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Turkish airliner crashes at Schiphol

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Turkish airliner crashes at Schiphol

Old 11th Apr 2009, 00:19
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1- Unreal. Has any type got such a device to warn of your 'unstable approaches'
No, but given the wealth of real time information collected in the modern digital cockpit it ought to be a trivial task to design and implement such a device. And if crews are going to fall asleep while monitoring the automation on a regular basis then it looks like we may need to.

2- big words from a light plane driver who is not Boeing trained, has no real comprehension of the system, and knows better than several hundred experienced Boeing developers! Pardon me, but how can you judge?
Irrelevant brow beating.

Nobody wants the crew to swing, they're dead. Killed because their flying was pants.
But some people seem to want to see their broken bodies strung up on public display nonetheless.

Where else lies the blame?
See, there's your problem right there. This whole discussion shouldn't be focused on assigning blame. The professional approach ought to be based on determining what happened and why, so that we can hopefully learn the right lessons and debate solutions that may help to prevent something similar happening in the future. Anything less is mere venting.
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Old 11th Apr 2009, 00:40
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At the first teensy-weensy sensation that the 'autos' are either doing something not EXACTLY what I told them to do, or something else..............................and it is usually sensed through my bottom

OFF.

off.


OFF!

I am the pilot. ( and I hope my F/O feels the same way)

I can fly the a/c.............and I will.

That is wot they pay me for.
 
Old 11th Apr 2009, 05:43
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MU3001A;
The professional approach ought to be based on determining what happened and why, so that we can hopefully learn the right lessons and debate solutions that may help to prevent something similar happening in the future.
The right lesson here was learned in 1903 and thousands of times later: Pay attention or die.

There is no substitute for situational awareness and no excuse whatsoever for stalling your aircraft. A radio altimeter failure is the blandest of failures - a non-event.

For real learning to occur here this must first be accepted. The lesson here is in why three experienced crew stalled their airplane.

Frankly, Rainboe is almost certainly correct: the CVR isn't going to tell us anything we can't reasonably surmise already: this crew was not flying the airplane, they were chatting, discussing whatever and got the wake-up call with the stick-shaker.

Whether you or anyone can accept this is immaterial - a perfectly serviceable airliner was stalled by its crew. This is not a case which has obscure, organizational or technical underpinnings.

We have one, very likely two stall accidents on our hands. Why? The Colgan report included some strong indications that a non-sterile cockpit was being examined as a factor in the Buffalo accident.

This discussion is most certainly not a discourse about blame. You need to come to terms with the difference between a blame culture and some very blunt facts about aviation - that very bad things happen if you don't pay attention to what you're doing all the time. That is what happened. It is where the problem began and ended. That isn't assigning blame, that is finding cause, and in this case, it is not complicated. If you think there are solutions to this, as a safety specialist with 40 years of flying (35 in heavy equipment), let me ask you what they are; more CRM? More enforcement of SOPs? More technology? More of . . . ?

At what point do we truly hand over our aircraft and our profession to the engineers and sit back, fat, dumb and happy, to use the old expression?

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Old 11th Apr 2009, 06:10
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PJ2

You write, "Pay attention or die"

I agree completely. Every pilot I worked with in the training environment, and most on the line, got the same encouragement .... "Flying is a lot of fun, but it can kill you real quick."

Those two statements are sobering thoughts and the reality of them has been demonstrated far too often in the recent past. If we take nothing else away from this entire discussion let us learn the above lessons well. Others have paid with their lives to teach them to us.

best regards,

Bruce Waddington
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Old 11th Apr 2009, 06:15
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And of all the lack of SA, nobody has mentioned the deck angle at vref-40. There had to be a mighty distraction.

Doesn't anybody remember the Lauda 767? IIRC, the reverser was not securely locked, and it deployed, something to do with lack of interlocks. After that all current Boeings got interlock upgrades, which included revised radio altimeter input. It's been about a dozen years, so I don't remember the details.

Does anybody know the thrust reverser interlock logic? One item is radio altitude, and squat switch no doubt another.

GB
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Old 11th Apr 2009, 06:24
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Bruce;
Others have paid with their lives to teach them to us.
That is the only lesson here: Respect.

And if that notion isn't clear enough for those who can't face facts or still think that this is a radio altimeter or autothrottle problem, respect for the fact that the machine is always trying to kill you, respect for human foibles and respect for gravity.

This crew did not have respect.

This is not complicated.
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Old 11th Apr 2009, 12:28
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PJ2

A reply to your post above.

Only my 2p worth but here goes.

In trying to make the business safer (surely a laudable aim if there ever was one) the job has been de-skilled.

1.They try to think of a SOP for every eventuality. This leads the crews to believe that if they can only memorise all the stuff in that big book..........they will be ok.

2. They encourage to too great an extent, the use of the autos. While this is certainly quite useful it can lead to a 'detached' flight crew. Not quite in the loop, not quite out of it.

3. If all the above lets you down, crews are SO encouraged to take it around.......as if that's the answer to all your problems

4. Airmanship is rarely given proper emphasis. Why? Easy; It's too variable, too hard to teach and too hard to test.

So you get crews trying their best to tick all the boxes, not breach their extensive SOPs and who rarely hand fly.

Now. Having criticised that way of operating I will admit/ State that it must have saved a lot of tin.

It is however, kicking off a entirely new sort of problem: Pilots who think slavish adherance to SOP and use of autos will keep them safe.........and in the final analysis, if it's gone tits-up just do a G/A.

The 'real' problem tho, is where do we go from here? What is the way back? Do we put ever firmer regs and SOPS in place, to try and make it safer or try to foster that elusive quality that could save the day. 'airmanship'?

Sadly, my money is on the former...........but I rely on the latter!

Never forget, as someone above wrote........the B@stard thing is trying to kill you!

Keep your guard UP!
 
Old 11th Apr 2009, 12:36
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Yes, there is a sense from this accident that the crew just weren't 'flying the aeroplane'. As Rainboe points out, I posted similar sentiments a month ago.

But I guess what I'm saying now is what actions need to be taken to stop this happening again? Or becoming a trend for the future?

I'm sure no pilots involved in a 'human factors' accident thought it would happen to them. By the nature of probability, most of us will not be involved in an accident. So our fundamentalist cry of 'just fly the aeroplane', 'don't get distracted', will to a great degree be a self-fulfilling prophecy.

But how do we ensure that 'other' crews will do these things which to 'us' seem second nature?

Let me suggest a starting point. Less focus in type training on the technology of the latest computer controlled system and much more on perfecting handling skills. A back-to-basics approach in aircraft design. In other words, the technology the pilots use should be for the most part invisible, and the pilots should control flight path and systems in what appears to be the 'old fashioned way'. ie, keep pilots in the loop. In line training, PF must be allowed to simply fly the aeroplane. Avoid a company culture of pilots trying to outsmart each other on who has the most technical knowledge, who can program the FMC to the nth degree etc. I'm sure we've all seen it. Keep SOP's and SID's and STAR's and approaches as simple as possible. Regulators, noise task-forces etc must be made to recognise the impact they have on flight safety. etc etc...

Of course, when we add in the cultural element to all this, it's not an easy task.
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Old 11th Apr 2009, 13:57
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Maximum

Good post and to the heart of the matter which is prevention based on lessons learned

Of course, when we add in the cultural element to all this, it's not an easy task.
The key is taking responsibility at some level.

If it aint the operator then it needs to be the regulator. If it aint the regulator then it needs to be the public within the country, if it is neither then it needs to be so stated within ICAO
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Old 11th Apr 2009, 14:43
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Been there done that attitudes are inevitable if you do this job long enough. The trick is not to get complacent.
Regardless of the length of duty day, stage of flight etc, someone must be flying the aircraft. I am in the sim more than the air these days and more and more I see the approaches being done with hands on knees. Almost always the reaction was they didn't realise they were not guarding the controls!
That means they had become complacent. And those of you old enough to have been Fleet Air Arm in the days of TUGG will remember his Flight safety Poster.
A skull and crossbones and the words... Complacency KILLS.
It's kept me alive through 47 years earning a crust in aviation. I reckon there are a couple of flight departments out there who would do well to resurrect that poster
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Old 11th Apr 2009, 17:04
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I am in the sim more than the air these days and more and more I see the approaches being done with hands on knees. Almost always the reaction was they didn't realise they were not guarding the controls!
Not too surprised by your comment.
I believe manufacturers, Airbus in that matter, unconsciously or not push for that as they elected to implement the notion of frozen command controls (sidesticks and thrust levers) which do not materialize the actions of the automation.
The pilots have now to exclusively rely on their vision and watch carefully theirs screens to know what's happening.
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Old 11th Apr 2009, 19:09
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Sounds familiar but thankfully with a better outcome:

The Aviation Herald
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Old 11th Apr 2009, 19:59
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BarbiesBoyfriend, Maximum, lomapaseo - all excellent comments which add to this important dialogue; one can hear the voice of experience here. One hopes that the industry will as well.

If I might add a couple of thoughts, and I apologize for the length, but I think this has opened a very important dialogue: - First, we have come a long way in accident prevention and investigation. Since the fifties we have, to a large extent, resolved fatal accident causes from weather, navigation (including CFIT and TCAS technology), ATC and communications (eliminating confusion both ways; reliability, ADS is a huge improvement), system mechanical/airframe failure, charting, (TERPS/PanOps) and the natural and inevitable outcome of computer technology, the introduction of automation. I think we would agree that all these have contributed positively to the nothing-less-than-spectacular reduction of fatal commercial aircraft accidents over the past fifty years.

But the rate wasn't reduced to zero. It was becoming apparent that fatal accidents were occuring in perfectly servicable aircraft.

Aviation was the first enterprise to do it's own "intervention" and admit that what it thought was "perfect" was, with different "glasses" on, substantially imperfect. The medical profession/industry is just now beginning to see the same thing about themselves and their enterprise, thankfully.

What hadn't changed until lately (last twenty years) was how the human being behaved within a complex, technical system in which risk was comparatively high and failure was extremely costly in terms of lives and property, (I know we could argue this given present economic conditions, but by "other complex human systems" I mean such systems as finance, politics, education, etc) and the notion of ergonomics and even the seemingly obscure contributions of semiotics, (signs, symbols, meaning) were introduced to assist human perceptions of data which had critical roles in risk reduction.

The notion and "science" of human factors emerged as multiple responses to the low but continuing level of fatal accidents.

CRM emerged. More effective instrumentation, (there will always be arguments otherwise but the 3-pointer altimeter vice the drum altimeter is an obvious case), crew interaction and data display were improved so that the potential for confusion was minimal. And, with early thinkers/observers such as Charles Perrow, (Complex Organizations: A Critical Essay, Normal Accidents: Living With High Risk Technologies), Jim Reason, Robert Helmreich, Sidney Dekker and many other important writers on the "new' notions of organizational accidents and human factors.

The focus turned from solely on "the pilot" to the larger, "facilitating" factors which, had they been different, may have prevented an accident. "Layering" of preventative barriers became a standard technique so that the causes of an accident were thwarted at varying levels throughout the "causal" chain to use one metaphor among a few. I think processes such as the "Why-Because", (Ladkin) analysis is a natural emergence of examination of all factors and not just the human ones in stripping away those illusions which can, and have, interferred with knowledge of what actually happened and why.

There is an old saying that, "nothing succeeds like failure and nothing fails like success". If you can bear a short diversion from which I promise to return to the topic at hand, the neoliberal economic model, (Milton Friedman, Chicago School economics), which has it's roots in the '30's but towards which Reagan-Thatcher moved their respective economies, reduced what we knew as the "welfare state"; characteristics of neoliberal economics were, privatization of formerly-government-run responsibilitis, wholesale de-regulation to "get the government out of the way of the running of the economy", the reduction/elimination of government programs for people which were perceived as "socialist" in nature and therefore wasteful of the populations' money, all of which changed regulations governing corporations, making possible the unbridled drive for profit, (including the legitimation of the idea that keeping a competitive edge required "bonuses"), and creating in both corporate and regulatory minds, the "importance" of a speculative (vice manufacturing/service) economy.

To return to the thread, as promised, airlines, like dentistry and other industries, are early bellweathers of an economy. De-regulation promised the illusion of lower airfares. Whether it has delivered or not can be argued elsewhere not here but the fact is, corporate behaviours changed to accomodate neoliberal notions of deregulation.

Slowly, employees and "difficult" suppliers (both of whom were only trying to retain some measure of economic viability in their own right against the increasing drive towards profit and the battle against all those forces which were getting in the way of that profit, all supported by changed regulation, the public view of profit and the discourse of unchecked capitalism. Employees began to be seen as expensive corporate liabilities that needed controlling. Given the digitalization and communication capabilities of the world's economies, work, in the form of manufacturing and services, began to leave North America for less expensive employees - a very short-term solution to the challenges of maximum profit-making at best.

Management target groups for cuts/changes etc emerged and were increasingly portrayed as untenable, unsupportable, without deep economic solutions, (reductions in salaries, benefits, pensions, etc). Chapter 11 and CCAA in Canada were used to dump corporate debt, "restructure" towards the above economic arrangements and ensure "cheaper labour" would move liabilities such as employees over to the profit column. Deregulation permitted first the notion then the emergence of the "lo-cost" model, the only real, lasting success of which remain Southwest in the US and, so far anyway, Westjet in Canada as well as a few in Britain and Europe.

In a political economy in which wages, benefits, pensions have been driven lower and lower in order to enhance corporate presence and profitability and in which the future of these same factors is deeply insecure, the ability for ordinary people to pay what airlines ought to be realistically charging in order to retain some measure of stability and viability, is itself reducing. To put it simply, the notion that Henry Ford had in paying his employees well enough to be able to buy the products they made, has been completely reversed and the only products we can afford are those made in "cheaper" economies. Such an economy has been "bought", in some measure, with the reductions in wages, benefits and company pension plans.

The notion that aviation can be done cheaply, with reduced oversight because of it's enormously successful reduction in fatal accident rates, has its roots in the above barebones outline of how our political economy has changed since 1970. Due regard for risk is diminished, justified by how expensive it is to mitigate "what little" risk remains as seen in the very low accident rate - success becomes failure; the notion that aviation is "high risk" has been intentionally diminished; with reduced oversight as regulatory responsibilities are privatized (passed on to individual airlines). Data programs themselves may be seen as impediments to profit rather than enhancing profitability through the mitigation of risk.

The forces at work described very briefly here and certainly in blunt terms which fail to appreciate the enormous complexity and clear exceptions to such an assessment, have, as those who fly airplanes and work commercially know, always been at work in aviation - it's a very thin margin at best even in good times - but these forces have been exacerbated by the turn towards a neoliberal political economy in which all corporations, businesses, governments and populations struggle to adjust and make money in.

I take up time/space/bandwidth here in discussing these factors because these are the same factors which have driven airlines towards "lo-cost" mentalities: - To deal with neoliberal economic realities.

The greatest challenges to airlines has always been the cost of employees first, then the cost of fuel. While the two see-saw'd recently, I'm not sure and would have to research it but I think employees have now taken second place to fuel as being the highest expense for an airline.

When we arrive at the details concerning flight crews, "solutions" such as the MPL, reduced training footprints, retiring/buying out "expensive" (but experienced) older crews and hiring less experience because the human factors responses such as SOPs/CRM etc are interpreted by managements as "solving" such problems, hunting/hiring high-quality MBA-level business graduates and placing them in positions of wide authority based upon education, not aviation experience and having manufacturer's make claims and promises regarding the automation panacea that can save airlines the expense of the third crew member while increasing safety, (another example of truth to be sure and which is embraced by cost-concious managements who need every cent, but the "qualifying conditions" such as reduced competency, reduced training, reduced cockpit oversight are largely ignored) - in short, we have, through a complex series of economic and political factors, ended up with institutionalized complacency and a regulator willing to vacate it's responsibility, all fully legitimated in the discourse of "automation" and other such responses to human factors, when in fact, the accident rates are telling us that this path is the incorrect one.

I write this because I think it is a valuable exercise in trying to understand why we have arrived where we have so that we can posit good solutions. I say this because we cannot just "go back". Our society has fundamentally, vastly, changed since the '70s - a "re-regulation" is certainly not in the cards nor is it the answer. I think we are smarter today than then but the solutions are difficult to get placed upon the table because they counter the economic trend and the economic discourse which has been established in peoples' minds regarding cost and profit and the value of experienced, well-trained and intelligent employees.

In other threads I and many have observed that those who would make excellent pilots are taking one look at the profession and choosing to go elsewhere to "make their fortune" because aviation not only is very bad bet in terms of remuneration and a secure future upon which one might raise a family (for non-aviation readers or non-pilots, it has been like that for much longer than since last October), but does not reward intelligence, independance of thought, experience and imagination. The industry wants, to use the term, "cookie-cutter pilots" because they think that this is a legitimate and "safe enough" response to present needs. I am well aware that a certain level of standardization is needed but those that fill such a bill are going elsewhere and airlines' pipelines are starting to run dry of experience.

Second, while those with experience and history are always retiring and taking their knowledge of history with them, the present circumstances are endemic and not transitory. Experience will, of course, be gained, but what is being forgotten is, that experience was gained at a very high cost and the industry that provided that experience is being dismantled and young people know it and see it.

For those who lament the comments made by seasoned professionals here and in other threads, think on these factors and the potential outcomes. Books could be written on this phenomenon but of course, they wouldn't sell more than a few thousand copies at best - such knowledge and certainly such views are not welcome in any board meeting that I am aware of and are not welcome at some corporate safety board meetings I know of.

While I am keenly aware that these factors are very much at work elsewhere, I am here concerned with aviation and the effects of such trends will have on the fatal accident rate which has lately exhibited signs of stress, not in numbers but in the quality and circumstances of the accident.

Safety people always risk being dismissed as "the sky is falling" harbingers of doom. As well, I know that some industrial issues in pilots' associations sometimes mask as safety issues - (and sometimes, sadly, that is the only way to get the attention of an airline's management or the regulator).

The current trends are not unclear. What is unclear is, a) the government and then corporate response, and b), the nature of the accidents and the trends to which they contribute, and the turn that the curve takes over the next five years - up or down? It cannot remain steady.

I posit that these two outcomes will determine which way the so-far very successfully-reduced fatal accident curve turns. I'm sure the literature will be worth watching as will the response of the regulator and the airlines.
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Old 11th Apr 2009, 20:01
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CONF iture;
The pilots have now to exclusively rely on their vision and watch carefully theirs screens to know what's happening.
If there was anything difficult about the transition from the 767 to the A320 that I found, that was it - very little tactile feedback - all visual, except for pitch attitude, sound (air and engine noise). One has to be glued to the FMA - we didn't call her Capricious Christine for nothing.
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Old 11th Apr 2009, 21:28
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Programmers and Pilots vs. Doctors and Lawyers

The first group are generally employees and have come under the dominion of the bean counters.

The second group generally work as individual practitioners or in partnerships and has the power to set their T's & C's so that they can have a reasonable lifestyle.

Both groups require some intelligence to do the job, but the second group requires credentials that take several years to acquire and restricts entrants.

Now line pilots do at least usually have a union that prevents mass replacement of the older, more expensive pilots with guys fresh out of school. This is good as long as your employer remains in business.

The whiz kids picked up a while ago that programming has become an entry level occupation and gravitated to the financial industry, where so far the Indians and Chinese have not (yet) taken over.

Eventually the accident rate will slide back up and beatings will increase until morale improves while the authorities promulgate ever thicker SOPs

Eventually there will be nobody up front and all flights will be run out of Bangalore by floors full of dispatchers communicating via uplinks
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Old 11th Apr 2009, 21:45
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No, that's rubbish! Bangalore would have developed and priced itself out of the market by then! Somewhere like Kinshasa, Zaire will house the call centre and communications uplink to fly the aeroplane!
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Old 11th Apr 2009, 22:27
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PJ2

A superb summary of where we are and how we got here.

I woud humbly request that you post it additionally on the Safety Forum. As you suggest, there are many of us who agree that the discussion surrounding the Schipol accident has cracked open a dialogue that should continue. That accident was one of the catalysts for that, here on pprune, but I for one would love to continue the discussion of "where are we really in terms of risk/threats to safety?" and the obvious follow-on: "what should we do now, and how do we do it?"

Thanks again.
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Old 11th Apr 2009, 23:04
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slf here, im assuming the gpws/at is on the left ralt ?
does this mean this aircraft was doing a dual channel approach for the autopilot to disconnect ? or does that happen with a gpws warning ?

----

AO-2009-013: BOEING 737-800 VH-VYL, Sydney Aerodrome NSW, 7 April 2009


While passing 150 ft on short final approach to runway 16R, the co-pilot's radar altimeter indicated 60 ft and the GPWS gave a 10 ft alert. As a result, the autopilot disconnected and the thrust levers moved towards idle. The crew manually increased the thrust. The investigation is continuing.


http://www.atsb.gov.au/publications/investigation_reports/2009/AAIR/aair200901859.aspx
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Old 11th Apr 2009, 23:25
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PJ2 What a clever post.

Just wish I was clever enough to take out of it all that you'd put into it.

Sadly, I'm not that clever.

When I work though, I am wary.

I'm wary of the weather. I'm wary of the aircraft.

I'm wary of the F/O and I'm wary of myself.

I watch the pushback guys and the engineer.

I'm wary of every damned thing that happens!

If I could find a pill that would make me even more wary, I'd eat it.

I see 'bulletproof' guys more and more and they give me the freakin' shivers.

It's a big ally tube doing 500mph. Its not hit anything yet but................
 
Old 11th Apr 2009, 23:46
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Grizz;

The tone of the dialogue on this emerging issue as seen not only throughout PPRuNe but through other forums to which seasoned professionals are contributing, the appearance and testimony of Captain Sullenberger before Congress a month or so after the ditching and the Adam Hanft article on "Deconstructing Sully; The Cult of Sully; More Than a Hero, a Holdover", saying the same things, and the nature of the accidents we have seen, (not all of course, but certainly the Schiphol accident, the Kentucky CRJ accident, probably the Madrid MD83 accident and, only in my opinion from what is known to this point, the Buffalo accident), are pointing to a pattern, spotty we know, but for those who do this work, sufficiently clear.

This isn't just about stalling an airliner by not paying attention. This is about an industry-wide malaise, the tip of the Frank Bird triangle which has at least three if not four accidents at the top and which has plenty of data down below.

Nor is the malaise I believe I am describing exclusive to "incidents or accidents". In fact the term "malaise" is not a term describing "cause" but is a cultural/social characteristic. But the Bird model does not attach cause or a "WBA" model to the numbers - it's just a graphic which portrays relative occurences. Seeing an emerging pattern is a tenuous exercise with such thin data but in this business, each incident carries antecedents, even the Schiphol accident.

Included in that kind of "pattern-making" analysis, which draws "the long line" and accepts/accomodates aberrations and individual examples contrary to the pattern, are the effects of economics, possibly de-regulation, possibly the factors which are only very briefly touched upon in the earlier post.

This doesn't deserve a wholesale assault response because the aviation industry is not falling down around our ears, but it deserves some careful examination and discussion by the industry itself as well as those doing flight safety work. In this industry as you likely know, it doesn't take many occurences for a pattern to form; that's one reason it's as safe as it is - very early, and hopefully aggressive, interventions.

These are thoughts that are occuring to me as I write - the only interest is to raise awareness of such patterns and invite examination of same.

Last edited by PJ2; 12th Apr 2009 at 00:01.
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