"To err is human": differing attitudes to mistakes in EK and Turkish accidents

[PJ2]

Gibon2;

Worse than this, if I have understood correctly, is that there's no agreement on what to do about the problem. PJ2 says of the TK crash:

Quote:
Further, there is no understanding in this accident that is useful in the addressing of organizational, systemic or human factors accidents.
So what to do? Are you saying these kinds of risks cannot be reduced

757_Driver makes the statement,

Anyway before we get too much into the self flaggelation lets not forget that for all its faults the aviation safety model is still amongst the best in the world.

with good reason. We are focussing on an extremely tiny but equally extremely visible aspect of the industry - the success rate of this industry (fatality rate) out-performs by magnitudes other industries which must accomodate and mitigate levels of risk such as the health-care system, the automobile transportation system, even one's private home where fatality rates are far higher a fact which is almost completely ignored by users, victims and regulators alike, (but not insurance companies).

To your question about "So what to do?", there are indeed good answers.

First, the notion of human performance is new as are the notions of the causal pathways to accidents, (which is one of a number of reasons why most should not be grouped as "accidents" but of "preventable occurrences" - that language however, would not suit the politically correct among the critics especially those in the direct line of responsibility - reminds me of the positions CEOs and now our bankers adopt - "Your Honor, the bed was on fire when I got in it", but...I digress).

Preventative action takes quite different forms today than it did in the 50's and 60's. Today the industry has largely solved the technical design, weather, navigational, and mechanical causes of accidents. We needn't delve into how, just to keep this short.

Almost all fatal accidents are caused by or have significant contributions from, "human factors". Machines and, to some extent, systems, may be robust (although how "brittle"* they are is an important question), but humans are not; we know why - we forget, get distracted, tired and have emotions all of which intervene in technically-perfect performances.

The defences do not emerge in terms of "a solution", but rather a layering of defences. This may seem obvious but it is these very layers which, when other priorities such as costs take over, are removed or defeated, usually employing justifications known as the "normalization of deviance". When a process (SOP) designed to prevent an untoward human respond or behaviour is assessed, usually by those who don't know what they're talking about when it comes to safety processes (such as those in the more senior ranks of Flight Operations and any executive level management), "suggest" that such processes are "expensive" and, because "nothing" comes of them, can be set aside, changed or removed.

Almost always, the removal of a layer of defence is met with short-term success, reifying such flawed decision-making as "good cost control".

Somebody here asked about FOQA programs. This is a good example to illustrate this point. These programs are expensive and require significant resources yet are not a "profit center", (a very common corporate approach which does not differentiate "safety" from "marketing" priorities, benefits or costs).

Since such programs don't produce "anything" in terms of adding to the bottom line and instead produce potentially "inconvenient" data, they do not enjoy wide acceptance. Most people simply do not wish to know things either because such things are beyond their control or because they are "too expensive" to fix and besides, "nothing happened when we stopped ___________, (fill in the program or SOP).

So a layer is removed.

You need to understand that in such a complex system, (apropos my comment on getting down to the details), many layers can be "successfully" removed before trends in incidents and close calls begin showing up. It can take years in some cases where high competence, good hiring practises and reasonable training regimes exist. (These notions relate to the MPL, both positively and negatively, but I will keep this short).

A manager who is intent on pleasing his supervisor must, in an SMS environment, be very careful about which safety issues he or she is going to draw attention to. In a self-regulating safety system where the first priority is profit and cost-control, (no corporation places safety first), what will be on any manager's mind will be "how will it look if I draw attention to an item and I am mistaken?". In a bureacracy, one only has "so many chances" for advancement before one becomes "suspect". The key in a healthy safety culture is to promote those who "disagree with reasons" and to eschew those who "go along to get along". That rarely occurs.

It should be quite clear, that such corporate dynamics are directly related to the notion of layering safety processes.

However such corporate dynamics unfold, the crucial aspect of "connections" is missing, simply because no one is ever assigned to see patterns. A manager's job is to put out fires, not to see causes - "that's for higher-ups". But those higher-ups, (described above as senior and executive level management), are doing the same thing - putting out corporate fires, watching costs and share prices as well as the competition. I know for a fact that at least some CEOs do not understand and cannot see safety processes. If the CEO doesn't want it, it almost always doesn't happen.

In summary - what has this got to do with the Turkish accident? As I said, precious little, so egregiously negligent were this crew's actions. However, as BOAC correctly observes, the stable approach criteria, if they had been adhered to, would have rendered this another "experience" for the crew instead of killing them and some of their passengers.

What this has to do with the issues described herein and the question, "what can we do?", is first of all "awareness" of what is already very successfully being done which includes the layered defence approach. Another important approach, which a non-use or non-engagement is today inexcusable perhaps even negligent, is the implementation of a robust data gathering program so that the airline knows what its airplanes are doing. It must be entirely confidential, trusted by the pilots and non-punitive. This is asking to live in an ideal world I know - Asians and even some European lo-cost carriers use FOQA data to "seek and destroy" individual crews rather than the wiser, smarter, less expensive learning route but the more enlightened approach is the rule. Airlines such as BA, BM, Lufthansa, Air France, QANTAS, United, Continental, US Airways, South African come to mind right away as having such robust, long-established programs which are significant layers of safety awareness and which have paid huge, though un-credited dividends.

As you already know Gibon2, none of this (not just in aviation but in human affairs) lends itself to polar-opposite measurement where the continuum is "good > bad". A far more subtle appreciation of what it is to "be safe" and to "do safety" while still making a profit for the shareholders is required. Otherwise, outcomes as we have seen will obtain. The tragic part is, very few can see connections and therefore only blame crews, ensuring that a repeat accident will occur.

These processes (or variations, depending upon the industry) are, (or should be) at work in all endeavours which are accompanied by risk. Medicine and the health-care industry is just beginning to see that killing patients at the numbers they do (iatrogenesis, incompetence, negligence), not the unavoidable deaths) can be addressed as can the number of deaths on highways, (45,000/year in the US alone, or a B747 fatal accident every 3 days).

I hope this is helpful in coming to terms with your important questions. Clearly bandwidth and a long and boring (for some) post is not the answer but reading in the titles I suggested is. There are some very positive posts here by many contributors/professional aircrews which should be gratifying that a) they have taken the time and b) understand all the above intuitively.

The extreme outliers, (good book, by the way) such as the TK accident, perhaps there is no rational explanation which can help us prevent such a vast and inexplicable human failing. While it isn't acceptable (to me and many) to say "to err is human", until organizations themselves begin to comprehend that the notion of "accident" must change, that will remain the only excuse.

* The notions of "brittleness" and "resilience" are useful in understanding how a system or set of SOPs designed to enhance safety, may respond. A brittle system is one in which small changes increase the potential for wide failure, while resilient systems are error-tolerant.

[mercurydancer]

This is a most interesting thread.

I work in risk management for the NHS (mainly- sometimes for H&S Executive) and frankly aviation safety is about 10 years ahead of medical safety which is why I find such fascination in threads such as this. I will gladly put my anorak on and explain why...................

This is not meant as a criticism in any way, I just want to know what is going on in the next level of thought...

Someone commented that possibly culture affected the crew, in that the person who can get away with something is not seen as wrong but clever. Almost everything established has some form of "creep" be it threads, bombing patterns or financial targets. Without ranting on about management, could I ask to what point is safety obstructed in companies and how does that sit with the crew? I know of several examples where I have been involved in safety issues with medical staff and the experience of taking the matter to the boardroom was made difficult and harrowing, and much of it didnt actually question my findings. Any interruption to service recieved a particularly hostile response.

Rainboe did describe flying an aircraft with automatic systems and there were some comments about cat 3 landing with autoland, and as is his way, he described it with clarity. I can understand if the machine does something different to what is intended, then the pilot should take over, but if the precision of the machine exeeds your own in certain circumstances and is not performing in a questionable way is the machine to be trusted? In many ways I think this is the crux of the matter - autoland. alpha floor and the other engineering (soft and hardware) is just another tool to aid the professional, and should not be considered to be anything more, but when functioning well it is reliable and can be trusted to aid the pilot to a safe landing in conditions where hand flying is not concievable.

Could I also ask a question about the comments about the aircraft is trying to kill you? I understand the general meaning that flight means involving physical forces and conditions which can easily exceed what humans are built to withstand, but is the comment an expression of the attitude of the flight crew? It seems to imply that there is some conflict between the aircraft and the pilots. Does it indicate a mistrust in the aircraft and its systems? If so to what extent?

[GlueBall]

I hate to say it here also, for fear of being flamed, but had it been a Lufthansa/Air France/BA rather than Turkish aircraft involved, perhaps slightly more understanding might have been shown.

Not so when LH had the dubious distinction of seriously crashing the first B747and killing a bunch of German tourists at NBO in 1974 due to crew error: Unverified leading edge flap setting. The european press had a field day, and LH's shiny image was dragged through the mud.

[The Real Slim Shady]

And Captain Van Zantem (KLM) is talked about to this day!

[Gegenbeispiel]

partial automation

Just one thing to add to this excellent thread: it seems to me that partial automation, as in the TK case, is more hazardous than the maximal (in that case, FMS-VNAV-LNAV to GS capture then autoland) or minimal (AT off, hand-fly or MCP control). In max. auto, the crew knows that the job is to watch the system very closely. In min. auto, the crew uses its classical training and is fully engaged with the aircraft. Anywhere between, things can get confused more easily. And TK at AMS was in such a mode.

[herkman]

My exposure to flight safety with the RAAF, reveals to me that one factor is often not the single cause of and incident or worse.

The Hercules fleet must have by now at least 800,000 hours of operation, with no lose of life and airframes over a period of 50 years.

This is because of the through training, and constant checks and non flying sim periods, which well exceed normal civilian ones, but it also the attitude that is continually re enforced in the operating climate that all crews must display constant diligence. Yet in spite of the constant operations, which are more demanding than civilian operations, the flying is a safe as it can be made. The RAAF has a safety record which is second to none and is the eveny of many Air Forces of the world. Many reasons including the constant training and requalification of crews and the fact that all know that we cannot afford the loss of an airframe and life.

My personal and observed experience show that seldom, even in a motor car, is there one factor which causes an accident. It is almost like when the events start, and little factors creep in, that unless someone breaks the cycle, then the cycle continues on its way with sometimes a fatal result.

One of the problems of commercial aviation is that it is often driven by cost factors, where the Bean Counters who have in my opinion too much say, often place operational restrictions on matters that should not be introduced.

If we look at the Melbourne instance where penny pinching, stopped providing two laptops, which should picked up that error, was the norm.

How much for flight safety, sometimes it cannot be fully calculated, until one has both a hull lose and human life. It is only then that the full costs come out. Who wants to be the one to tell the loved ones, that in this case a lousy $2000 lap top, means your men will not be coming home tonight.

Regards

Col

[PJ2]

mercurydancer;

could I ask to what point is safety obstructed in companies and how does that sit with the crew? I know of several examples where I have been involved in safety issues with medical staff and the experience of taking the matter to the boardroom was made difficult and harrowing, and much of it didnt actually question my findings. Any interruption to service recieved a particularly hostile response.

The venue of the "corporate safety board meeting" carries similar characteristics. "Who" rapidly or chronically becomes more important than "What", and the result if a posturing defensiveness on the part of the manager of the department "under the lights", instead of a discussion of 'what', and how to fix it. Territoriality, siloing, denial of data and saving face are all very active pressures and forces if a safety culture is not healthy.

Now, nobody likes to have their performance reviewed harshly so to keep the process going and to prevent people from being driven towards such responses (or worse, being driven underground where nothing is admitted/mentioned), a process of support for dissidence is crucial but an atmosphere of professionalism and deep respect for the integrity and personal qualities of the participants is an absolute must.

The other important aspect of this is, the organization may not know that anything is wrong. NASA "normalized deviance" in both the Challenger and Columbia accidents, (see the book list, previous page). Nobody thought they were doing anything wrong or even unsafe.

In fact, this is how most accidents happen: good, highly-trained, well-intentioned people acting within a flawed system in which risk is masked or dismissed and therefore responses are not seen as needed. In other words, it is extremely rare, especially in aviation, (I suspect in medicine too, but cannot speak to it), for intentional acts or even negligence or imcompetence to be the cause of an accident. The job of safety people is changing awareness and highlighting the unseen - the job isn't to admonish somebody for not wearing a safety vest on the ramp, etc. That is the key point most managements miss entirely and by which they dismiss their safety people's observations and entreaties.

I believe it is eminently possible to accomplish but it requires solid leadership straight from the top and that, in turn, requires some familiarity and understanding with the processes of doing safety work and what makes a company safety-minded. Some think that all safety is, is admonishing individual "unsafe" acts. Others believe that if employees feel that it is safe to report unsafe acts, that is a safety culture. It isn't unless/until the information feedback loop is completed through changes that are led and supported right at the top of the organization. One approach is a "way of doing and travelling" and the other is just swatting at flies - they always come back and land.

The intention is never to management-bash - not at all. That implies irrational anger without the intent or expectation of change. Such an approach informs far too many management-employee, management-union discussions today. Safety is not the basis of industrial-type discussions; safety is not an industrial matter.

Management is just that: in a leadership position, and as such it is expected to lead, make critical decisions and, under SMS, be accountable for all outcomes as a result of their decisions. The messages sent by senior management will be hearkened to by "all the knights and those knights are going to ride out among the people with the message the king has proclaimed".

To return to the critical point you made regarding the hostility with which safety decisions are often greeted - yes, that has been, and in some places remains, the way safety information is received within airlines. That is a culture which historically has had to learn the hard way through aviation's (or medicine's) harshest lesson - a serious incident or a fatal occurrence which, in some circumstances (such as these days), can place the organization itself at risk.

Some posters above chose to mention decades-old examples of fatal accidents as exceptions to the general notions posited here, (in 2009). At that time, (30+ years ago), flight data analysis only existed at British Airways, pioneers in the field, (and still are, where management, the union and the regulator all have access to FOQA flight data). Also, CRM - crew/cockpit resource managment and other human factors understandings were not widely known or understood. What is missing in the posts citing these two examples is the acknowledgement that these carriers, and the ones mentioned, learned and changed and are today models of an active safety culture - not perfect, but still excellent examples of how it should be done.

QANTAS is another example of positive change. Before their accident at Bangkok, their flight data was telling them the risk of an overrun was high on the 747, (ATSB Report states this). They changed after the accident.

It is extremely difficult to "make the safety case" to managers who are driven by the pressures of the bottom line, creating shareholder "value" and the pressures of departmental performance which never measures "how safe" one's department is because such a concept can't be quantified as '6', or powerpointed in dot-points and attention-getting graphics in the ten minutes usually alloted for such discussions at such venues as corporate safety board meetings.

If hostility and diffidence is what you are greeted with, it is my experience that the only other way that an organization will embrace good sense is the school of hard knocks.



Re the saying, "the airplane trying to kill you", it's more of an acknowledgement that if you don't pay attention, the machine will have an accident, as we have seen. Reagan said years ago, "trust, but verify". I think that applies here: a Category 3 landing (CATIII) can be done in 600' visibility where it is tougher (and, apparently in Canada, illegal now) to taxi to the terminal than it is to do the autoland. Pilots trust such systems implicitly, mainly because they perform now and historically, nearly flawlessly. It is the benign, sunny day (in both our "operating theatres) which one must be cautious of.

"Autoland", "Alphaprot", TCAS, EGPWS, ADS, airport ground radar etc etc and the hundreds of technological changes now available are all "aids" designed to reduce operational tolerances while still keeping a constant level of safety. There must be medical changes in procedures, tools and insights which do the same thing - get closer to heightened risk but maintaining a high degree of safety.

[infrequentflyer789]

Originally Posted by herkman

The Hercules fleet must have by now at least 800,000 hours of operation, with no lose of life and airframes over a period of 50 years.
[...]
One of the problems of commercial aviation is that it is often driven by cost factors, where the Bean Counters who have in my opinion too much say, often place operational restrictions on matters that should not be introduced.

With no disrespect to your fleet safety record, there is no general exemption from cost factors, bean counters, etc. in military or any non-commercial aviation. You may also be more likely to end up with politicians involved as well...

The recent history of the Nimrod program is the obvious military example, but there are plenty of others.

[Mad (Flt) Scientist]

The Hercules fleet must have by now at least 800,000 hours of operation, with no lose of life and airframes over a period of 50 years.

And, of course, the historic accident rate for large commercial aircraft over the last 20-30 years (based on Boeing and ICAo studies, and generally accepted to the extent that it's virtually part of the regulations now) is one accident per million FH. So no accidents in 800,000 hours actually isn't really that out of the ordinary - it's somewhat close to what you might expect.

[White Knight]

Herkman - there have been TWO laptops aboard EKs' aeroplanes for at least a year already. However the SOP was to use ONE for the take-off performance calculations so you are incorrect in your summary.
As for 800,000 hours accident free, well the EK Airbus fleet is way past the 1,000,000 hour mark... Just the 345 fleet alone I would guess to be around 250,000 hours in 5 years, but I mention the whole fleet because most of us fly MFF..

[CONF iture]

Originally Posted by herkman

How much for flight safety, sometimes it cannot be fully calculated, until one has both a hull lose and human life. It is only then that the full costs come out. Who wants to be the one to tell the loved ones, that in this case a lousy $2000 lap top, means your men will not be coming home tonight.

To me a single laptop is good enough, what matters is the way you use it :

1. PF gets some perf figures from the laptop, inserts them in the FMS, exit the program.
2. When ready PNF takes the same laptop, gets some perf figures as well and compares with what was already inserted in the FMS.

If a difference exits, then both guys discuss ... ?

I don't know if it's the way EK SOP are, but I would find it logical.
At least that's the way we proceed with a single set of performance paper charts.

[Uncle Fred]

Very good thoughts PJ2 particulary in your mention of the pitfalls of looking at accidents that have occured before the advent of FOQA, CRM, trend analysis etc. We have collectively learned from previous accidents.

I very much agree with your (at least as to how I interpreted it) thought that airline safety is not beaking on someone for not wearing a safety vest but rather striving for both a changed awareness and looking for flaws that might occur in "the" system e.g., the NASA review.

It has taken decades to adopt an attitude of "fix the problem and not the blame" The more enlightened operators in any industry, airline or not, realize that fixing the only the blame ends up fixing nothing. Safety is an attitude that is fostered, grown, and reminded not mandated.

Great remarks as well about fatigue that you posted in another thread- definately the 800 lb Gorilla in the room that one all too often only pays lip service to but never seems to seriously acknowledge. As it was once well put, if you awaken Rip van Winkle from a 20 year slumber and keep him awake for one night, the 20 years of sleep are for nought." Why it is so constantly denied that rising at 1 a.m. body time for a ten hour flight is not a fatigue risk to me beggars belief although that is a topic for a different thread...

[PJ2]

Uncle Fred;

Re your response...these are the reasons why I don't fully trust the IOSA process. I've seen an IOSA safety audit give a passing grade to a carrier in circumstances that didn't deserve it, (and another country to which the carrier flew agreed and banned their flights until the issue was dealt with). Too much politics and economic pressures in trade for the title, and not sufficient diligence in my view.

The certification is at risk of being a sought-after label or even a brand and not an "ISO 9004" type standard. IATA is a corporate lobby group for airlines and while it has a significant presence in flight safety, they also strongly lobbied for example, against changes in flight time and duty regulations in Canada.

It's never black and white of course but you can't suck and blow at the same time.

The industry is extremely good at what it does but there exist illusions and denials which are inappropriate, and at odds with the known data in, for example, FOQA, LOSA and ASAP programs. That's the only message I am ever really, constantly serious about - illusions are fine for stage management but don't work in aviation. "Fly the airplane" (meaning, know you're in the aviation business and all that entails including knowing what your airplanes are doing), whether you're the CEO or the guy who checks the oil, and the business can be profitable over the long run and you won't hurt people.

[4Greens]

For those who wish to delve deaper into why safety is so difficult to achieve with error prone humans, try reading up on Risk Homeostasis. A gentleman called Wilde is the chief guru.

[alf5071h]

Error is a very complex subject. An interesting view is given by Woods & Cook in Perspectives on Human Error. Error could be a categorization after the accident (hindsight bias), or considered as a process generating the accident. The references to knowledge in this paper, IMHO are important both to this discussion and aviation safety.
Other error categorizations are given by Reason in GEMS (generic error modeling system) which includes Skill, Rule, and Knowledge based behavior (note that rule in this instance refers to the ‘rules of mind’ not SOPs); there are similar categorizations in HFACS.

A more practical view is given in Errors in Aviation Decision Making (Orasanu et al). Here decision error is broken down as a failure to understand the situation, or with correct awareness, an incorrect choice of action; these definitions appear to relate to the TK and ET accidents respectively.

A cultural view of situation assessment (or accident review) might come from New Scientist “East meets west: How the brain unites us all.”
My very simplistic interpretation of this is that a traditional ‘Eastern culture’ might perceive a situation holistically – a wider view including the relationships within it, whereas the ‘Western culture’ perceives a situation analytically – a narrower logical view.
These views would not be restricted to national culture, thus organisation and professional cultures (independent of nationality) should be considered, possibly with the largest divide amongst the ‘professionals’ e.g. commercial pilots / GA.

Relating the above to the original question, then the different views might indicate to how the situation preceding the accident is judged in hindsight. In addition, there could be bias due to different understandings of human factors (beliefs, myths, experience, knowledge of error) and the expected professional standard; see my post at http://www.pprune.org/4904796-post2429.html

Thus the mode of thought (or capability for measured thought) might account for the differing views of the accidents.
If this is relevant then a focus on our thinking skills could open opportunities for safety solutions. Crews should be trained how to perceive situations and assess their own performance (self awareness - thinking). i.e. we cannot train-out type 3 mistakes as they are inherent in human behavior, but we could train crews how to think more effectively instead of relying on rules, procedures, and guidance, which have limited applicability.

A form of ‘self’ TEM, or ‘self’ LOSA, but aren’t they the basis of airmanship?

[FlexibleResponse]

mercury dancer,

Could I also ask a question about the comments about the aircraft is trying to kill you? I understand the general meaning that flight means involving physical forces and conditions which can easily exceed what humans are built to withstand, but is the comment an expression of the attitude of the flight crew? It seems to imply that there is some conflict between the aircraft and the pilots. Does it indicate a mistrust in the aircraft and its systems? If so to what extent?

Just to take this one point...perhaps the phrase "the aircraft is trying to kill you" is analogous to "the patient is trying to die on you".

One false move, or one moment's inattention and the patient will die on you due to the way in which you conducting or are failing to conduct the procedure.

In aviation, those in the team assisting the Captain are empowered and encouraged to voice their concerns if they perceive that some action or decision might be in some way to be detrimental to safety of the flight. They are not ridiculed or punished in any way if such concerns ultimately are shown to be unfounded due to whatever (say inexperience). In fact the concern expressed is directly addressed and justified or explained or the decision is found to be faulty and modified. Anyone contributing will be rewarded with a thank you for their observation and interjection.

Special phrases are sometimes used to alert the Captain that a concern is not a minor event and a very positive acknowledgment and response is required. Some well known airlines use the phrase, "Captain, you must listen to me..."

This is a real attention getter and cannot be ignored.

The outcome of a flight is the product of the team not just the Captain. In the same way the outcome of an operation is the outcome of the team and not just the chief surgeon.

That is not to say that the individual skill of one of the team may not be the determining factor of a good outcome, but it is to say that an aircraft or life is not lost due to an error that was noted by one of the team and was not vocalized in a timely manner.

Oh, I thought he saw or realized that, so I didn't say anything at the time...

I have spent a lot of time training pilots to fly airliners. But, the first lesson is preceded by, "If you don't understand what I am doing, or if you see me doing something wrong, you must tell me immediately." On occasion trainees have made a very direct contribution to safety of my flights.

I didn't invent this type of crew training and interaction, it came from CRM training that was given at my airline and is now part of the curriculum to gain an airline pilots licence.

[dessas]

WHY???

Some questions and my answers:
Q: Why this new Boeing did not have "ALPHAPROT" or at least low-energy warning as all buses do?
A: Because it is cheaper to make it like this (higher mark-up for Boeing)...
Q: Why do we have to use LPCs and various similar customer programs to calculate the speeds in an un-pilot like manner?
A: Because it is cheaper to do it this way, rather than implement a totally new on-purpose design that will never allow the proverbial alignment of the cheese holes...
Q: Why, after so many incidents and accidents Boeing has not yet redesigned the oxy supply on the 737?
A: Because it is cheaper to make it like this (higher mark-up for Boeing)...
I can go on for ever!

On a different tack:
IMHO the problem is that the machine-human interface is becoming ever more sophisticated, but dangerous as well as it invites operators to diminish the importance of experience! Because operators and regulators are so being told by Airbus and Boeing!!!
I got my first taste of wide-body flying about 6 years and 3500 hours into my career. It was close to the industry standard of the mid-80'. Now every other time I have an f/o on my right with about 1500h, the "playstation" type as someone rightfully named them.
These playstation guys can interpret fairly well what the dials and various fancy diagrams are telling them, but can they use this chewed-up info to build a good enough "greater picture", especially under extreme stress?
On the other side, could the "old hands" be lured into the "cheese trap" by just becoming happily complacent because the computer "flies itself so well"
I guess the last ones are the zillion dollar type question, but they keep coming to me on these long, long, long 2-man operated flights...

[Kerosene Kraut]

"Not so when LH had the dubious distinction of seriously crashing the first B747and killing a bunch of German tourists at NBO in 1974 due to crew error: Unverified leading edge flap setting. The european press had a field day, and LH's shiny image was dragged through the mud."

Gluey,
the lufty flightcrew got cleared by a german court back then. There was no proof against them but a possible problem with the slat indicator in the cockpit that seemed to have happened to a british 747 in a similar way shortly before too. However the germans had not been aware of that incident before.

[Blacksheep]

From EASA Safety Information Bulletin 2009-12 published as a result of the Copenhagen accident.

"If one LRRA provides erroneous altitude readings, the
associated flight deck effects may typically include:
• Inappropriate Flight Mode Annunciation (FMA)
indication of autothrottle RETARD mode during
approach phase with the airplane above 27 feet Above
Ground Level (AGL). There will also be corresponding
thrust lever movement towards the idle stop. The FMA
will continue to indicate RETARD after the thrust levers
have reached the idle stop rather than change to ARM.
• Large differences between displayed radio altitude.
• Inability to engage both autopilots in dual channel
approach (APP) mode.
• Unexpected removal of the Flight Director Command Bars
during approach on the pilot’s side with the erroneous radio
altimeter display.
• Unexpected Configuration Warnings."

Faced with multiple unexpected and confusing indications and warnings a crew should "fly the aeroplane". Human nature is however, attuned to solving problems by shutting out everything but the task in hand. The instinctive reaction to multiple problems is to focus on the first to be noticed and ignore the rest. It is this conflict between instinctive behaviour and trained behaviour that lies at the root of "human factor" accidents.

[mercurydancer]

pj2 and flexible response

Thank you for your replies. its appreciated.