Gulfstream IV in Bedford MA
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What surprises me on this thread is the amount of energy being spent on understanding the gust lock system - compared to the amount of energy spent on understanding and working out a solution to habitual non-compliance...
Others are entitled to their opinion, but in my mind, it was not GLs design of the gust-lock system (inelegant and inefficient as it may be) that killed them boys. Them boys were killed by crew that lost respect for what they were doing. We all do mistakes - but this was no mistake. This wasn't 'pilot error'.
Sure - if the QAR had shown that they always carried out their flight control checks, apart from on that fatal day, then it would be pilot error and a 'there-but-for-the-grace-of-God-go-I' from the rest of us.
But that wasn't the case.
I'll get my coat...
Others are entitled to their opinion, but in my mind, it was not GLs design of the gust-lock system (inelegant and inefficient as it may be) that killed them boys. Them boys were killed by crew that lost respect for what they were doing. We all do mistakes - but this was no mistake. This wasn't 'pilot error'.
Sure - if the QAR had shown that they always carried out their flight control checks, apart from on that fatal day, then it would be pilot error and a 'there-but-for-the-grace-of-God-go-I' from the rest of us.
But that wasn't the case.
I'll get my coat...
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Don't leave Empty Cruise because you are absolutely correct. If this crew had survived they should have been prosecuted - they were criminally negligent. Earlier this year I prepared a presentation for the company I work for highlighting the dangers of "Normalisation of Deviance" which despite its name has nothing to do with kinky behaviour but is really one of the biggest killers in aviation. This crash was a prime example of that and it formed a large part of my presentation.
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As a counter-argument, I would submit that human brains are a lot harder to change than aircraft systems and procedures. So while you are correct with all your points, the fact remains that we have to put warm bodies into seats, and as pilots of today are neither treated, paid or trained like astronauts, we will always get a certain percentage of colleagues who are prone to sub-standard behavior.
It's safe to say that all attempts to assess, motivate, select and ramp-check these people out of the cockpit have failed up to now...
So, one of the more productive ways of improving the overall safety record is to improve systems, interfaces, cockpit ergonomics, procedures and checklists so that even the "worst" pilots tend not to screw it up with fatal consequences.
In order to do that, the kind of "post-mortem" analysis we have seen on this thread ultimately delivers the clues needed to improve the system.
That being said, of course the idiot-proof system does not exist, and probably never will. Of course we all need to be more vigilant towards the normalization of deviation. And we also need to be less tolerant towards colleagues who underperform.
As we were heading to Dubai a couple months back, I was remarking to my sim-partner that it had been quite a few year since I'd approached a recurrent check with trepidation, much less the fear of failing to meet the required standard. Now, I'm not that good, so it can only mean that maybe some of the hurdles we are required to jump over these days are a bit low... I'd be interested to hear some of your opinions on that.
It's safe to say that all attempts to assess, motivate, select and ramp-check these people out of the cockpit have failed up to now...
So, one of the more productive ways of improving the overall safety record is to improve systems, interfaces, cockpit ergonomics, procedures and checklists so that even the "worst" pilots tend not to screw it up with fatal consequences.
In order to do that, the kind of "post-mortem" analysis we have seen on this thread ultimately delivers the clues needed to improve the system.
That being said, of course the idiot-proof system does not exist, and probably never will. Of course we all need to be more vigilant towards the normalization of deviation. And we also need to be less tolerant towards colleagues who underperform.
As we were heading to Dubai a couple months back, I was remarking to my sim-partner that it had been quite a few year since I'd approached a recurrent check with trepidation, much less the fear of failing to meet the required standard. Now, I'm not that good, so it can only mean that maybe some of the hurdles we are required to jump over these days are a bit low... I'd be interested to hear some of your opinions on that.
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What surprises me on this thread is the amount of energy being spent on understanding the gust lock system - compared to the amount of energy spent on understanding and working out a solution to habitual non-compliance...
Others are entitled to their opinion, but in my mind, it was not GLs design of the gust-lock system (inelegant and inefficient as it may be) that killed them boys. Them boys were killed by crew that lost respect for what they were doing. We all do mistakes - but this was no mistake. This wasn't 'pilot error'.
Others are entitled to their opinion, but in my mind, it was not GLs design of the gust-lock system (inelegant and inefficient as it may be) that killed them boys. Them boys were killed by crew that lost respect for what they were doing. We all do mistakes - but this was no mistake. This wasn't 'pilot error'.
I go out of my way to read every Part 25 accident and I put myself in the pilots shoes and ask what I would have done...NO WAY do I get anywhere near the threshold without completing the requisite checklists. NO WAY do I initiate a takeoff roll with a primary control issue. NO WAY do I continue a takeoff without required N1/EPR of the day. This was an embarrassing display of "airmanship." I take no enjoyment in saying this, but it was simply amateur hour on that fateful night. As you mention, if there is a discussion to be had, it is how in the world does someone get so complacent?! I find it unfathomable...
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The complacent and disinterested performance by the flight crew should have been shocking, but it increasingly appears such behavior happens far more often than we are willing to acknowledge.
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I think FlyMD has hit the nail on the head regarding training and checking. Every time we encounter someone sub-standard on the line or on the sim, we do our utmost to bring them back into the fold - but getting to the point where we say 'Thanks, but no thanks' seems to be a battle in most companies (present employer excepted, I must say...).
While no-one advocates a return to the bad, old 'the engine's dead and the captain's on fire'-days, I have myself during TRs afterwards have words with the provider. Depress scenario where they tell us not to put the masks on for 'hygienic reasons', fire scenarios where they just wanted us to sit in the sim on flt freeze reading the checklist and not simultaneously trying to return the aircraft to the ground are but two of the 'better' (or worse) examples I've come across.
As for recurrent training - I'm fortunate enough to be the one that designs that, but have had the usual "oh, you guys are fine", when we both knew we'd delivered a very mediocre performance. There are literally no pressure anywhere in the process or organisation to go out and improve or go out and be a better pilot unless you work for the right people. Many don't - so where is their incentive?
Basically, the question is: is it ok to be a bit rubbish, just because you don't work for the best-paying or most caring outfit?
While no-one advocates a return to the bad, old 'the engine's dead and the captain's on fire'-days, I have myself during TRs afterwards have words with the provider. Depress scenario where they tell us not to put the masks on for 'hygienic reasons', fire scenarios where they just wanted us to sit in the sim on flt freeze reading the checklist and not simultaneously trying to return the aircraft to the ground are but two of the 'better' (or worse) examples I've come across.
As for recurrent training - I'm fortunate enough to be the one that designs that, but have had the usual "oh, you guys are fine", when we both knew we'd delivered a very mediocre performance. There are literally no pressure anywhere in the process or organisation to go out and improve or go out and be a better pilot unless you work for the right people. Many don't - so where is their incentive?
Basically, the question is: is it ok to be a bit rubbish, just because you don't work for the best-paying or most caring outfit?
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Just to put this crash and crew into perspective. The company had only one G4 and the crew were the only crew for the aircraft, they were not inexperienced in the aircraft either. At every renewal, proficiency check (done by external company) and audit this crew did it by the book. It was only when they were on their own did they let the standard slip so abysmally. They were a crash looking for a place to happen.
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PLovett - couldn't agree more. They were so dedicated to doing things non-standard that they were bothered spending the mental resources and energy on having 2 sets of procedures: one for training & checking, and another for the line. Sounds like hard work to me, but there you go...
@ westhawk - agree again. This is something we often see - the smaller outfits (or should I say fleets?) don't get the resources or attention. So is there an argument that larger organisations with larger fleets are (in the long run, and everything else being equal) just that little bit stronger and therefore safer?
@ westhawk - agree again. This is something we often see - the smaller outfits (or should I say fleets?) don't get the resources or attention. So is there an argument that larger organisations with larger fleets are (in the long run, and everything else being equal) just that little bit stronger and therefore safer?
