AA Crash Jamaica
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Forgive me, but I don't really undertand why some of these overrun accidents keep happening.
It seems to me that if you're going to land and you KNOW ahead of time that your stopping margins are going to be NARROW (due to tailwind, short-contaminated-sloping-wet runway, etc), then you KNOW the landing and stopping has to proceed correctly. Since TR deployment is the commitment point, what is so hard about making sure that events prior to TR deployment have happened correctly?
It seems to me you will KNOW if you touched down long or not, or if you bounced the airplane or not (and thus have to brake late). Once down you can quickly know if the spoilers deployed or not, and if the brakes are slowing the aircraft or not. If these things don't happen correctly, then go around because you KNOW the stopping margins are NARROW. Since a NARROW stopping margin landing is an "alert and focused crew" landing, you will quickly know that touchdown, spoilers and brakes happened correctly, then you can deploy the thrust reversers.
This seems very straight forward to me, or am I missing something? Why not treat TR deployment on landing, something like V1 is treated on takeoff?
It seems to me that if you're going to land and you KNOW ahead of time that your stopping margins are going to be NARROW (due to tailwind, short-contaminated-sloping-wet runway, etc), then you KNOW the landing and stopping has to proceed correctly. Since TR deployment is the commitment point, what is so hard about making sure that events prior to TR deployment have happened correctly?
It seems to me you will KNOW if you touched down long or not, or if you bounced the airplane or not (and thus have to brake late). Once down you can quickly know if the spoilers deployed or not, and if the brakes are slowing the aircraft or not. If these things don't happen correctly, then go around because you KNOW the stopping margins are NARROW. Since a NARROW stopping margin landing is an "alert and focused crew" landing, you will quickly know that touchdown, spoilers and brakes happened correctly, then you can deploy the thrust reversers.
This seems very straight forward to me, or am I missing something? Why not treat TR deployment on landing, something like V1 is treated on takeoff?
Last edited by Flight Safety; 24th Dec 2009 at 17:45. Reason: To add the V1 comment.
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Plan Continuation Bias, snowballing workload ...
Problem stated in slot #105:
“Pressing the Approach”
A NASA study of 19 recent accidents yields a new perspective on pilot error.
By Benjamin A. Bermin and R. Key Dismukes,
Aviation Safety World December 2006 | Flight Safety Foundation
Pressing the Approach 6 pages. [PDF 297K]
_Aviation Safety World_, December 2006, pgs 28-33
Some interesting concepts here, subtly implicated in “unstable” approaches, eg:
[A special thanks to FSF’s K. Ehrlich, Production Coordinator, Flight Safety Foundation, for her sending the un-locked pdf file. That protection-free file made these excerpts easily available for you to read below.]
= = = \/ = = = EXCERPTS = = = \/ = = = =
“... two of the most common themes in the 19 accidents studied:
“Too often, pressing an approach ... is attributed to complacency or an intentional deviation from standards .... To understand why experienced pilots sometimes continue ill-advised approaches, we must examine the insidious nature of plan continuation bias. Plan continuation bias appears to underlie what pilots call “press-on-itis,” which a Flight Safety Foundation task force found to be involved in 42 percent of accidents and incidents they reviewed.Similarly, this bias was apparent in at least nine of the 19 accidents in our study. Our analysis suggests that this bias results from the interaction of three major components:
“...Although plan continuation bias is powerful, it can be countered once acknowledged. One countermeasure is to analyze situations more explicitly than is common among crews. This would include explicitly stating the nature of the threat, the observable indications of the threat and the initial plan for dealing with the threat. Crews then should explicitly ask, “What if our assumptions are wrong? How will we know? Will we know in time?” These questions are the basis for forming realistic backup plans and implementing them in time, but they must be asked before snowballing workload limits the pilots’ ability to think ahead.
“ Airlines should periodically review normal and non-normal procedures and checklists for design features that invite errors....
“... Operators should carefully examine whether they are unintentionally giving pilots mixed messages about competing goals such as stabilized approaches versus on-time performance and fuel costs. For example, if a company is serious about compliance with stabilized approach criteria, it should publish, train and check those criteria as hard-and-fast rules rather than as guidelines....”
= = = = /\ = = = END excerpts = = = /\ = = =
"... I don't really undertand why some of these overrun accidents keep happening...."
Excerpts from “Pressing the Approach”
A NASA study of 19 recent accidents yields a new perspective on pilot error.
By Benjamin A. Bermin and R. Key Dismukes,
Aviation Safety World December 2006 | Flight Safety Foundation
Pressing the Approach 6 pages. [PDF 297K]
_Aviation Safety World_, December 2006, pgs 28-33
Some interesting concepts here, subtly implicated in “unstable” approaches, eg:
-- Plan Continuation Bias,
-- late cognitive demands may overwhelm the human’s capabilities, and then inhibit his decision for go-around;
-- mixed messages from the airline (merely suggesting guidelines rather than imposing standards).
The cognitive-limitations described in this FSF paper (from Bermin and Dismukes) suggest the earliest activation of Honeywell’s hosted RAAS [Rwy Awareness Advisory System] and SAM [Stabilized Approach Monitor].-- mixed messages from the airline (merely suggesting guidelines rather than imposing standards).
[A special thanks to FSF’s K. Ehrlich, Production Coordinator, Flight Safety Foundation, for her sending the un-locked pdf file. That protection-free file made these excerpts easily available for you to read below.]
= = = \/ = = = EXCERPTS = = = \/ = = = =
“... two of the most common themes in the 19 accidents studied:
*** plan continuation bias — a deep-rooted tendency of individuals to continue their original plan of action even when changing circumstances require a new plan — and
*** snowballing workload — workload that builds on itself and increases at an accelerating rate....
“... the problems encountered by the crews seem to have centered on these two themes....*** snowballing workload — workload that builds on itself and increases at an accelerating rate....
“Too often, pressing an approach ... is attributed to complacency or an intentional deviation from standards .... To understand why experienced pilots sometimes continue ill-advised approaches, we must examine the insidious nature of plan continuation bias. Plan continuation bias appears to underlie what pilots call “press-on-itis,” which a Flight Safety Foundation task force found to be involved in 42 percent of accidents and incidents they reviewed.Similarly, this bias was apparent in at least nine of the 19 accidents in our study. Our analysis suggests that this bias results from the interaction of three major components:
-- social/organizational influences,
-- the inherent characteristics and limitations of human cognition, and
-- incomplete or ambiguous information....
“... Our study suggests that ... -- the inherent characteristics and limitations of human cognition, and
-- incomplete or ambiguous information....
-- when standard operating procedures are phrased not as requirements ... that may appear to tacitly approve of bending the rules,
-- pilots may ... place too much importance on schedule and cost when making safety/ schedule/ cost tradeoffs.
“Also, pilots may not fully understand ... that the cognitive demands ... from an unstabilized approach severely impair their ability to assess ... the approach ...”-- pilots may ... place too much importance on schedule and cost when making safety/ schedule/ cost tradeoffs.
“...Although plan continuation bias is powerful, it can be countered once acknowledged. One countermeasure is to analyze situations more explicitly than is common among crews. This would include explicitly stating the nature of the threat, the observable indications of the threat and the initial plan for dealing with the threat. Crews then should explicitly ask, “What if our assumptions are wrong? How will we know? Will we know in time?” These questions are the basis for forming realistic backup plans and implementing them in time, but they must be asked before snowballing workload limits the pilots’ ability to think ahead.
“ Airlines should periodically review normal and non-normal procedures and checklists for design features that invite errors....
“... Operators should carefully examine whether they are unintentionally giving pilots mixed messages about competing goals such as stabilized approaches versus on-time performance and fuel costs. For example, if a company is serious about compliance with stabilized approach criteria, it should publish, train and check those criteria as hard-and-fast rules rather than as guidelines....”
= = = = /\ = = = END excerpts = = = /\ = = =
Last edited by IGh; 24th Dec 2009 at 17:08. Reason: correct link to pdf
Trash du Blanc
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what is so hard about making sure that events prior to TR deployment have happened correctly?
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Life and Death Decisions
I hope this isn't thread drift, as I think this discussion may be relevant to this accident and others.
Here's a link from a retired NYFD fire chief, on the subject of training for life and death decisions.
Life and Death Decision-Making
Pilots are also confronted with life and death decisions, however pilots are generally required to decide and act within seconds, unlike most first responder life and death decisions. However I wonder if much airline pilot training focuses on this aspect of emergency procedures training. It's the emotional impact of being confronted with a sudden life and death decision, that must be responded to correctly within seconds, that may need special attention in training. My general understanding is that when someone is immediately confronted with a life and death situation that requires an immediate response, the reaction is usually one of fear and strong emotion rather than reason, the fight or flight reaction. I think training could help overcome the expected strong viceral reactions, if the training treated the problem for what it really is, a life and death decision. The simulator seems like a good place to do this.
Here's a link from a retired NYFD fire chief, on the subject of training for life and death decisions.
Life and Death Decision-Making
Pilots are also confronted with life and death decisions, however pilots are generally required to decide and act within seconds, unlike most first responder life and death decisions. However I wonder if much airline pilot training focuses on this aspect of emergency procedures training. It's the emotional impact of being confronted with a sudden life and death decision, that must be responded to correctly within seconds, that may need special attention in training. My general understanding is that when someone is immediately confronted with a life and death situation that requires an immediate response, the reaction is usually one of fear and strong emotion rather than reason, the fight or flight reaction. I think training could help overcome the expected strong viceral reactions, if the training treated the problem for what it really is, a life and death decision. The simulator seems like a good place to do this.
Last edited by Flight Safety; 24th Dec 2009 at 18:01.
I think training could help overcome the expected strong viceral reactions, if the training treated the problem for what it really is, a life and death decision. The simulator seems like a good place to do this.
The idea around training is to reinforce planning that does not get you boxed in to life and death decisions within seconds.
So we have the investigating challenge, is this equipment failure, knowlege based misteps, skill based misteps or failure to follow procedures that got them into the seconds preceding the overrun?
AA hull losses in the last 10 years
How many hull losses has AA suffered in the last 10 years?
Aviation Safety Network > ASN Aviation Safety Database > ASN Aviation Safety Database results
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I'd take any of the news reports with a grain of salt. The official reports will be the ultimate fact providers.
With that said, the latest news said 92 taken to hospital for treatment, 13 admitted(USA Today, 12/24/09).
The allegation that the pilot pushing the wheelchair is NOT the operating Captain is supported by the statement that the operating Captain suffered a broken arm. If true, why would the guy with the broken arm be pushing a wheelchair, especially when other able bodied people are available?
Take the longevity numbers provided by the West Palm Beach News with a grain of salt.
With that said, the latest news said 92 taken to hospital for treatment, 13 admitted(USA Today, 12/24/09).
The allegation that the pilot pushing the wheelchair is NOT the operating Captain is supported by the statement that the operating Captain suffered a broken arm. If true, why would the guy with the broken arm be pushing a wheelchair, especially when other able bodied people are available?
Take the longevity numbers provided by the West Palm Beach News with a grain of salt.
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flight safety
you simply cannot regulate and train for every conceivable situation. sometimes a pilot just ACTS and sometimes it works out for the best and sometimes it doesn't.
What you can do is train and discuss and hope for understanding. IF a pilot doesn't landin the first third of a runway, then you should go around...but if going around would cause a midair collision then stay on the ground.
What needs to be done is simply this. Acknowledge that there will be overruns...put 1000' of EMAS over run material on all runways. IF this plane had hit EMAS...it would be flying again by now...think about that.
I am all for more training, better training...more frequent training. In fact I think three times as much time in the sim/classroom and at least 3 times as much money should be spent. I also think a good amount of flying in a REAL PLANE loaded with sandbags should be part of the equation.
Why not? MONEY...that's the answer for all crashes...MONEY.
What you can do is train and discuss and hope for understanding. IF a pilot doesn't landin the first third of a runway, then you should go around...but if going around would cause a midair collision then stay on the ground.
What needs to be done is simply this. Acknowledge that there will be overruns...put 1000' of EMAS over run material on all runways. IF this plane had hit EMAS...it would be flying again by now...think about that.
I am all for more training, better training...more frequent training. In fact I think three times as much time in the sim/classroom and at least 3 times as much money should be spent. I also think a good amount of flying in a REAL PLANE loaded with sandbags should be part of the equation.
Why not? MONEY...that's the answer for all crashes...MONEY.
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kappa - You can see the drop behind them. If the perimeter fence is 6' the 90 degree drop to the roadway is about 12-15', followed by an 45-60 degree, 10' incline on the other side.
Ouch.
Ouch.
The allegation that the pilot pushing the wheelchair is NOT the operating Captain is supported by the statement that the operating Captain suffered a broken arm. If true, why would the guy with the broken arm be pushing a wheelchair, especially when other able bodied people are available?
Take the longevity numbers provided by the West Palm Beach News with a grain of salt.
Take the longevity numbers provided by the West Palm Beach News with a grain of salt.
The 20 year number is probably accurate. Regarding the broken arm; could be small fracture with the pain covered by pure shock. Totally understandable in a breakup as severe as that. Never had a sim session that covered something that bad, and how to handle the aftermath after evacuation.
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Flight Safety: It seems to me that if you're going to land and you KNOW ahead of time that your stopping margins are going to be NARROW (due to tailwind, short-contaminated-sloping-wet runway, etc), then you KNOW the landing and stopping has to proceed correctly. Since TR deployment is the commitment point, what is so hard about making sure that events prior to TR deployment have happened correctly?
It seems to me you will KNOW if you touched down long or not, or if you bounced the airplane or not (and thus have to brake late). Once down you can quickly know if the spoilers deployed or not, and if the brakes are slowing the aircraft or not. If these things don't happen correctly, then go around because you KNOW the stopping margins are NARROW. Since a NARROW stopping margin landing is an "alert and focused crew" landing, you will quickly know that touchdown, spoilers and brakes happened correctly, then you can deploy the thrust reversers.
This seems very straight forward to me, or am I missing something? Why not treat TR deployment on landing, something like V1 is treated on takeoff?
While jumpseating during my former employment, Isaw a technique for slippery runways. Land with the autobrakes set to medium. If you don't feel the deceleration at touchdown apply thrust and go somewhere else. Only apply reverse thrust after confirming that the brakes are working. During aircraft certification, there is no performance credit for R/T giving the pilots some margin. However in operations, some operations eat up this credit leaving no margin.
Dick Newman
It seems to me you will KNOW if you touched down long or not, or if you bounced the airplane or not (and thus have to brake late). Once down you can quickly know if the spoilers deployed or not, and if the brakes are slowing the aircraft or not. If these things don't happen correctly, then go around because you KNOW the stopping margins are NARROW. Since a NARROW stopping margin landing is an "alert and focused crew" landing, you will quickly know that touchdown, spoilers and brakes happened correctly, then you can deploy the thrust reversers.
This seems very straight forward to me, or am I missing something? Why not treat TR deployment on landing, something like V1 is treated on takeoff?
While jumpseating during my former employment, Isaw a technique for slippery runways. Land with the autobrakes set to medium. If you don't feel the deceleration at touchdown apply thrust and go somewhere else. Only apply reverse thrust after confirming that the brakes are working. During aircraft certification, there is no performance credit for R/T giving the pilots some margin. However in operations, some operations eat up this credit leaving no margin.
Dick Newman
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Thinking about the go-around decision after touch-down, it occurred to me that in 13 years in the airline industry, I have never once had training in a go-around after touchdown. Go-arounds are indeed trained, but it is always a go-around at DH. Maybe it is time to include go-arounds after touch-down in the annual recurrent training syllabus.
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Bounce recovery.
Let's say the copilot landed...and it didn't go well and the captain started to takeover control and didn't go around as bounce recovery...but things happened too far down the runway.
and he didn't check for spoiler deployment...after all things are a bit hairy after an unexpected change of control...and he tried to salvage the landing....
I had to salvage a bounced landing in a 737 once ...but I had a long runway, dry day vfr condtions. IF i had to recovery a bounced landing at night, rain, short runway...I might have just ''cobbed it'' and flown around again.
we trained for a go around off the deck...after all in a CAT II manual approach/landing it is possible to touch after a go around decision.
Let's say the copilot landed...and it didn't go well and the captain started to takeover control and didn't go around as bounce recovery...but things happened too far down the runway.
and he didn't check for spoiler deployment...after all things are a bit hairy after an unexpected change of control...and he tried to salvage the landing....
I had to salvage a bounced landing in a 737 once ...but I had a long runway, dry day vfr condtions. IF i had to recovery a bounced landing at night, rain, short runway...I might have just ''cobbed it'' and flown around again.
we trained for a go around off the deck...after all in a CAT II manual approach/landing it is possible to touch after a go around decision.
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I wonder why the pf did not initiate a go-around after 500ft?..
According to pax, the aircraft touched down halfway on the runway..
I saw this article where they have are looking at the approach lights at the airport..
AMR Jet Had to Use Jamaica Runway Lacking Some Approach Lights - Bloomberg.com
According to pax, the aircraft touched down halfway on the runway..
I saw this article where they have are looking at the approach lights at the airport..
AMR Jet Had to Use Jamaica Runway Lacking Some Approach Lights - Bloomberg.com
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Miami Herald photo gallery... some interesting photos.
American Airlines flight AA331 crash landed in Jamaica - Miami Herald
Edited to state that I am sorry for the duplication as this link has already been posted!
American Airlines flight AA331 crash landed in Jamaica - Miami Herald
Edited to state that I am sorry for the duplication as this link has already been posted!