SQ286 return to AKL with tail strike damage.
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Captain got load sheet.
Read out wrong figure to F/O (230t instead of 330t)
Captain was recently off airbus (used to lower weights)
Captain, F/O and third pilot in jump seat all missed this. (poor form I would hasten to say)
Result V speeds 20-30 knots slower than rqrd.
SIA fmc's don't give V speed predictions based on weight like Qf machines. They just have blank lines to be entered by crew. Thus a huge discrepancy of numbers didn't stand out.
F/O's tkoff. Basically re-created boeing's min unstick test.
Broke the fire loop in tail. Unresolved fire warning.
Hence the shenanigan's back on to terrafirma.
$$$$ ouch
Read out wrong figure to F/O (230t instead of 330t)
Captain was recently off airbus (used to lower weights)
Captain, F/O and third pilot in jump seat all missed this. (poor form I would hasten to say)
Result V speeds 20-30 knots slower than rqrd.
SIA fmc's don't give V speed predictions based on weight like Qf machines. They just have blank lines to be entered by crew. Thus a huge discrepancy of numbers didn't stand out.
F/O's tkoff. Basically re-created boeing's min unstick test.
Broke the fire loop in tail. Unresolved fire warning.
Hence the shenanigan's back on to terrafirma.
$$$$ ouch
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Straits Times reported that....
"The pilot, 49, is believed to have been with SIA for about two years but has about 20 years of flying experience. He and the first officer will continue to receive their base salary, but without any flight bonus."
So putting it all together the PIC has been at SQ for two years and has just come off the 340 onto the 744. We are also saying he is dyslexic and the other two missed the transposed figures.
Then noone noticed the low V numbers and the FMC doesn't have the idiot check installed.
They then failed to make haste slowly and missed the first approach.
Excuse my cynicism, but something doesn't quite gel.
"The pilot, 49, is believed to have been with SIA for about two years but has about 20 years of flying experience. He and the first officer will continue to receive their base salary, but without any flight bonus."
So putting it all together the PIC has been at SQ for two years and has just come off the 340 onto the 744. We are also saying he is dyslexic and the other two missed the transposed figures.
Then noone noticed the low V numbers and the FMC doesn't have the idiot check installed.
They then failed to make haste slowly and missed the first approach.
Excuse my cynicism, but something doesn't quite gel.
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Now I'm a bit confused. Flew the B744 for ten years with SIA.
Standard procedure when preparng the a/c: insert estimated ZFW into FMC, (taken from CFP), aircraft fuelled to required state, this would automatically give an estimatedTO weight, when the load sheet arrived verify and amend FMC as necessary, there must have been a massive discrepancy staring them in the face?
I have been away a while now but was always under the impression that the FMC did give estimated Vspeed numbers which would only blank when the de-rated (assumed) temperature was inserted?
Have heard from friends within SIA that it was indeed an error in the FMC, difficult to understand how it was missed though.
Standard procedure when preparng the a/c: insert estimated ZFW into FMC, (taken from CFP), aircraft fuelled to required state, this would automatically give an estimatedTO weight, when the load sheet arrived verify and amend FMC as necessary, there must have been a massive discrepancy staring them in the face?
I have been away a while now but was always under the impression that the FMC did give estimated Vspeed numbers which would only blank when the de-rated (assumed) temperature was inserted?
Have heard from friends within SIA that it was indeed an error in the FMC, difficult to understand how it was missed though.
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The near tragedy of SQ286 has allowed us the privilege of learning from the unfortunate mistake of other professionals in our fragile industry.
The transposition of 2's and 3's in the culture, which surrounds us here, is not quite a daily event, but better than weekly in daily life and no less often in aviation which has so eventfully been demonstrated.
As a family we will get 2 instead of 3 or vv in shops, money amounts and floor levels just as examples.
English was NOT the first language of any of the crew involved just to add to the chances of an error.
Pressure, time constraints and the stress of the early days of a new type command all add to the scenario of 286.
Also the statistical gurus will also point to the graphs, which highlight that this crew fell into the so-called "high risk" exposure in hours of any new aircraft type.
The 3 Pilots and the rest of us will hopefully know the results of the Operational Investigation shortly and all will proceed with our lives, altered as well they may be.
Many previous and all current Pilots for SIA will watch, wait and pass judgement on the SIA decision on the fate of our unfortunate colleagues. Past events can cause us to have very firm opinions on the expectations and even the results in this matter.
SIA has, in spite of itself, has begun the process of metamorphosis in Flight Operations and in my own recent case, was seen to be fair and professional in its deliberations.
I dont exuse the past or predict the future, only call as happens to myself.
All that aside, it beholds us to be ABC ( Awfully Bloody Careful) out there and try to delay the next error in our own lives.
After all of 43 years in this Industry I still have to meet a pilot who hasn't made a mistake, even if it's to lie he never has!!!
C YA
The transposition of 2's and 3's in the culture, which surrounds us here, is not quite a daily event, but better than weekly in daily life and no less often in aviation which has so eventfully been demonstrated.
As a family we will get 2 instead of 3 or vv in shops, money amounts and floor levels just as examples.
English was NOT the first language of any of the crew involved just to add to the chances of an error.
Pressure, time constraints and the stress of the early days of a new type command all add to the scenario of 286.
Also the statistical gurus will also point to the graphs, which highlight that this crew fell into the so-called "high risk" exposure in hours of any new aircraft type.
The 3 Pilots and the rest of us will hopefully know the results of the Operational Investigation shortly and all will proceed with our lives, altered as well they may be.
Many previous and all current Pilots for SIA will watch, wait and pass judgement on the SIA decision on the fate of our unfortunate colleagues. Past events can cause us to have very firm opinions on the expectations and even the results in this matter.
SIA has, in spite of itself, has begun the process of metamorphosis in Flight Operations and in my own recent case, was seen to be fair and professional in its deliberations.
I dont exuse the past or predict the future, only call as happens to myself.
All that aside, it beholds us to be ABC ( Awfully Bloody Careful) out there and try to delay the next error in our own lives.
After all of 43 years in this Industry I still have to meet a pilot who hasn't made a mistake, even if it's to lie he never has!!!
C YA
Moderate, Modest & Mild.
Yoy beat me by a whisker, Greybeard
The fact that none of the crew were native English speakers, but were communicating in that language is a only one factor that needs to be taken into consideration - I understand that each of the crew members on the flight deck that day were of different races.
As you have pointed out, something that seems very common in Asia, and not only Singapore, is the pronunciation (transposition) of 2 to 3, and 3 to 2.
It is an area that needs particular attention when native English speakers are dealing in these two numbers.
From my experience with SQ, I also would like to know the preceding crew patterns, the rest period in AKL (or CHC), and the reporting time in New Zealand.
New Zealand is 5 hours ahead of Singapore.
I recall one of the New Zealand trips for which I was rostered with SQ, had been preceded by an 8 day States trip, followed by 4 days "Off", and then the trip Down Under.
The circadian cycles are shot for a six - but crew scheduling apparently don`t give this consideration!
The fact that none of the crew were native English speakers, but were communicating in that language is a only one factor that needs to be taken into consideration - I understand that each of the crew members on the flight deck that day were of different races.
As you have pointed out, something that seems very common in Asia, and not only Singapore, is the pronunciation (transposition) of 2 to 3, and 3 to 2.
It is an area that needs particular attention when native English speakers are dealing in these two numbers.
From my experience with SQ, I also would like to know the preceding crew patterns, the rest period in AKL (or CHC), and the reporting time in New Zealand.
New Zealand is 5 hours ahead of Singapore.
I recall one of the New Zealand trips for which I was rostered with SQ, had been preceded by an 8 day States trip, followed by 4 days "Off", and then the trip Down Under.
The circadian cycles are shot for a six - but crew scheduling apparently don`t give this consideration!
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Beats me why you guys are going so easy on SQ here. If this was a QF crew, the calls to lynch the offenders would be heard from all quaters of the Dunnuda forum.
Justifiably.
This is not one mistake leading to a commonly occuring error. This was at least three major errors that went unchecked. Where was the cross checking procedure? Where was the CRM? Where was the basic knowledge of the aeroplane?
Sorry, you guys can apologise for them all you want but the fact remains that these sorts of errors are what we are PAID to pick up, despite circadian disruptions and possible language problems. We do this by adherence to SOPS and crosschecking everything, particularly such vital and basic information as the aeroplanes weight.
From my knowledge of Singapore, to state that English was not the first language of the crew is a red -herring.
Justifiably.
This is not one mistake leading to a commonly occuring error. This was at least three major errors that went unchecked. Where was the cross checking procedure? Where was the CRM? Where was the basic knowledge of the aeroplane?
Sorry, you guys can apologise for them all you want but the fact remains that these sorts of errors are what we are PAID to pick up, despite circadian disruptions and possible language problems. We do this by adherence to SOPS and crosschecking everything, particularly such vital and basic information as the aeroplanes weight.
From my knowledge of Singapore, to state that English was not the first language of the crew is a red -herring.
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C of B
Easy on SQ?
No not really, just making hopefully informed statements as to the on board circumstances which allowed this situation to develop to the near tragedy it was.
The language situation IS NOT A RED HERRING, in the day to day living in Asia as I and the Kaptin have said, the numbers are a major potential source of misunderstanding, not at all well understood by the locals and missed at times even by the long term Expats who have suffered by the error. See my post ref shopping.
As to who made this error and who didn't pick it up, the Flt Ops will sort that out from the data available.
Your "Profile" does not indicate your current fleet or experience, so at the risk of giving egg sucking lessons where possibly not needed,
Multi cultural, multi language and low total/type experience cockpits are quite normal operations of SIA and other Asian Airlines.
The subtle differences from other places are the traps.
Take the simple task of lowering/raising the undercarriage.
All the locals on my fleet will say "GEARS" UP/DOWN.
Which to me is a statement of fact not a request to lower or raise the wheels, as normal English is GEAR as is the Operations Manual.
Change them, I have tried, others have tried, no change as yet.
Normal ops all OK, under pressure, you can be caught.
You are right, we are paid and expected to do our professional duty and on average we do pretty well on a statistical basis, not becoming a statistic is the trick.
Try to be at the enquiry, not the subject is the next best we can all hope for.
In a group of 20 or so Pilots, we can have 150 years and 250,000 hrs total experiences in the room. Very rarely do we have anyone who has had an accident or even a major incident, so we do pretty well.
The after event flying skills of the unfortunate Captain of 286 turned a potential tragedy into what we have now able comment on. Hopefully we all could have done as well, I hope I never have to pass the test.
Ref QF, one language, one culture, lots of experience and off the end they went. That crew is still flying.
Easy on SQ?
No not really, just making hopefully informed statements as to the on board circumstances which allowed this situation to develop to the near tragedy it was.
The language situation IS NOT A RED HERRING, in the day to day living in Asia as I and the Kaptin have said, the numbers are a major potential source of misunderstanding, not at all well understood by the locals and missed at times even by the long term Expats who have suffered by the error. See my post ref shopping.
As to who made this error and who didn't pick it up, the Flt Ops will sort that out from the data available.
Your "Profile" does not indicate your current fleet or experience, so at the risk of giving egg sucking lessons where possibly not needed,
Multi cultural, multi language and low total/type experience cockpits are quite normal operations of SIA and other Asian Airlines.
The subtle differences from other places are the traps.
Take the simple task of lowering/raising the undercarriage.
All the locals on my fleet will say "GEARS" UP/DOWN.
Which to me is a statement of fact not a request to lower or raise the wheels, as normal English is GEAR as is the Operations Manual.
Change them, I have tried, others have tried, no change as yet.
Normal ops all OK, under pressure, you can be caught.
You are right, we are paid and expected to do our professional duty and on average we do pretty well on a statistical basis, not becoming a statistic is the trick.
Try to be at the enquiry, not the subject is the next best we can all hope for.
In a group of 20 or so Pilots, we can have 150 years and 250,000 hrs total experiences in the room. Very rarely do we have anyone who has had an accident or even a major incident, so we do pretty well.
The after event flying skills of the unfortunate Captain of 286 turned a potential tragedy into what we have now able comment on. Hopefully we all could have done as well, I hope I never have to pass the test.
Ref QF, one language, one culture, lots of experience and off the end they went. That crew is still flying.
Moderate, Modest & Mild.
The point that Greybeard and I are trying to impress on the majority of those who are reading this thread, in this forum, TCoB, is that certainly there are issues of SOPs that would involve checking and cross-checking that MIGHT (or might NOT)have been circumvented, however the readers MUST remember that there were at least TWO and most likely THREE versions of "English" involved that could be added to the list of probable root causes.
QF, does not have this factor on a day-to-day basis.
Again, as PILOTS, we should ALL be looking at trying to find out what factors caused these professional crew members of a major international airline to be led down a path that supposedly has many checks and balances built in to prevent such incidents/accidents.
"Pilot error" is NOT sufficient reason, and must not be accepted by any of us as the reason.
There are plenty of other non-pilots who are ready to crucify us, without other pilots jumping on to the bandwagon. It is not going to further any of YOUR careers by joining the uninformed baggers!!
QF, does not have this factor on a day-to-day basis.
Again, as PILOTS, we should ALL be looking at trying to find out what factors caused these professional crew members of a major international airline to be led down a path that supposedly has many checks and balances built in to prevent such incidents/accidents.
"Pilot error" is NOT sufficient reason, and must not be accepted by any of us as the reason.
There are plenty of other non-pilots who are ready to crucify us, without other pilots jumping on to the bandwagon. It is not going to further any of YOUR careers by joining the uninformed baggers!!
With one big IF [which I'll get to in a moment] the 2s and 3s argument, while interesting must in this case be a red herring BECAUSE;
The ZFW, which G Khan says you enter from the Flight Plan when setting up the FMC, MUST be somewhere in the range from about 170,000 Kg, the aircraft's typical empty weight, to somewhere around 250,000 Kg, depending which Maximum ZFW your company has purchased from Boeing. Freighters of course have higher ZFWs, but self-evidently, this was not a freighter.
Now a reasonable ZFW with the passenger load ex AKL and with a typical freight uplift would indeed be about 230,000Kg. To make a gross error downwards, sufficient to cause a geometry limited strike, would require a ZFW value starting with the figure '1' to be entered, not '3', so there goes the '2s and 3s Proposition', right out the window. if you tried to enter a ZFW starting with '3' instead of '2', firstly I do not think the FMC would accept the input, and if it did you would end up with V1,VR,V2 speeds too high, not too low.
Now for the Big IF ;
The -400 FMC accepts entries into either the ZFW position on the Performance Initialisation Page, i.e. the third line down, or into the GR WT position, the top left key. IF it is SIA company policy for the pilots to update the weights when the Final is received by over-typing the finalised Gross Weight value into the top line, then that procedure is faulty and fraught with danger, as has just been shown in Auckland.
IF it is SIA company policy to update the weights by over-typing the final ZFW into the third line down on the FMC Performance Initialisation page, then that is much better. However, bear in mind that it remains possible for a pilot to enter a value, such as the ZFW for example, erroneously into the Gross Weight line of the FMC. This would produce a large error, of the order of magnitude which appears to have occurred in this case.
The ZFW, which G Khan says you enter from the Flight Plan when setting up the FMC, MUST be somewhere in the range from about 170,000 Kg, the aircraft's typical empty weight, to somewhere around 250,000 Kg, depending which Maximum ZFW your company has purchased from Boeing. Freighters of course have higher ZFWs, but self-evidently, this was not a freighter.
Now a reasonable ZFW with the passenger load ex AKL and with a typical freight uplift would indeed be about 230,000Kg. To make a gross error downwards, sufficient to cause a geometry limited strike, would require a ZFW value starting with the figure '1' to be entered, not '3', so there goes the '2s and 3s Proposition', right out the window. if you tried to enter a ZFW starting with '3' instead of '2', firstly I do not think the FMC would accept the input, and if it did you would end up with V1,VR,V2 speeds too high, not too low.
Now for the Big IF ;
The -400 FMC accepts entries into either the ZFW position on the Performance Initialisation Page, i.e. the third line down, or into the GR WT position, the top left key. IF it is SIA company policy for the pilots to update the weights when the Final is received by over-typing the finalised Gross Weight value into the top line, then that procedure is faulty and fraught with danger, as has just been shown in Auckland.
IF it is SIA company policy to update the weights by over-typing the final ZFW into the third line down on the FMC Performance Initialisation page, then that is much better. However, bear in mind that it remains possible for a pilot to enter a value, such as the ZFW for example, erroneously into the Gross Weight line of the FMC. This would produce a large error, of the order of magnitude which appears to have occurred in this case.
Last edited by Captain Gidday; 31st Mar 2003 at 12:38.
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Not too sure elektra , but if you read Boeing Bulletin 747-400-46 dated 31Mar00 you'll find a treatise on this very subject, to wit - "Inadvertant Enrty of Zero Fuel Weight (ZFW) into the gross Weight (GW) Line of the FMC".
Third last para gives a future option for inhibition.
Another quote -
"the following adverse effects are possible:
* tail strike"
A sense of deja vue ?
G'day
Third last para gives a future option for inhibition.
Another quote -
"the following adverse effects are possible:
* tail strike"
A sense of deja vue ?
G'day
Moderate, Modest & Mild.
Good points, gents (and/or ladies) - it's good to see some REASONS being put forward, rather than outright crucifixions.
And IF "finger trouble" was one of the contributing factors in the chain of events, then I would be interested to know what OTHER links were involved that PREVENTED the crew from picking up on the error.
Were they tired? Was it a language problem. Were there other aircraft problems that may have distracted/diverted their attention? Was the FMC operative and reliable?
Assuming that an incorrect ZFW was entered, or that the ZFW was entered into the GWT boxes, this might also give a clue as to why the first approach ended up in a go-around, might it not? The (heavier) a/c would have been performing much differently to the one that was showing in the FMC.ie. the deceleration rate. So to say that they "rushed' the approach is possibly somewhat premature, because HAD the aircraft been at the weight which they THOUGHT (and which was reflected in the Vref from the FMC) then the circuit carried out most likely WOULD have been one that would have resulted in a landing first time.
I, for one, would like to know more about their scheduling and rest patterns immediately prior to this flight. How long did they have in AKL, and was it preceded by a CHC stopover?
Would someone be kind enough to please refresh us on the departure time of this flight, please?
And IF "finger trouble" was one of the contributing factors in the chain of events, then I would be interested to know what OTHER links were involved that PREVENTED the crew from picking up on the error.
Were they tired? Was it a language problem. Were there other aircraft problems that may have distracted/diverted their attention? Was the FMC operative and reliable?
Assuming that an incorrect ZFW was entered, or that the ZFW was entered into the GWT boxes, this might also give a clue as to why the first approach ended up in a go-around, might it not? The (heavier) a/c would have been performing much differently to the one that was showing in the FMC.ie. the deceleration rate. So to say that they "rushed' the approach is possibly somewhat premature, because HAD the aircraft been at the weight which they THOUGHT (and which was reflected in the Vref from the FMC) then the circuit carried out most likely WOULD have been one that would have resulted in a landing first time.
I, for one, would like to know more about their scheduling and rest patterns immediately prior to this flight. How long did they have in AKL, and was it preceded by a CHC stopover?
Would someone be kind enough to please refresh us on the departure time of this flight, please?
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The aircraft departed at around 1530 on the 12th of March.
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Sorry Kaptin M and others, the errors committed by this crew simply do not add up. I am not saying we as aircrew do not commit errors, but basic adherence to SOP's catches most of them.
As seen below, someone made a two simple errors, the kind that anyone having a bad day might make. I cannot for the life of me however see why it went any further than that?
Lets have a quick review....
Crew errors..
Error 1. Transposing 230T into 320T
Error 2. Entering erroneous number on to GW line instead of ZFW line
Error 3. Not crosschecking Erroneous GW with correct Loadsheet figure in front of them.
Error 4. Not realising derived V speeds were 27-30 knots low for aircraft weight
Error 5. All three pilots committing errors 3 and 4.
All of these errors could have been nullified by ONE crosscheck by one of the pilots.
Possible SQ systemic errors.
1. Not requiring provisional ZFW to be entered on to FMC to allow for ball park figures to be derived and crosschecked before arrival of final loadsheet. (And if SQ do have this procedure then it becomes Error 6 for the crew)
2. Not requiring Load sheet GW figure to be cross-checked by all crew before calculation/validation of final takeoff figures. (And if they do require this then this crew broke SOP).
To add to all of this, as pointed out, the GW on the FMC would have been around 65 Tonnes too low on approach as well. How close was this aircraft to stalling over the threshold due to erroneous Vref on arrival... twice?
You may say their but for the grace of God go I...and I certainly hope there is more to the story than so far gleaned, but this has all the hallmarks of a signature screwup that purely by the grace of the design team at Boeing, ended happily.
What I mean by signature screwup is the sort of accident that people refer to simply by one word... Erebus.... Tenerife.... Fort Worth... you all know what I am referring to.
Once again, thanks to Boeing we are not now referring to the "Auckland" accident, sadly shaking our heads..
As seen below, someone made a two simple errors, the kind that anyone having a bad day might make. I cannot for the life of me however see why it went any further than that?
Lets have a quick review....
Crew errors..
Error 1. Transposing 230T into 320T
Error 2. Entering erroneous number on to GW line instead of ZFW line
Error 3. Not crosschecking Erroneous GW with correct Loadsheet figure in front of them.
Error 4. Not realising derived V speeds were 27-30 knots low for aircraft weight
Error 5. All three pilots committing errors 3 and 4.
All of these errors could have been nullified by ONE crosscheck by one of the pilots.
Possible SQ systemic errors.
1. Not requiring provisional ZFW to be entered on to FMC to allow for ball park figures to be derived and crosschecked before arrival of final loadsheet. (And if SQ do have this procedure then it becomes Error 6 for the crew)
2. Not requiring Load sheet GW figure to be cross-checked by all crew before calculation/validation of final takeoff figures. (And if they do require this then this crew broke SOP).
To add to all of this, as pointed out, the GW on the FMC would have been around 65 Tonnes too low on approach as well. How close was this aircraft to stalling over the threshold due to erroneous Vref on arrival... twice?
You may say their but for the grace of God go I...and I certainly hope there is more to the story than so far gleaned, but this has all the hallmarks of a signature screwup that purely by the grace of the design team at Boeing, ended happily.
What I mean by signature screwup is the sort of accident that people refer to simply by one word... Erebus.... Tenerife.... Fort Worth... you all know what I am referring to.
Once again, thanks to Boeing we are not now referring to the "Auckland" accident, sadly shaking our heads..
Last edited by The_Cutest_of_Borg; 1st Apr 2003 at 09:49.
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Yes, just a little mistake with only the PPRuNe people to see, the 286 guys got front page.
The real trouble with all of this is that we are HUMAN, we will make mistakes,
I SAY AGAIN--WE WILL MAKE MISTAKES.
LOSA data from that area indicates we make an average of 2 errors per flight, up to 17 observed errors on one isolated flight.
A sucessful one we assume as the data from the observer survived.
So, even if "WE" think "WE" are twice as good as the average, "WE" will still make one so called error per flight.
It makes the hair on your neck stand up.
Be careful out there. (appol to Avweb)
C YA
The real trouble with all of this is that we are HUMAN, we will make mistakes,
I SAY AGAIN--WE WILL MAKE MISTAKES.
LOSA data from that area indicates we make an average of 2 errors per flight, up to 17 observed errors on one isolated flight.
A sucessful one we assume as the data from the observer survived.
So, even if "WE" think "WE" are twice as good as the average, "WE" will still make one so called error per flight.
It makes the hair on your neck stand up.
Be careful out there. (appol to Avweb)
C YA
Moderate, Modest & Mild.
But what percentage did NOT, TCoB?
Additionally, your post was sitting there unchanged, whereas once the entry is made into the FMC and executed, more than likely another page is then selected.
"Yes", a mistake WAS made, and "yes" it was not caught in the safety net that SIA employs.
But the question that NEEDS answering is "Why wasn't it picked up?" by at least one of the the three crew members?
BTW, TCoB, Erebus was NOT a crew stuff up.
In the Teneriffe accident, the F/O in fact did voice his concern that KLM was not cleared for take-off, however the domineering personality and the rush to get going by the Captain were considered the overriding causes.
And your final point of "crew errors"...Error 5. All three pilots committing errors 3 and 4., begs the question once again.
What distraction prevented at least ONE crew member from picking up the error?
Additionally, your post was sitting there unchanged, whereas once the entry is made into the FMC and executed, more than likely another page is then selected.
"Yes", a mistake WAS made, and "yes" it was not caught in the safety net that SIA employs.
But the question that NEEDS answering is "Why wasn't it picked up?" by at least one of the the three crew members?
BTW, TCoB, Erebus was NOT a crew stuff up.
In the Teneriffe accident, the F/O in fact did voice his concern that KLM was not cleared for take-off, however the domineering personality and the rush to get going by the Captain were considered the overriding causes.
And your final point of "crew errors"...Error 5. All three pilots committing errors 3 and 4., begs the question once again.
What distraction prevented at least ONE crew member from picking up the error?