Bmi Airbus lands with park brake on (Report)
Below the Glidepath - not correcting
Not underestimating the HF failures of the ergonomic layout, there are also confirmatory checks required that a control selection has been effective that may have prevented this - ie. the flap position would have shown that full flaps had not been selected. This guy was clearly distracted for a number of reasons, but the whole concept of CRM is that you are not acting alone. It's not like there were not other indications that something was not right in the cockpit. Before we redesign the Airbus, just consider how many thousand crews get this sequence of events right every single day.
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I know that this is a forum to speculate about aviation issues, but do we have any knowledge of the previous incidents where a similar problem occured?
I think we should like look to what was in the PNF mind to do such a thing.
I am Bus Driver and it's hard for me to get an explanation how could oneself mistake the flap lever for the parking brake. The levers are different, operate in different ways and give different indications (Landing memo would show flaps 3).
However, I agree on software change (ECAM) to indicate the pilots when parking brake is on without WoW.
Check Six krueger...
I think we should like look to what was in the PNF mind to do such a thing.
I am Bus Driver and it's hard for me to get an explanation how could oneself mistake the flap lever for the parking brake. The levers are different, operate in different ways and give different indications (Landing memo would show flaps 3).
However, I agree on software change (ECAM) to indicate the pilots when parking brake is on without WoW.
Check Six krueger...
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I agree it seems hard to believe that the park brake was mistaken for the flap lever and the landing memo was disregared. But on the point of it not happening on a 737 . I agree it could not be mistaken, but I do remember years ago someone applying the park brake whilst airbourne for some reason and this led to another problem altogether, that is once set and released I believe the antiskid becomes inop. The fact that it may have been set earlier in the flight and flap full was still taken would mean that there would still be an appropriate landing memo.
It is obvious from many posts that there is justified disbelief that the error (operate park brake instead of flap lever, and not spot the warning) could happen at all.
But the point is that it has happened, because it can happen.
At the risk of being boringly repetitive, it is not enough simply to improve the chance of capturing the error prior to landing, as recommended by AAIB.
Action is needed to eliminate the possibility of the error occurring in the first place. Perhaps some or all operators have done that, by going well beyond the AAIB's recommendation.
But because of the financial consequences, perhaps not. In which case, the error WILL occur again. Let's hope that when it does the only consequence is some burst tyres. But what if the surface is very wet, maybe not even grooved?
But the point is that it has happened, because it can happen.
At the risk of being boringly repetitive, it is not enough simply to improve the chance of capturing the error prior to landing, as recommended by AAIB.
Action is needed to eliminate the possibility of the error occurring in the first place. Perhaps some or all operators have done that, by going well beyond the AAIB's recommendation.
But because of the financial consequences, perhaps not. In which case, the error WILL occur again. Let's hope that when it does the only consequence is some burst tyres. But what if the surface is very wet, maybe not even grooved?
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Finding the error
I am slightly surprised that people are suprised you can make this kind of error :-) Perhaps I am unusually dozy, but there are many "automatic motor actions" that I interchange on a regular basis. I have certainly, for example, picked up the coffee pot when I was looking for the frying pan, turned on the car windshield wipers when I meant to turn on the headlights, and to be more on topic, turned on the aircraft fuel boost pumps when I meant to turn on the ignitors.
The key is in identifying the error in the chain. For example, if the checklist calls for "igniters on", I reach over and flick a couple of switches. If the other pilot says - "Hey, the igniters are not on" - then we might go ahead and look again, and switch them on. BUT the other importnant task is to go back and determine - what the heck DID we turn on last time?
The same opportunity was present in the park brake incident. The PF called for the flaps, and PNF did an action. On later review, the PF noticed that the flaps were not set, and called for flaps again. The PNF selected flaps. The missed opportunity was to say - "Since it wasn't the flaps, I wonder what you did LAST time I called for flaps...". That may have got some much needed attention back inside the cockpit for a moment or two, and avoided an embarrassing rubber stripe down the runway.
This seems like an excellent CRM learning example.
The key is in identifying the error in the chain. For example, if the checklist calls for "igniters on", I reach over and flick a couple of switches. If the other pilot says - "Hey, the igniters are not on" - then we might go ahead and look again, and switch them on. BUT the other importnant task is to go back and determine - what the heck DID we turn on last time?
The same opportunity was present in the park brake incident. The PF called for the flaps, and PNF did an action. On later review, the PF noticed that the flaps were not set, and called for flaps again. The PNF selected flaps. The missed opportunity was to say - "Since it wasn't the flaps, I wonder what you did LAST time I called for flaps...". That may have got some much needed attention back inside the cockpit for a moment or two, and avoided an embarrassing rubber stripe down the runway.
This seems like an excellent CRM learning example.
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Four, not one, pilot errors occurred, as follows:
Error one - selected park brake on instead of flap.
Error two - failed to check that the selected flap position was actually achieved after selection.
Error three - after PF requested a repeat of the selection, failed to ask himself what he had actually selected previously if it wasn't flap.
Error four - if the Captain was so concerned about landing conditions at Leeds, he should have elected himself as PF for that sector. Basic command error.
One eror is unfortunate, two errors are careless, but four errors?
Wasn't "management", was he?
Bet if you gave me the pilots name he'd be on my list of "accidents waiting to happen". Unless he was someone I hadn't flown with before I left the sinking ship. Interesting how I have a much shorter list in my current airline.
The solution starts with the pilot selection process, of course. The whole sorry can of worms opens up, though, when you look at that.
That wouldn't be the self proclaimed (delusional?) Appollo astronaut, Space Shuttle pilot, "consultant to every major aviation issue in the last twenty years" and "ace airliner pilot after two sim rides" would it? God help you.
In fairness, the psychologist comments (as far as quoted in the report) seem to be sensible (can't be the same bloke, then!). They are also extremely obvious. Wonder if I could get a job doing stating the obvious as a sideline? Easy money!
Watch this space. More like it to come, IMHO. (and don't anybody mention the Kegworth crash, emergency landing Luton without any oil in either engine, F27 crash EMA, attempting to fly LHR to MME with only a fraction of the required fuel, taking off with gear pins in, trying to take off from a taxyway or severe damage by hailstones which other operators avoided, to name but a few).
Error one - selected park brake on instead of flap.
Error two - failed to check that the selected flap position was actually achieved after selection.
Error three - after PF requested a repeat of the selection, failed to ask himself what he had actually selected previously if it wasn't flap.
Error four - if the Captain was so concerned about landing conditions at Leeds, he should have elected himself as PF for that sector. Basic command error.
One eror is unfortunate, two errors are careless, but four errors?
Wasn't "management", was he?
Bet if you gave me the pilots name he'd be on my list of "accidents waiting to happen". Unless he was someone I hadn't flown with before I left the sinking ship. Interesting how I have a much shorter list in my current airline.
The solution starts with the pilot selection process, of course. The whole sorry can of worms opens up, though, when you look at that.
The operator even called in a psychologist to help them with this aspect.
In fairness, the psychologist comments (as far as quoted in the report) seem to be sensible (can't be the same bloke, then!). They are also extremely obvious. Wonder if I could get a job doing stating the obvious as a sideline? Easy money!
Watch this space. More like it to come, IMHO. (and don't anybody mention the Kegworth crash, emergency landing Luton without any oil in either engine, F27 crash EMA, attempting to fly LHR to MME with only a fraction of the required fuel, taking off with gear pins in, trying to take off from a taxyway or severe damage by hailstones which other operators avoided, to name but a few).
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acbus1 has ground enough axes to chop down the amazon rain forest, he is an extremely disgruntled ex employee with a rather worrying personality flaw when it comes to getting over being given the push I would regard his opinions as the rantings of a rather sad individual
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Ergonomic Cockpits?
Perhaps there are some of us here old enough to recall the moves necessary to get the gear and flaps in motion on a DC3.
We seem to have managed it well enough most of the time. But then we were from a different era.
We seem to have managed it well enough most of the time. But then we were from a different era.
Very interesting reading here and I would put money on that incident NOT being the last of its kind,as said further up the post,it happened because it COULD happen.One A340-600 operator (not VS which may narrow it down!) had a similair incident when the park brake was activated instead of the taxi camera,the switches are fairly close together on the centre console,oops.Several bangs later....Theres a pic on airliners.net for the curious,right where was I? Oh yes,whether it was intentionally designed to prevent little 'oops' moments or not I dont know but the B744 method of fully applying the brakes before being able to set the park brake seems more 'Murphy's' proof. (Thats the law,not the beer)
Force of habit and not in our SOPs, I always check the residual brake pressures befroe landing. With two needles pointing at the '3' mark on the standby brakes, it would have been a big clue!
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but the B744 method of fully applying the brakes before being able to set the park brake seems more 'Murphy's' proof
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ACBUS1 "Got an axe to grind with BMI then!"
I merely listed a combination of pilot errors which contributed (IMHO) to the incident. I was attempting to suggest that the incident was caused, in this instance, more by human error than defective design or ergonomics. The designers can attempt to design error out of the system (and I'm obviously in favour of that) but, in the end, it all boils down to having a minimum level of competence from the cockpit crew. Just my opinion, supported by a list of what I saw as obvious errors. At least I attempted to contribute to the thread topic, unlike those who seem to populate PPRuNe in order to berate contributors, rather than add to the discussion.
As an aside to the thread topic, I certainly do have an axe to grind with the authorities who permit unregulated involvement by psychologists. From my observations, backed by the opinions from the vast majority of colleagues, some of these individuals actually do the industry a disservice. There was a widespread opinion that one such individual was in urgent need of treatment and was certainly unsuitable for the job.
ACBUS1.
Quote - "ACBUS1 "Got an axe to grind with BMI then!"
Certainly agree with your views on airlines' "tame" psychologists, particularly ones with an obsession about the mental powers of leeches !
Collecting a whole list of incidents though, dating back to the days when the airline was in its infancy, seems to reflect an unhealthy paranoia with your own weaknesses.
Could it be that you spent your whole time watching your back instead of confidently looking ahead and getting on with the job ( and your fellow crewmates ?)
Just a thought.
Don't let's get away from the thread though.
Rgds, Sleeve.
Quote - "ACBUS1 "Got an axe to grind with BMI then!"
Certainly agree with your views on airlines' "tame" psychologists, particularly ones with an obsession about the mental powers of leeches !
Collecting a whole list of incidents though, dating back to the days when the airline was in its infancy, seems to reflect an unhealthy paranoia with your own weaknesses.
Could it be that you spent your whole time watching your back instead of confidently looking ahead and getting on with the job ( and your fellow crewmates ?)
Just a thought.
Don't let's get away from the thread though.
Rgds, Sleeve.
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Collecting a whole list of incidents though, dating back to the days when the airline was in its infancy...
They are fact and were included to ask the question....Is this part of a pattern, into which the topic incident fits?
Asking such questions is healthy, is it not? It is all part of the normal process of identifiying trends, bad habits, bad practices and system deficiencies. Only by identifying such will we ever improve air safety.
...an unhealthy paranoia with your own weaknesses.
Not a low grade psychologist are we, Sleeve Wing?
Could it be that you spent your whole time watching your back instead of confidently looking ahead and getting on with the job
....and it isn't healthy, I agree completely!
acbus1 has ground enough axes to chop down the amazon rain forest, he is an extremely disgruntled ex employee with a rather worrying personality flaw when it comes to getting over being given the push I would regard his opinions as the rantings of a rather sad individual
I must say it is all getting rather repetetive and tedious now , so come on acbus1 give it a rest!!
Lets face it ALL airlines have minor incidents from time to time ,happily the vast majority come to nothing and hysterical journos never get to hear about them, bmi has a safety culture that is up there with the best (as it rightly should be) and I find it distasteful in the extreme for ex employees to suggest that their former colleagues are less than professional and competant in any aspect of performance.
acbus1 you have a worrying and unhealthy obsession which you need to let go of, do yourself a favour and move on !
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Whether acbus has an axe to grind or not is irrelevant to the four errors he puts forward. Please do not confuse the messenger with the message. Rediculing the messenger does not help and often hinders the message.
Checks and confirmations in the cockpit are there for a reason and this incident is one of many, with many airlines worldwide, why such checks are required. Hence when you select flap full you check that you achieve flap full on the ECAM.
Checks and confirmations in the cockpit are there for a reason and this incident is one of many, with many airlines worldwide, why such checks are required. Hence when you select flap full you check that you achieve flap full on the ECAM.
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Wasn't "management", was he?
Bet if you gave me the pilots name he'd be on my list of "accidents waiting to happen". Unless he was someone I hadn't flown with before I left the sinking ship.
Bet if you gave me the pilots name he'd be on my list of "accidents waiting to happen". Unless he was someone I hadn't flown with before I left the sinking ship.
Just a very good line captain, decent bloke, excellent CRM etc and certainly wouldn't feature on anyone's list of an accident waiting to happen. In fact I can't think of a single pilot - in either seat - who would fit that particular bill. As for watching your back - we're getting shafted far more by balpa than we are by the company! And no, I'm not management either.
As others have said: If it can happen, it will.
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Airbus lands with Park Brake set
I recall an incident identical to this back around 1992/3 on 27L at LHR. I was at the time an apprentice engineer with BA. I attended the scene to recover a Lufthansa A320, it had blown 3 of the 4 mainwheels (numbers 2, 3, & 4), and the 4th was not in a very good way. The 3 axles carrying the burst mainwheels also saw extreme damage to the brake units, worn completely flat through almost 50% of their diameter, the aircraft gouged 3 'trenches' down the runway, and took us several hours to clear, using crocodile jacks, main aircraft jacks, and bags, big mess, fortunately no-one was hurt, although the trolley dollies stood taking pictures of the one remaining inflated tire were lucky to escape harm as that one could have blown at any time.
It strikes me as ludicrous that you can select the park brake on whilst the aircraft is airborne, what purpose does that serve - maybe a pit stop in the sky ???? But that's airbus for you, I am currently a B2 certifier on these types and find many strange anolomies, another example is the RAT deploy switch, which is a guarded switch identical in size, shape, and action as well as very similar location to the emergency gen test switch, the only difference being colour of the guard. And on numerous occasions whilst carrying out hangar checks has the RAT been deployed instead of the emergency generator test being initiated, the question I am asking is why should that system need to be live on the ground ? You would hardly want to deploy the RAT in 'anger' whilst on the ground now would you ????
It strikes me as ludicrous that you can select the park brake on whilst the aircraft is airborne, what purpose does that serve - maybe a pit stop in the sky ???? But that's airbus for you, I am currently a B2 certifier on these types and find many strange anolomies, another example is the RAT deploy switch, which is a guarded switch identical in size, shape, and action as well as very similar location to the emergency gen test switch, the only difference being colour of the guard. And on numerous occasions whilst carrying out hangar checks has the RAT been deployed instead of the emergency generator test being initiated, the question I am asking is why should that system need to be live on the ground ? You would hardly want to deploy the RAT in 'anger' whilst on the ground now would you ????