Indonesian B737 runway overrun/crash
A37575,
I am struggling to believe that simple "loss of face" is enough to cause a man to ignore several hard indicators that are shouting "you are probably going to crash".
I am struggling to believe that simple "loss of face" is enough to cause a man to ignore several hard indicators that are shouting "you are probably going to crash".
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Yes - it is conceivable. It is called Loss of Face Syndrome also known as Real Men Don't Go Around syndrome. Common in some cultures and the direct cause of many aircraft accidents.
Fell free to slam the pilot with such "real men don't go around syndrome" despite him having the reputation otherwise... but don't go knocking on everyone else who shares the same nationality...
Next time you see an Indonesian plane going around, I wonder what would you say? "I didn't see that" perhaps??????
PK-KAR
Last edited by PK-KAR; 22nd Apr 2007 at 12:54.
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Hmmm....here we go again with the loss of face syndrome.For the uninitiated, there is an offshoot thread in DnG Forums.
Real Men Don't Go Around
While some posters here are entitled to their opinions, sometimes I wonder where they based their opinions from.
My post on the said matter :
As the recent deadly shooting in USA shows, the family of the said shooter was 'ashamed' of his actions.Classic case of a 'loss of face for an asian family' 
Real Men Don't Go Around
While some posters here are entitled to their opinions, sometimes I wonder where they based their opinions from.
My post on the said matter :
to the uninitiated, Loss Of Face is a very subjective subject, even for asians!Numerous books are written by westerners on this subject but I believe that most authors have yet to grasp the gist of it.
Let me give you a classic example.Loss Of Face can also occur to the surviving families of the dead crew.Where, let's say, hypothethically in an accident where the pilots were asians,the findings of the AI Board puts the blame on the 'incompetent' pilots.The grieving crew's family now will suffer a "loss of face" syndrome, as due to the fault of the crew, they have to carry the burden of shame for the misdeeds of their dearly departed.So. like I said earlier, it's a matter of perspective.
I believe in most cases of accidents due to unstabilized approaches, they are more than likely caused by a high "macho & ego" factor or "goal oriented & tunnel vision".These factors are prevalent in most cases & aren't ethnic or gender biased.
Let me give you a classic example.Loss Of Face can also occur to the surviving families of the dead crew.Where, let's say, hypothethically in an accident where the pilots were asians,the findings of the AI Board puts the blame on the 'incompetent' pilots.The grieving crew's family now will suffer a "loss of face" syndrome, as due to the fault of the crew, they have to carry the burden of shame for the misdeeds of their dearly departed.So. like I said earlier, it's a matter of perspective.
I believe in most cases of accidents due to unstabilized approaches, they are more than likely caused by a high "macho & ego" factor or "goal oriented & tunnel vision".These factors are prevalent in most cases & aren't ethnic or gender biased.
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ego
Ego is a funny thing. Most of us, when considering our career or what ever we do, like to think we are just a bit above average. It's human nature. And we tend to look for those things that will substantiate that assessment.
A pilot might think of himself as being good at approaches. The evidence that supports this, in his mind, could be the small number of times when a go around is needed.
Such a pilot has self programed himself for a crash.
A pilot might think of himself as being good at approaches. The evidence that supports this, in his mind, could be the small number of times when a go around is needed.
Such a pilot has self programed himself for a crash.
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Do you mean to say that certain cultural upbringings inevitably result in incapable aviators
FC, re your reasons (the answer is 42 – the secret of life and everything) – post #339, are those expected from a rational human, but again I suggest only in hindsight. What reasons (mitigations) could be provided for an ‘irrational’ human in the pre-accident situation. In this sense irrational is ‘the suppression of information directing a particular course of action’ (J. Reason). Reason (Human Error), continues: – “erroneous behavior is more in keeping with past practices than the current circumstances demand”. Thus, your background, education, life events, or training might provide a degree of protection from irrational behavior.
However, what can be said (in hindsight) about other people. Even though it is reported that the accident Captain usually ‘followed the rules’, this external perception needs validating; we should remember that culture (mainly professional culture) is how we actually do things – ‘what we do when no-one is looking’.
I agree that ‘feelings’, those fundamental beliefs and biases, are strong behavioral drivers, which protect us from danger. Problems arise if we do not see the danger – we do not recognize the situation that we are in. A hazardous situation might be of our own making; thus, there could be strong mental drivers for us to believe it, similarly a plausible ‘situation’ could have been created by others.
I too hope that the reasons for the feelings (beliefs and biases) and the components of the situation are found, but with some of BOAC’s skepticism I doubt that all of the human issues will be identified or even identifiable. The ICAO format for accident investigation with its factual approach and the reluctance of investigators to ‘speculate’ is unlikely to provide substantial recommendations to prevent similar accidents – the issues are predominantly human factors. How do you establish what a person’s perception was in a given situation, how to you determine ‘intent’ or ‘willful suppression of factors’ (Captain and First Officer).
I suppose that if the industry had the capability to answer the questions above, the investigators at Burbank etc would have recommended specific defenses and there could be some hope that this and future accidents are avoided. Generally, the industry is presented with a loosely disguised conclusion of ‘human error’, blame, and recommendations for adhering to procedures (stabilized approach) and CRM (whatever one’s definition of that is).
I think that more investigative speculation would provide meaningful resources for safety action, which I hope in some small part this thread is doing. In this respect I also think that this supports 100%’s suggestion (post #340) to step back for a ‘broader look around’. As J Reason explains, there are two types of accident, those which happen to individuals and those that happen to organizations. I suggest that the 737 crew could have experienced a cognitive failure (not an accident), precipitated by organizational issues which would categorize this as an ‘organizational accident’. “One, which has multiple causes, which involves many people at many organizational levels, even outside of the organization”.
Runway overrun availability is relevant as it is part of the wider picture that may eliminate a component which contributed to the accident or its severity.
A similar, wide ranging view would be to compare the 737 with other aircraft – not necessarily just for the type or rate of overrun accidents. I recall that there was a comparison made between 737 and A320 for unstabilized approaches where the 737 was much more prone to high speed approaches. Along similar lines of thought, what type of ASI did the 737 have – mechanical, EFIS, strip or dial, – what was the crews experience with such an instrument? Answers to these ‘incidental’ questions often provide greater clarity in understanding and highlight some hazards to be aware of.
For some other ‘speculative’ defenses that may apply to this accident, see the thread on TEM post #4.
However, what can be said (in hindsight) about other people. Even though it is reported that the accident Captain usually ‘followed the rules’, this external perception needs validating; we should remember that culture (mainly professional culture) is how we actually do things – ‘what we do when no-one is looking’.
I agree that ‘feelings’, those fundamental beliefs and biases, are strong behavioral drivers, which protect us from danger. Problems arise if we do not see the danger – we do not recognize the situation that we are in. A hazardous situation might be of our own making; thus, there could be strong mental drivers for us to believe it, similarly a plausible ‘situation’ could have been created by others.
I too hope that the reasons for the feelings (beliefs and biases) and the components of the situation are found, but with some of BOAC’s skepticism I doubt that all of the human issues will be identified or even identifiable. The ICAO format for accident investigation with its factual approach and the reluctance of investigators to ‘speculate’ is unlikely to provide substantial recommendations to prevent similar accidents – the issues are predominantly human factors. How do you establish what a person’s perception was in a given situation, how to you determine ‘intent’ or ‘willful suppression of factors’ (Captain and First Officer).
I suppose that if the industry had the capability to answer the questions above, the investigators at Burbank etc would have recommended specific defenses and there could be some hope that this and future accidents are avoided. Generally, the industry is presented with a loosely disguised conclusion of ‘human error’, blame, and recommendations for adhering to procedures (stabilized approach) and CRM (whatever one’s definition of that is).
I think that more investigative speculation would provide meaningful resources for safety action, which I hope in some small part this thread is doing. In this respect I also think that this supports 100%’s suggestion (post #340) to step back for a ‘broader look around’. As J Reason explains, there are two types of accident, those which happen to individuals and those that happen to organizations. I suggest that the 737 crew could have experienced a cognitive failure (not an accident), precipitated by organizational issues which would categorize this as an ‘organizational accident’. “One, which has multiple causes, which involves many people at many organizational levels, even outside of the organization”.
Runway overrun availability is relevant as it is part of the wider picture that may eliminate a component which contributed to the accident or its severity.
A similar, wide ranging view would be to compare the 737 with other aircraft – not necessarily just for the type or rate of overrun accidents. I recall that there was a comparison made between 737 and A320 for unstabilized approaches where the 737 was much more prone to high speed approaches. Along similar lines of thought, what type of ASI did the 737 have – mechanical, EFIS, strip or dial, – what was the crews experience with such an instrument? Answers to these ‘incidental’ questions often provide greater clarity in understanding and highlight some hazards to be aware of.
For some other ‘speculative’ defenses that may apply to this accident, see the thread on TEM post #4.
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A37575 wrote,
Well then, could you lobby your government (Australia), to close all flying schools there that caters to the Asian students (which you kindly associate with the so called "loss of face syndrome"), because it would be such a waste of resources & time
It would at least stop the stench of hypocrisy emanating from your post.
However, alf5071h post with ref to professional culture is spot on."Get-homeitis" or "Get-thereitis" isn't exclusive to a certain ethnicity or be gender specific.
Of course there is. Anyone that has had dealings in aviation accidents knows this although the problem is hidden under the mask of political correctness in today's society
Well then, could you lobby your government (Australia), to close all flying schools there that caters to the Asian students (which you kindly associate with the so called "loss of face syndrome"), because it would be such a waste of resources & time
It would at least stop the stench of hypocrisy emanating from your post.However, alf5071h post with ref to professional culture is spot on."Get-homeitis" or "Get-thereitis" isn't exclusive to a certain ethnicity or be gender specific.
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Preliminary report was out a couple of months back.
The draft for the final report is out and about... but I've yet to come across it. No changes in the factual findings, the major additions I am told are the effects of not anticipating tailwinds (way larger than what normally happens here on a domestic flight) on the descent leading to steeper and quicker descent, which would normally be OK, but there's also the is human factor analysis (which will definitely make this hard to obtain due to additional confidentialities) covering certain abnormalities in the crew's actions and probable factors affecting their behaviour (on and off the job)...
Data on the preliminary report covering the last 4000ft ft of flight is likely to be deemed as "a result" of the above.
No defects were attributable to the crash as far as I know (except or the wrong type of FDR was installed).
I've seen the FDR data on it, but cannot obtain that data... if you want to rely on my (sometimes rusty) memory on the FDR, feel free to ask on the PM.
PK-KAR
The draft for the final report is out and about... but I've yet to come across it. No changes in the factual findings, the major additions I am told are the effects of not anticipating tailwinds (way larger than what normally happens here on a domestic flight) on the descent leading to steeper and quicker descent, which would normally be OK, but there's also the is human factor analysis (which will definitely make this hard to obtain due to additional confidentialities) covering certain abnormalities in the crew's actions and probable factors affecting their behaviour (on and off the job)...
Data on the preliminary report covering the last 4000ft ft of flight is likely to be deemed as "a result" of the above.
No defects were attributable to the crash as far as I know (except or the wrong type of FDR was installed).
I've seen the FDR data on it, but cannot obtain that data... if you want to rely on my (sometimes rusty) memory on the FDR, feel free to ask on the PM.
PK-KAR
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Dear Mr. PK-KAR.....I have great difficulties getting accident reports from your countries safety board. No new reports in years. Perhaps I am doing something wrong. No updates in at least 4 years.
http://www.dephub.go.id/knkt/ntsc_home/ntsc.htm
Could you please help.
http://www.dephub.go.id/knkt/ntsc_home/ntsc.htm
Could you please help.
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punkalouver,
According to them, there's no obligation for the NTSC to release the reports to the public. From 4 years ago until recently, someone else headed the NTSC, and only now has the NTSC opened up more information to the public (some say because of the Garuda crash, some say it was due to the new head of NTSC, though the reasons are likely to be somewhere between the two).
You're not the only one in the dark here!
PK-KAR
According to them, there's no obligation for the NTSC to release the reports to the public. From 4 years ago until recently, someone else headed the NTSC, and only now has the NTSC opened up more information to the public (some say because of the Garuda crash, some say it was due to the new head of NTSC, though the reasons are likely to be somewhere between the two).
You're not the only one in the dark here!
PK-KAR
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Perhaps then, they have an idea of why their countries accident reate is so horrendous. Attitude. Keeping safety lessons a secret is a a very bad attitude and I suspect that it is widespread.
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http://www.abc.net.au/news/stories/2...22/2066577.htm
The final report on the crash of a Garuda plane in Indonesia earlier this year has delivered scathing criticism of the pilots and airline regulators.
Five Australians were among the 21 people killed when Garuda flight 200 crash-landed in March.
The final report on the crash has strongly condemned the pilot in charge for flying too fast for the plane's wing-flaps to be operated properly.
It says the pilot in charge of Garuda flight 200 did not follow company procedures and make a stabilised approach to the runway in Yogyakarta on the day of the accident.
He was also criticised for not aborting the landing and going around when alerts sounded 15 times, as well as the copilot screaming to the chief pilot to go around when the aircraft first bounced off the runway.
The copilot was also criticised for not taking control of the aircraft when it was clear the landing conditions were unsafe.
The report also finds the copilot received no simulated training in taking over control of the plane from the chief pilot to execute a go-around when conditions were unsafe.
Indonesia's Director General of Civil Aviation was also criticised for not identifying deficiencies in the pilot's training.
Rescue and firefighting services at Yogyakarta Airport are also criticised in the report for not being able to access the crash site and not having the appropriate fire suppressant when they got there.
The delay in extinguishing the fire and the lack of appropriate fire suppressant agents may have significantly reduced the passengers' chances of surviving the crash, the report says.
The final report on the crash of a Garuda plane in Indonesia earlier this year has delivered scathing criticism of the pilots and airline regulators.
Five Australians were among the 21 people killed when Garuda flight 200 crash-landed in March.
The final report on the crash has strongly condemned the pilot in charge for flying too fast for the plane's wing-flaps to be operated properly.
It says the pilot in charge of Garuda flight 200 did not follow company procedures and make a stabilised approach to the runway in Yogyakarta on the day of the accident.
He was also criticised for not aborting the landing and going around when alerts sounded 15 times, as well as the copilot screaming to the chief pilot to go around when the aircraft first bounced off the runway.
The copilot was also criticised for not taking control of the aircraft when it was clear the landing conditions were unsafe.
The report also finds the copilot received no simulated training in taking over control of the plane from the chief pilot to execute a go-around when conditions were unsafe.
Indonesia's Director General of Civil Aviation was also criticised for not identifying deficiencies in the pilot's training.
Rescue and firefighting services at Yogyakarta Airport are also criticised in the report for not being able to access the crash site and not having the appropriate fire suppressant when they got there.
The delay in extinguishing the fire and the lack of appropriate fire suppressant agents may have significantly reduced the passengers' chances of surviving the crash, the report says.
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Media release
http://www.dephub.go.id/knkt/ntsc_ho...ease_GA200.pdf
Here is the media release and findings in a little more detail.
Here is the media release and findings in a little more detail.
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Speechless
From the Media Release:
"During the approach, the Ground Proximity Warning System (GPWS) alerts and warnings sounded 15 times and the copilot called for the PIC to go around.
The PIC continued the approach with flaps 5 degrees, and the aircraft attained the glideslope near the runway 09 threshold. Flaps 5 degrees is not a landing flap setting.
The aircraft crossed the threshold, 89 feet above the runway, at an airspeed of 232 knots, 98 knots faster than the required landing speed for
flaps 40 degrees."
Why?
"During the approach, the Ground Proximity Warning System (GPWS) alerts and warnings sounded 15 times and the copilot called for the PIC to go around.
The PIC continued the approach with flaps 5 degrees, and the aircraft attained the glideslope near the runway 09 threshold. Flaps 5 degrees is not a landing flap setting.
The aircraft crossed the threshold, 89 feet above the runway, at an airspeed of 232 knots, 98 knots faster than the required landing speed for
flaps 40 degrees."
Why?