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SQ006 final report out 26/4/02

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SQ006 final report out 26/4/02

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Old 1st May 2002, 05:08
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Interesting that Singapore is waiving the ICAO flag.

Not too long ago (it is all in the PPRuNe archives) when I fought SIA in the United States Federal court over SIA's unsafe flight operations (First officer in the Captain's seat without proper training and license as required by ICAO annexes), all the loyal soldiers of SIA in endless PPRuNe posts laughed at the ICAO annexes. They called it advisory only but not mandatory (are you reading this Si?).

Now they are waiving the ICAO flag and the attached annexes. After dealing with CAAS (CAA Singapore) and SIA I must express my opinion. They are a joke.

Outcome of the case, they had to stop this practice.
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Old 1st May 2002, 12:11
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Hey, Gladiator, watch your spelling. In that first sentence you're actually writing the opposite of what you mean.
Cheers,
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Old 1st May 2002, 12:14
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Hi Hawkeye 18,

Good background, thanks very much. Can't corroborate it or otherwise.

Interesting input from Gladiator on ICAO matters, though!
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Old 1st May 2002, 13:42
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Gladiator,

"""Interesting that Singapore is waiving the ICAO flag.

Not too long ago (it is all in the PPRuNe archives) when I fought SIA in the United States Federal court over SIA's unsafe flight operations (First officer in the Captain's seat without proper training and license as required by ICAO annexes), all the loyal soldiers of SIA in endless PPRuNe posts laughed at the ICAO annexes. They called it advisory only but not mandatory (are you reading this Si?).

Now they are waiving the ICAO flag and the attached annexes. After dealing with CAAS (CAA Singapore) and SIA I must express my opinion. They are a joke.

Outcome of the case, they had to stop this practice."""



Interesting that u brought up your court case with SIA.

So you won or lost!( u din come thru too clear there)

If U have won than SIA was wrong but if U have lost then SIA was right!! .....For that particular court case that is.

But to have a jundiced view of an establishment with reference to just an "unpleasant" encounter will be stretching things abit too far......( just a personal view without being employed by them nor have any vested interest of the company.)

I do admire them for their bussiness acutement and management and safety record prior to SQ006 ........ well I could be wrong here, if so , please do enlighten me with an airline that is as profitable and with a better safety record!


It appeared that u have an axe to grind with them hahhaa !! For whatever personal reasons......... I wun speculate!

Likewise, for whatever reason u call them a joke, be it You deal with them or They deal with you, do substaintiate it so that we can laugh at it along with you. If not , by inference, other lesser airliners or Aviation Authorities will be even worst then your joke..!!

See !!! I am also falling into the trap of concentrating on the tree and missing the wood............. arh!!! Or should it be the other way round in this case!!!! ... barking at the wood and missing the tree!

Cheers!!!!!!!!

Last edited by hawkeye18; 1st May 2002 at 14:09.
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Old 1st May 2002, 18:02
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An Explanation of the Seemingly Inexplicable

Rockhound
Re your comments above: "Surely the crucial question is, what circumstances led to this mindset? Why were the pilots satisfied that no error had been committed and all was in order?"

Although I realise that visibility was down to 400 to 600 metres, they only had visibility through the forward area of the windscreens being swept by the wipers. Sometimes, on a dark clear night you lose depth perception and a busy airfield can be swimming in a sea of lights.

And on a dark and rainy night, you can tend to be transfixed by (and fixate on) the few things that you can see.

I remain unconvinced that no runway edge lights were on. That conclusion seems to rest upon what was seen by distant security cameras.

But it doesn't change the fact that an opening was left and a crew was duped through it. I'd guess that the "dominant perception"

syllogism
was operative and that what they were looking at simply failed to register against the background of "getting on with the show".

Syllogism: In Logic. A form of deductive reasoning consisting of a major premise, a minor premise, and a conclusion. It more often than not is a subconscious thought process.
(All humans are mortal, the major premise, I am a human, the minor premise, therefore, I am mortal, the conclusion)

begets in this case (subconsciously) the dismissive mindset of:

We are lined up for departure on the runway and cleared for take-off.
What we must be seeing out the front must be that runway.
Therefore there is no safety problem nor cause for alarm or query.

i.e. a simple failure to mentally register any inconsistency.... no alerting mechanisms present at all. Because the predominant concern is about darkness and weather and visibility, a perverse mechanism of reassurance is always tending to suppress any disquiet (the PVD....). That's the sentient side of human nature.


Alarm generators must be active stimulants. The singular red depressurisation warning light on a Beech 200 does not flash and is not attention-getting and, although double filamented, is no substitute for an aural alarm. That's probably what caused the "failure to pressurise" overflight (and death of eight) in the Payne Stewart type crash ex Perth last year. The sun was from over the pilot's shoulder and washing out that light as he climbed out in the late afternoon on an Easterly heading. It's a good example for the assertion that "alarm and warning generation" is a wholly active (and never a passive) affair. You can probably think of numerous other examples where this suppression syndrome consciously copes with the environmentals while the "dominant perception" syllogism perceptively accommodated the desired sense of well-being.

Simple Solutions in hindsight
They could have used a Dreadle Treadle hooked to pyrotechnics alongside the 05R threshold and still used it as an exit taxiway. (i.e. A B => A progression across the treadle lights off the fire-works yet an A => B progression for taxiing aircraft exitting 05R taxiway (across the same treadle) does nothing).
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Old 1st May 2002, 18:13
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Don't worry too much about my spelling or grammer. It sucks.

Ax to grind or not I am still a former insider with certain information. In reference to ICAO and SQ006, let me inform you that the crewmember configuration on the ill fated flight or other SIA flights did not meet ICAO minimum standards.

ICAO requires certain licensing standards on aircraft certified to be operated by a two man crew. In the case of a B747-400, all crewmembers are required to hold an ATPL, or in the case of the first officer(s), a frozen ATPL.

SIA and CAAS (CAA Singapore) for years have/had ignored this minimum standard having the status of 'SHALL' as opposed to 'SHOULD' by ICAO.

SQ006 had a three crewmember configuration. One captain and two first officers. One or both of the first officers may or may not have met this standard, and even if those two particular first officers did, SIA's other B747-400 flights did not.

Therefore we are back to the original discussion. Singapore waiving the ICAO flag to show that Taiwan did not meet ICAO minimum standards in their airport markings while they themselves did not meet ICAO miminum standards in flight operations.

BTW reason behind SIA not meeting the minimum crewmember certification standards is/was obvious. It costs less. A first officer is cheaper than an additional Captain. A first officer qualified in the right hand seat is cheaper than a first officer qualified in both the left and right hand seat (in cruise). A first officer without the frozen ATPL costs less than one with a frozen ATPL. It goes on and on. To put this paragraph in simple form, it is/was possible for an SIA B747-400 to be in cruise, Captain sleep in the crewmember bunk (without quick doning oxygen), two 20 year old first officers without ATPL or frozen ATPL at the controls (Ofcourse the service in the cabin would be world class).

Reference was made to SIA's safety record and profits. SQ006 was only a matter of time, SIA's operation, particularly CRM was a ticking time bomb. We as insiders were surprised they got away with it for so long. Many times they came very very close.
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Old 1st May 2002, 19:02
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An Explanation of the Seemingly Inexplicable

Rockhound
Re your comments above: "Surely the crucial question is, what circumstances led to this mindset? Why were the pilots satisfied that no error had been committed and all was in order?"

Although I realise that visibility was down to 400 to 600 metres, they only had visibility through the forward area of the windscreens being swept by the wipers. Sometimes, on a dark clear night you lose depth perception and a busy airfield can be swimming in a sea of lights.

And on a dark and rainy night, you can tend to be transfixed by (and fixate on) the few things that you can see.

I remain unconvinced that no runway edge lights were on. That conclusion seems to rest upon what was seen by distant security cameras.

But it doesn't change the fact that an opening was left and a crew was duped through it. I'd guess that the "dominant perception"

syllogism
was operative and that what they were looking at simply failed to register against the background of "getting on with the show".

Syllogism: In Logic. A form of deductive reasoning consisting of a major premise, a minor premise, and a conclusion. It more often than not is a subconscious thought process.
(All humans are mortal, the major premise, I am a human, the minor premise, therefore, I am mortal, the conclusion)

begets in this case (subconsciously) the dismissive mindset of:

We are lined up for departure on the runway and cleared for take-off.
What we must be seeing out the front must be that runway.
Therefore there is no safety problem nor cause for alarm or query.

i.e. a simple failure to mentally register any inconsistency.... no alerting mechanisms present at all. Because the predominant concern is about darkness and weather and visibility, a perverse mechanism of reassurance is always tending to suppress any disquiet (the PVD....). That's the sentient side of human nature.


Alarm generators must be active stimulants. The singular red depressurisation warning light on a Beech 200 does not flash and is not attention-getting and, although double filamented, is no substitute for an aural alarm. That's probably what caused the "failure to pressurise" overflight (and death of eight) in the Payne Stewart type crash ex Perth last year. The sun was from over the pilot's shoulder and washing out that light as he climbed out in the late afternoon on an Easterly heading. It's a good example for the assertion that "alarm and warning generation" is a wholly active (and never a passive) affair. You can probably think of numerous other examples where this suppression syndrome consciously copes with the environmentals while the "dominant perception" syllogism perceptively accommodated the desired sense of well-being.

Simple Solutions in hindsight
They could have used a Dreadle Treadle hooked to pyrotechnics alongside the 05R threshold and still used it as an exit taxiway. (i.e. A B => A progression across the treadle lights off the fire-works yet an A => B progression for taxiing aircraft exitting 05R taxiway (across the same treadle) does nothing).
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Old 2nd May 2002, 05:57
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One aspect of this tragic accident is, of course, that it not only puts SIA under global scrutiny but - by extension - "Singapore Inc.", a government-controlled business environment that by its own understanding can never do any wrong.

It's amazing how - for a wider international audience - SIA have been successful in limiting the fall-out from the Silk Air 185 crash. Even a very recent air safety "advisory" by an otherwise reputable German magazine (Focus), simply ignores the existence of MI and gives Singapore (as an aviation nation) a pre-SQ006 fatality-free bill of health. Amazing but sadly true.

Given such PR successes, we can all imagine how high the stakes must be on SQ006 at the Istana.

Last edited by Alpha Leader; 2nd May 2002 at 08:47.
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Old 2nd May 2002, 12:24
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Sorry, Glad, I don't see the relevance of your last post to the SQ006 accident. Both first officers held ATPLs.
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Old 2nd May 2002, 13:02
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Belgique,
That's very interesting, although I must confess I don't understand the Dreadle Treadle (too technical for me, I guess).
Of course, my question was rhetorical. I disagreed with In the Slot's premise that one or more members of the SQ006 crew was unsure they were on the correct runway but, collectively, they decided, what the hell, it probably is, let's go. I don't think airline crews would do that but maybe that's wishful thinking on my part. (Then I hark back to the China Airlines crew taking off from a taxiway bearing 246 deg when cleared for a Rwy 32 departure at ANC in January and I don't know what to think).
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Old 2nd May 2002, 13:29
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Gladiator,

"Ax to grind or not I am still a former insider with certain information. In reference to ICAO and SQ006, let me inform you that the crewmember configuration on the ill fated flight or other SIA flights did not meet ICAO minimum standards. "


Obviously u are not that well informed on the crewing of SQ006 after all .... and I take it that your utterance "of the other flights not meeting ICAO minimum standards is also a pure conjecture on your part.

This is from the ASC report :

CM1 The Captain was issued an ATPL on Jan 3 1993

CM2 The First Officer was issued an ATPL on August 6,1999

CM3 The Relief Pilot was issued an ATPL on January 7,1997


There is a great difference between an insider and a use-to-be insider!

Therefore we are back to the original discussion. Singapore waiving the ICAO flag to show that Taiwan did not meet ICAO minimum standards in their airport markings while they themselves did not meet ICAO miminum standards in flight operations.


As Rockhound rightly pointed out what relevance are these with reference to the report on SQ006? Especially now we know the fact of crewing of SQ006 as reported in the ASC!??

By the way , have u thumb thru the ASC and MOT reports as yet... if u did then obviously u are "not reading" alot of things in them!

It appear to me that u are more interested in "SIA/Singapore Bashing" then what the reports could help to prevent another similar accident.

Alpha Leader,

One aspect of this tragic accident is, of course, that it not only puts SIA under global scrutiny but - by extension - "Singapore Inc.", a government-controlled business environment that by its own understanding can never do any wrong

If I am not mistaken they admitted it was pilot error right from the start ( to the effect that our pilot took off on the wrong runway) . And I dun think they operate SIA within the confine of Singpaore Airspace only........

So I an rather confuse as to your "a government-controlled business environment that by its own understanding can never do any wrong"

I think it is also not relevant to the topic we are on ......, with reference to the reports and what could be done to prevent another similar accident from happening.


..........hmmmm another case of wood and tree!

Solli Folks , no offense intended as I am more interested in the facts of the case rather than history, the company or the country........ perhaps some other times!!


Cheers!!

Last edited by hawkeye18; 2nd May 2002 at 15:25.
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Old 2nd May 2002, 15:34
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Alpha Leader,
Like Hawkeye, I think your last post is off-topic but I am amazed that you are amazed that there's been so little fallout from Silk Air 185. Do you really believe that a significant proportion of the travelling public has anything but the vaguest notion of this accident, a crash of an airliner somewhere in SE Asia? Hell, half of them don't even know where Sumatra is and no way would they associate Silk Air with Singapore Airlines. A thriller writer would be hard-pressed to come up with the story behind the story of this accident, yet, as far as I am aware, not a single well-researched magazine article, let alone a book, has been published on it.
No, I'm afraid that all but a few outside the industry have the foggiest idea of the airliner-related incidents and accidents that so exercise us on PPrune. Do you think many people refused to fly KLM after Tenerife 1977, or Korean after Guam, or Qantas after QF1? Do people stop taking the train after seeing all the gory details of a fatal derailment or collision? Whether they admit it or not, people operate on the principle of when your number is up, your number is up.
And when all is said and done, SQ does have a good safety record, notwithstanding what Gladiator and others may say or impugn.
Sorry, I've ranted on long enough.
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Old 2nd May 2002, 19:04
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Red face

As in any final accident report its not who f*cked up thats of prime importance but what f*cked up. In the SQ006 prang there are many links in the chain which ultimately are part of the what. The what factors are the points that need to be learned so that the rest of us can recognise these same links and hopefuly prevent an accident like this one before it has a chance.

Unfortunatley the 2 countrys involved put loss of face ahead of pragmatism and safety. MI185 proved Singapore in that regard, and I expect the SQ006 reports to be but a stalemate with one side blaming the other with no solutions proffered, nor any real facts made public.
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Old 2nd May 2002, 19:55
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DREADLE

Rockhound

re Dreadle treadles

Try this link with many other pages linking from that.

It also had a number of write-ups in Air Safety Week
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Old 2nd May 2002, 20:21
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:o ROCKHOUND...I do not miss the point. I think you are missing MY point! That is, probably something that BELGIQUE was referring to with blinding words of science.
In my informed opinion, the crew THOUGHT they were on the correct runway, but obviously they were not. What caused this spatial disorientation, to make 3 pilots all wrong. THINKING or BELIEVING you are somewhere is not enough!

Last edited by In the slot; 2nd May 2002 at 20:58.
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Old 2nd May 2002, 20:45
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As the report points out, not only were the pilots convinced they were on the correct runway, but everything about the signage and lighting suckered them into the wrong one.

Of all that I have heard about SQ, much of it here, if there is only 50% truth then there is cause for concern with the airline's safety structure.

However, it does not appear to have been a factor in this incident.

There is never a single cause of any accident. There is a chain. "Pilot Error" is an exceedingly dangerous concept. What needs to be examined is what lead a pilot into making an error, and examining how it can be improved since, let's face it, no pilot ever wants an accident in which, at best, he may lose his job.

I have never flown in the Far East. Quite a few pilots here have, and will have flown into Taipei many times. How many, no doubt some PPRuNers among them, raised concerns about the lighting and signage with anyone in a position to address the problem? If you were there, saw it, and did nothing except tut-tut, then you are also part of the problem. You were a contributing cause of that accident.

Several times in this thread the word "fault" has been used. This also I have a big problem with. Only when we can move away from apportioning blame, finding fault with individuals' performances and looking at the inherent errors in the system will we be able to evaluate incidents with the sort of eye which can see how to avoid similar incidents in the future.
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Old 2nd May 2002, 22:49
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Hawkeye 18:

The initial admission of pilot error notwithstanding, the fact remains that the Singapore side is now trying to make a case that this was virtually forced upon the crew.
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Old 2nd May 2002, 23:55
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HugMonster - If most of what you have heard about SIA and safety has come from PPRuNe then you can indeed rest easy.

Most of what has been posted on PPRuNe has come from disenchanted ex SIA pilots who have their own personal agenda, often that they are being chased to pay their training bond having 'jumped ship' and respond by attacking the safety aspect of SIA and going to what they hope are friendly courts in foreign lands who will declare training bonds illegal.

Very little of what has appeared on PPRuNe is genuine concern for safety and has much more to do with saving their own face, having run away, and their guarantor's money.

I have worked for a few major carriers and SIA is no worse than any of the others, the overall experience of the few that choose to try and bash SIA is such that they often don't actually know what they are talking about, IMHO.
 
Old 3rd May 2002, 01:24
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Reading through the thread, I am struck by two things. Firstly that most of you have not read the reports (or you read different versions than I did), and secondly that some of you are falling for the SIA press strategem, and believing that the Sg and Tw reports are equally partisan documents.

Slasher for instance:

"Unfortunatley the 2 countrys involved put loss of face ahead of pragmatism and safety. MI185 proved Singapore in that regard, and I expect the SQ006 reports to be but a stalemate with one side blaming the other with no solutions proffered, nor any real facts made public."

I have read the reports, and think it might be useful to summarize at least the ASC report for all those too lazy to read it for themselves! You will see that Taiwan does not entirely escape blame in the ASC report.


1. The Pilots failed to determine that the runway condition should have been classified as ‘contaminated’ due to the inevitable buildup of standing water under cyclone conditions. This determination would have downgraded the cross-wind limit for takeoff from 45 knots (wet runway) to 15 knots (contaminated runway) and therefore prevented the scheduled departure.

2. The Pilots low-visibility taxiing performance was deficient during the final stage of taxi, and their navigation procedure was inadequate and did not utilize runway charts, signage, markings or cockpit instruments to guide them to the correct runway. The attention of the co-pilot Latiff and the relief pilot Ng was ‘inside’ the cockpit focused on the pre-takeoff checklist and calculating the cross-wind component. Only Captain Foong’s attention was ‘outside’ the cockpit focused on taxiing slowly in the slippery conditions and following the green taxiway lights to the runway.

3. The reason Captain Foong made a premature turn onto runway 05R was because:
i) he had the false impression that ATC could see the aircraft. He was under that impression because ATC issued his takeoff clearance just as he reached the end of the taxiway and was beginning his turn onto the runway. Co-pilot Latiff also confirmed that the timing of the takeoff clearance gave him the impression that everything was in order.
ii) the captain did not use the runway chart or the compass to guide him to the correct runway. Instead he stated that he “followed the green taxiway lights” despite the fact that this technique could not be used at CKS where visual navigation is required.
iii) he also failed to notice signs, markings and lights which indicated he was turning onto the wrong runway. These included the green taxiway lights to 05L (which were more widely spaced than normal), a clearly illuminated 05R sign as he turned into the runway, and the 05R marking painted on the runway in front of him as he lined up for take-off.

4. As they held for takeoff, all 3 pilots thought they saw a ‘normal runway scene’ and failed to recognize crucial indicators that they were on the wrong runway including:
i) that the center runway lights were green and not white (a printout record from calibration and maintenance equipment showed that the center runway lights were on 4 minutes before the crash)
ii) that it did not have touch-down lights or high-intensity runway edge lights (lack of evidence from security and passenger video, together with eyewitness testimony from the pilot of a plane on the taxiway 110m from the 05R indicated that the runway edge lights were almost certainly off).
iii) that the runway was 15m narrower than it should have been
iv) that the PVD instrument had not unshuttered.

5. Several factors were speculated to have led to these navigational deficiencies and observational failures including that:
i) the pilots were accustomed to using runway 06 and had not used 05L for 2-3 years and were therefore unfamiliar with it.
ii) Although having read a NOTAM concerning the construction on 05R, the pilots had not read the SIA INTAM that contained important information on the status of 05R’s center and edge lights
iii) Captain Foong had not been officially trained in low-visibility taxiing
iv) the pilots all had an incomplete understanding of why the PVD did not unshutter and incomplete training on the operational context of its usage.
v) the green taxiway lighting that led to 05L was abnormally spaced and instead of being 7.5 m apart, each light was 23 m apart
vi) All 3 pilots were fixated on taking-off quickly before the weather conditions deteriorated further and prevented takeoff (although there was no evidence of ‘organizational pressure’ on the pilots to take off that night).

6. The CKS airport authority was derelict in their maintenance and safety responsibilities. By not placing mandatory construction warnings at the entrance of 05R, they failed to address the risk that aircraft might inadvertently attempt to take off from a partially closed runway. They also failed to adequately maintain taxiway lights and marking to accepted international standards.



Maybe I am missing something, but this seems a pretty unbiased statement of facts. If you look at the NTSB comments in the appendix, they seem to think so too. Don’t be fooled by the spin doctors.
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Old 3rd May 2002, 04:19
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In the Slot,
I don't wish to belabour this point, since we basically seem to be in agreement, but, with respect, although in your opening sentence you do acknowledge that the crew lost situational awareness, the rest of your post is concerned with what a crew should do if there is any element of doubt in their minds as to their position. I assumed you felt that they were unsure of where they were. I think they were, to a man, wholly satisfied that they were correctly positioned for takeoff but I realize others disagree. This point was debated in this forum at length last year; unfortunately, not all the protagonists of the opposing viewpoints have rejoined the fray.
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