots the same.
Procedures & A/C design/equip are just a back up which worked in this case.
Wmk2
I believe in a 2 crew environment that the PF ought to have a smaller picture of what's going on round him/her than the PNF. That way the PF can concentrate on the 'minding the shop' philosophy where as the PNF can look at the big picture all around them. PF fly's the plane inc it's configuration, looking ahead (if VMC) towards the rwy (if aligned)forming that part of the picture of where he's going and limit what you try to comprehend with regards to what's going on around you as the human brain is a finite peace of equipment with a break down point.
SOP's are a good thing, there to make us all do the same thing at the same time to reduce errors but they can also be just a guide at times. You can make 10 airframes identical but you will never make 10 pilots the same.
Procedures & A/C design/equip are just a back up which worked in this case.
Wmk2
Nunc est bibendum
Tower boy. I did say I was wrong but those with a confirmation bias to bag out others tend not to see that.
Of course those with even a basic understanding of CRM know that there can often be other things that lead to being 'wrong'. Those that don't understand those issues, and are therefore unable to work to mitigate them, are the real danger. So which are you?
Of course those with even a basic understanding of CRM know that there can often be other things that lead to being 'wrong'. Those that don't understand those issues, and are therefore unable to work to mitigate them, are the real danger. So which are you?
Join Date: Mar 2007
Location: Roguesville, cloud cuckooland
Posts: 1,197
Likes: 0
Received 16 Likes
on
5 Posts
Can someone point out to me a post from a bona-fide QF pilot that states they never make errors?
Qantas has a safety culture. That is not the same as saying they never make errors. Every pilot in every airline makes errors from time to time. What makes a safety culture is how those errors are addressed.
I'd bet my fourth stripe that this crew self reported. We already know they went around as they discovered their error. We all know airlines that would have done neither.
I personally came within a few hundred feet of doing the same thing a few years ago. I went around even though the GPWS hadn't gone off and I self reported. The circumstances; distractions and weather, were very similiar. Does that make me an unsafe pilot?
The level of immaturity displayed by some of these posts is disturbing. Are you really professional pilots?
Qantas has a safety culture. That is not the same as saying they never make errors. Every pilot in every airline makes errors from time to time. What makes a safety culture is how those errors are addressed.
I'd bet my fourth stripe that this crew self reported. We already know they went around as they discovered their error. We all know airlines that would have done neither.
I personally came within a few hundred feet of doing the same thing a few years ago. I went around even though the GPWS hadn't gone off and I self reported. The circumstances; distractions and weather, were very similiar. Does that make me an unsafe pilot?
The level of immaturity displayed by some of these posts is disturbing. Are you really professional pilots?
Join Date: Apr 2000
Location: Oz
Posts: 754
Likes: 0
Received 0 Likes
on
0 Posts
It's too easy to say "well you just screwed up".
It takes a bit more thought and application to assess the contributing factors as to why that screwup might have occurred. It's not like they didn't put the gear down because they couldn't be bothered that day.
It takes a bit more thought and application to assess the contributing factors as to why that screwup might have occurred. It's not like they didn't put the gear down because they couldn't be bothered that day.
'P Dub' I didn't actually say ATC made errors of judgment with ref to this particular event, the words 'such' and 'or' where added to avoid any actual blame of anyone agency or individual in this case. It was of a generic nature in the opening of my post. ATC make errors & poor judgment just like the rest of us, 'tis human to err inc ATC. The stupidity of Pollies & their curfew crap are to blame a lot in these cases.
Wmk2
Wmk2
Join Date: Oct 2011
Location: The Lab
Posts: 2
Likes: 0
Received 0 Likes
on
0 Posts
There's a difference between finding the contributing factors to a safety incident and defensive blameshifting. ATC have already been mentioned in this thread half a dozen times, when I can't see one single aspect about this particular incident that warrants their mention. In 15 odd years of operating at Sydney I could count on the fingers of one hand the number of times I've been transferred to the tower frequency EARLIER than 2500' (excluding those silly PRM thingies). I'm not saying they don't make mistakes like the rest of us do, but why did the PF see the need to make the point to an ATSB investigator that this was a late transfer and cause of distraction?
As someone interested in CRM and wider human factors in aviation I see James Reason's model increasingly and incorrectly used to fling crap at as many factors as someone's mind can grasp so that they can lessen their own feelings of guilt. In the end, no-one 'owns' anything because we can dish off 2% here, 5% there etc. "It's always someone else's fault." And it's not just aviation...
As someone interested in CRM and wider human factors in aviation I see James Reason's model increasingly and incorrectly used to fling crap at as many factors as someone's mind can grasp so that they can lessen their own feelings of guilt. In the end, no-one 'owns' anything because we can dish off 2% here, 5% there etc. "It's always someone else's fault." And it's not just aviation...
Join Date: Aug 2011
Location: Australia
Posts: 423
Likes: 0
Received 0 Likes
on
0 Posts
That way the PF can concentrate on the 'minding the shop' philosophy where as the PNF can look at the big picture all around them.
In 15 odd years of operating at Sydney I could count on the fingers of one hand the number of times I've been transferred to the tower frequency EARLIER than 2500' (excluding those silly PRM thingies).
What about, I didn't do what I should have done...I was wrong
At least pilots are only distracted for a few seconds.
Geoff Dixon has stated that management was so distracted they didn't really do their jobs for more than six months. And (unlike the company) pilots didn't wreck the jet!
We don't get paid Wirth's $1m, but that shouldn't stop us having a go. Full page ad in the Tele stating same??
The only things the pilots didn't achieve was a massive bonus for a job well done!
Geoff Dixon has stated that management was so distracted they didn't really do their jobs for more than six months. And (unlike the company) pilots didn't wreck the jet!
We don't get paid Wirth's $1m, but that shouldn't stop us having a go. Full page ad in the Tele stating same??
The only things the pilots didn't achieve was a massive bonus for a job well done!