EK407 Tailstrike @ ML
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Too many cooks!
It is a two man cockpit, for heavens sake. Let them work accordingly. If you bring in the incoming crew (you barely ever meet them), the augmenting crew (their in everyone's way, having no place to go), any administrator (that couldn't be bothered by anything else but the next cricket match) or any kind of remote computer/laptop/calculator/adminstrators handheld prodigy, with programming that defies Windows 95 with a 386 processor, then you're heading the wrong way.
Too many cooks simply spoil the meal, especially those who know little about real cooking, if you get my drift.
It should be entrirely left up to the two operating pilots with the final loadsheet, provided mostly 10-15 minutes before ETD. The TO calculation should be done together and only then, with the actual loadsheet and the actual numbers and (most probably) actual runway and its conditions. That may sound late, but having done all the preflight preparations, the last 10 minutes should be calm and reserved for these crucial calculations and inputs, and subsequently adequate and specific briefing. The operating pilots should throw out ANYBODY during this phase, even including the augmenting Captain who has 30000 hours more on his cap, is TRE and comes from the land that invented better North Atlantic crossings than Lufthansa.
Any calculations and endless briefing-blahblahs done before are useless and dangerously mind pre-setting, as we subconsciously tend to thinks "it's already done".
I tend to go for fighting distractions, as a main ennemy before take-off.
As it appears in this incident, some distraction was "self induced and augmented" and might have accelerated resignation. We will see ....
It is a two man cockpit, for heavens sake. Let them work accordingly. If you bring in the incoming crew (you barely ever meet them), the augmenting crew (their in everyone's way, having no place to go), any administrator (that couldn't be bothered by anything else but the next cricket match) or any kind of remote computer/laptop/calculator/adminstrators handheld prodigy, with programming that defies Windows 95 with a 386 processor, then you're heading the wrong way.
Too many cooks simply spoil the meal, especially those who know little about real cooking, if you get my drift.
It should be entrirely left up to the two operating pilots with the final loadsheet, provided mostly 10-15 minutes before ETD. The TO calculation should be done together and only then, with the actual loadsheet and the actual numbers and (most probably) actual runway and its conditions. That may sound late, but having done all the preflight preparations, the last 10 minutes should be calm and reserved for these crucial calculations and inputs, and subsequently adequate and specific briefing. The operating pilots should throw out ANYBODY during this phase, even including the augmenting Captain who has 30000 hours more on his cap, is TRE and comes from the land that invented better North Atlantic crossings than Lufthansa.
Any calculations and endless briefing-blahblahs done before are useless and dangerously mind pre-setting, as we subconsciously tend to thinks "it's already done".
I tend to go for fighting distractions, as a main ennemy before take-off.
As it appears in this incident, some distraction was "self induced and augmented" and might have accelerated resignation. We will see ....
Good point.
Has anyone ever actually done a study on that?
What % of Part 121 flights have more than the normal crew compliment v's what % of Part 121 aircraft involved in a major incident have more than a normal compliment.
I would guess about 10% of flights I do have someone extra on the Flight deck yet it seems that about 30% - 50% of accidents I hear about have someone extra on.
Anyone know the stats?
Has anyone ever actually done a study on that?
What % of Part 121 flights have more than the normal crew compliment v's what % of Part 121 aircraft involved in a major incident have more than a normal compliment.
I would guess about 10% of flights I do have someone extra on the Flight deck yet it seems that about 30% - 50% of accidents I hear about have someone extra on.
Anyone know the stats?
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Finger Trouble- How costly it can be on a modern aircraft
I was waiting for some sort of reliable data from investigation to emerge before posting this story. Though the enquiry report is not published yet, the scenario of a mix up of a "2" and "3" looks most realistic.
I am with aviation for nearly 4 decades. I relate an incident that I recall very vividly which can high-light the perils of finger trouble on a modern aircraft and how pilots of yesteryears had a better knack of spotting gross errors.
It was a 747-200, 3 man crew, and I was in the cockpit (I am not a pilot). During take off preparation the 3rd crew, Flight Engineer prepared a Take off card with speeds V1, Vr, etc and kept on the pedestal. This was the norm in the airline I was working at that time. The pilot in command while setting the white bugs on his airspeed indicator, paused, gave back the card to the FE and said "Re-check, these are wrong". The First officer had already set the bugs on his side and did not see the error. The FE , re-checked the speeds, and corrected the error. There was an 11 knots error and by this time he was sweating profusely, which I remember very well. He told me later in the flight, "if the Captain reports the matter he will be fu****". A few weeks later I found out that the incident was indeed reported by the Captain, the FE was grounded and send for retraining.
A question will arise for many present day pilots, "How did the captain spot the error"? Well the year was 1982, when computers were not available and crew had a fair idea of these important figures for a particular flight. They flew one type of aircraft.
In today's scenario, everything in the cockpit is automated. The Laptop calculated figures are entered in FMC CDU, are automatically set on the PFD for V1 speeds etc for both pilots. Pilots have less chance of detecting the error, as they fly A330 one day and A345 the very next. One flight can be on a short 2 hour sector and the next can be a 14 hr one on A340. The errors from finger trouble are rarely reported and highlighted only when disasters occur.
I feel sorry for the crew. One single mistake can ruin an impeccable career. In EK407 case the error nearly killed them and the paxs. Probably could have killed off the airline as well. Any airline would have punished them unfortunately the same way (Except the highly unionized ones)
Human factors could be the main cause, but for such gross errors, you pay with your job. That is life for a pilot, I suppose. Hope the crew had no mortgage on Dubai property as well, in whcih case their next shock will be when they go to close their Bank accounts!!
I am with aviation for nearly 4 decades. I relate an incident that I recall very vividly which can high-light the perils of finger trouble on a modern aircraft and how pilots of yesteryears had a better knack of spotting gross errors.
It was a 747-200, 3 man crew, and I was in the cockpit (I am not a pilot). During take off preparation the 3rd crew, Flight Engineer prepared a Take off card with speeds V1, Vr, etc and kept on the pedestal. This was the norm in the airline I was working at that time. The pilot in command while setting the white bugs on his airspeed indicator, paused, gave back the card to the FE and said "Re-check, these are wrong". The First officer had already set the bugs on his side and did not see the error. The FE , re-checked the speeds, and corrected the error. There was an 11 knots error and by this time he was sweating profusely, which I remember very well. He told me later in the flight, "if the Captain reports the matter he will be fu****". A few weeks later I found out that the incident was indeed reported by the Captain, the FE was grounded and send for retraining.
A question will arise for many present day pilots, "How did the captain spot the error"? Well the year was 1982, when computers were not available and crew had a fair idea of these important figures for a particular flight. They flew one type of aircraft.
In today's scenario, everything in the cockpit is automated. The Laptop calculated figures are entered in FMC CDU, are automatically set on the PFD for V1 speeds etc for both pilots. Pilots have less chance of detecting the error, as they fly A330 one day and A345 the very next. One flight can be on a short 2 hour sector and the next can be a 14 hr one on A340. The errors from finger trouble are rarely reported and highlighted only when disasters occur.
I feel sorry for the crew. One single mistake can ruin an impeccable career. In EK407 case the error nearly killed them and the paxs. Probably could have killed off the airline as well. Any airline would have punished them unfortunately the same way (Except the highly unionized ones)
Human factors could be the main cause, but for such gross errors, you pay with your job. That is life for a pilot, I suppose. Hope the crew had no mortgage on Dubai property as well, in whcih case their next shock will be when they go to close their Bank accounts!!
"How did the captain spot the error"? Well the year was 1982, when computers were not available and crew had a fair idea of these important figures for a particular flight.
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There was still enough automation in those days to make errors. Consider KAL007 in 1983 when a simple mistake concerning the autopilot and INS inputs had catastrophic implications.
On that fateful day, the Russians were conducting tests at Kamchatka Base and were on high alert, hence the response.
In other words there was no entry error. The INS story was a cover-up
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tbaylx, what you say is right and that this should be a leaning experience for the industry as a whole. Sacking people is not a means to an end. All that i am saying is that this thread is full of strange and imaginative reasons why the aircraft left a lot of aluminium on the runway at melbourne. As the investigation is pointing towards the wrong infromation being put into the computer ( to suggest any sort of cover up or conspiracy only insults the professionals working in this industry). I have been in engineering for 35 years and have never sacked anyone for putting there hand up for making a mistake. We are all in this industry together lets keep it professional and safe for our customers. thanks guys.
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Sounds like the old saying, The only silly mistake or silly question is the one thats has not been answered or learned. !!!
It can prove to be a very good/cheap way of learning and saving lots of money and face. !!!
Anyone that withholds said information should think of the next event and how they will feel. ????
But for the above to work, all operators should be on a learning curve full time.......
It can prove to be a very good/cheap way of learning and saving lots of money and face. !!!
Anyone that withholds said information should think of the next event and how they will feel. ????
But for the above to work, all operators should be on a learning curve full time.......
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Pool! Spot on.
In an earlier post I mentioned the 767 that had ZFW instead of TOW in the TODC.
After that they introduced a feature that compared the TOW with the flight number. If the numbers were not in accordance with a set parameter you had to recheck and confirm the numbers.
When the A340 entered service they opted not to have this. Ended with an "EK407" in PVG 2005.
Until I have a better system I do my own check. I check the TOW at the briefing and calculate the expected V2. If the FMC calculated one differs I investigate. Many pilots use this but it is not learned during training. Wonder why? Would be very useful for new crewmembers.
In an earlier post I mentioned the 767 that had ZFW instead of TOW in the TODC.
After that they introduced a feature that compared the TOW with the flight number. If the numbers were not in accordance with a set parameter you had to recheck and confirm the numbers.
When the A340 entered service they opted not to have this. Ended with an "EK407" in PVG 2005.
Until I have a better system I do my own check. I check the TOW at the briefing and calculate the expected V2. If the FMC calculated one differs I investigate. Many pilots use this but it is not learned during training. Wonder why? Would be very useful for new crewmembers.
A simple mistake concerning the figures into an Ins, although not in the cockpit, resulted in Erebus.
That was one factor in the accident.
Like most accidents there were several factors that, if any one of them had been removed, the accident would not have occurred.
One could just as easily say " A simple error of judgement , going below the company VMC minima of 6000ft, resulted in Erebus"
But that would be equally inaccurate.
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Air NZ & Erebus
As framer has said, the change to an INS coordinate made by AirNZ navigation staff was one factor which contributed to the loss of the DC10 and all on board. Descending below the area MSA whilst believing to be visual, but in fact being in "white out" conditions, was just as much to blame. Having flown into the nearby McMurdo Base a number of times in the previous summer (1978),and having been thoroughly briefed beforehand an the perils of "white out", we maintained a regular sked with McMurdo en-route. If the trend was favouring a "white out" happening we would return to Christchurch before PNR. Incidentally, the McMurdo Rescue Crews were fearful of an accident involving a sight-seeing polar flight. They knew that even if the impact was survived they did not have the resources to conduct a rescue of such magnitude, especially as most on those flights would have been in light clothing and would quickly succumb to the extreme low temperature.
KAL007
I thought they were off course for the entire journey due to incorrect INS inputs made prior to departure from Anchorage. In any event, 'cutting corners' should not have taken the aircraft over the Kamchatka Peninsula.
Chart
I thought they were off course for the entire journey due to incorrect INS inputs made prior to departure from Anchorage. In any event, 'cutting corners' should not have taken the aircraft over the Kamchatka Peninsula.
Chart
Last edited by Teal; 15th Apr 2009 at 02:27. Reason: typo
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With the greatest of respect, Tyres...
A simple mistake concerning the figures into an Ins, although not in the cockpit, resulted in Erebus.
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Big question, of course, is whether it was
-finger trouble or
-using wrong figure from loadsheet, or
-insert in wrong place or
-zillions of other possibilities,
that caused this incident?
Always wondered with my own company why the layout of our ACARS loadsheet wasn't changed (e.g. separate header with just figures used for input), same for layout on FMS performance page, etc...
I feel sorry for the crew they had to resign, but now they can give honest feedback (f.i. if they think that factors like schedule contributed) with no pressure from anybody. This will hopefully lead to useful feedback/recommendations.
-finger trouble or
-using wrong figure from loadsheet, or
-insert in wrong place or
-zillions of other possibilities,
that caused this incident?
Always wondered with my own company why the layout of our ACARS loadsheet wasn't changed (e.g. separate header with just figures used for input), same for layout on FMS performance page, etc...
I feel sorry for the crew they had to resign, but now they can give honest feedback (f.i. if they think that factors like schedule contributed) with no pressure from anybody. This will hopefully lead to useful feedback/recommendations.
Last edited by LLuke; 15th Apr 2009 at 11:43. Reason: several typo's
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So much for the "Just Reporting Culture" we should all aspire to
Two careers and family lives shattered - all for a possible finger input or other unintentional human error.
This should have been addressed/reported as part of a Just Culture policy, encouraging full and open reporting, ASAPs voluntarily filed, learn from what happened, apply lessons learned, share the information gained openly, train to proficiency if determined to be appropriate by the Event Review Committee, and move on.
Two "resignations" make the owners happy I guess, and they will sleep well tonight. But if I am going to be fired, sorry - resign, for an honest non premeditated error, I will not be offering any debrief information to help determine what happened. Why should I hand them the gun?
This should have been addressed/reported as part of a Just Culture policy, encouraging full and open reporting, ASAPs voluntarily filed, learn from what happened, apply lessons learned, share the information gained openly, train to proficiency if determined to be appropriate by the Event Review Committee, and move on.
Two "resignations" make the owners happy I guess, and they will sleep well tonight. But if I am going to be fired, sorry - resign, for an honest non premeditated error, I will not be offering any debrief information to help determine what happened. Why should I hand them the gun?
Last edited by Oilhead; 15th Apr 2009 at 14:37.
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all for a possible finger input or other unintentional human error.
Separate loadsheet header, dual entry (from both pilots) in FMS, etc...
