Lionair plane down in Bali.
BOAC, re “… a little concerning given the prevalence of 'magenta-line kids'.” (#487)
Yes; IMHO the example incident (#484) shows that even with experience (which may take at least 10 yrs to accumulate) there are some situations where all experience, quick and accurate appreciation of the situation, and correct action, are required to avoid an accident.
The human aspects in accidents appear to be a problem of continuing assumptions in regulation, where in a few rare and extreme occurrences the human is expected to manage. However this assumption may not now be valid throughout the industry, particularly with reduced opportunity to gain the required level of experience.
This evolving problem may originate with selection and training standards, which appear to be in decline, or that the regulations expect too much of human capability given the current professional and social cultures; instant gratification, weak attention span, a Google-its knowledge base, etc, etc, and ‘follow the line’ (SOP-its, use autos / FD / computer generated answers).
Thus what appears as human weaknesses in operation – ‘why weren’t threats and errors detected/avoided/mitigated’, are artefacts of the industry’s expectation. Thus the industry should perhaps not have such high expectations, limit operations, and provision aids to help the human; e.g ground based wind-shear warning and precision approach paths.
Note that in the example incident (#484), the crew generated an altitude/range model for their NPA; the Bali approach chart does not have a range/altitude table.
Yes; IMHO the example incident (#484) shows that even with experience (which may take at least 10 yrs to accumulate) there are some situations where all experience, quick and accurate appreciation of the situation, and correct action, are required to avoid an accident.
The human aspects in accidents appear to be a problem of continuing assumptions in regulation, where in a few rare and extreme occurrences the human is expected to manage. However this assumption may not now be valid throughout the industry, particularly with reduced opportunity to gain the required level of experience.
This evolving problem may originate with selection and training standards, which appear to be in decline, or that the regulations expect too much of human capability given the current professional and social cultures; instant gratification, weak attention span, a Google-its knowledge base, etc, etc, and ‘follow the line’ (SOP-its, use autos / FD / computer generated answers).
Thus what appears as human weaknesses in operation – ‘why weren’t threats and errors detected/avoided/mitigated’, are artefacts of the industry’s expectation. Thus the industry should perhaps not have such high expectations, limit operations, and provision aids to help the human; e.g ground based wind-shear warning and precision approach paths.
Note that in the example incident (#484), the crew generated an altitude/range model for their NPA; the Bali approach chart does not have a range/altitude table.
Last edited by PEI_3721; 17th Apr 2013 at 17:24. Reason: edit re #491
Those suggesting weather cannot have played a role should read the the report linked in PEI's most informative post.
I do not however agree with comments from others that Lionair's role in eroding terms and conditions and its safety culture should be ignored. I know people who have worked at Lionair. They are highly critical. These pilots may have been experienced. But anyone unaware of a problematic safety culture is not terribly well informed.
The facts should be known soon enough. But the possibilities include:
1. Something on the airplane failing....brand new plane and not much indication in that direction.
2. Act of God, weather exceeding the capability of the aircraft....cannot be excluded, but unlikely to be the only cause
3. Pilot error.....never very palatable for fellow pilots, but more often than not a factor
If there was pilot error combined with deficiencies in safety culture then the cost of insurance for their huge new fleet will probably increase. Given nobody was killed it will not be such a big insurance event. However it is indicative of what could happen.
Hopefully this will make the management of Lionair and other airlines, who consider pilots an expensive and largely avoidable cost, stop and rethink how they recruit, train and retain their pilots.
I do not however agree with comments from others that Lionair's role in eroding terms and conditions and its safety culture should be ignored. I know people who have worked at Lionair. They are highly critical. These pilots may have been experienced. But anyone unaware of a problematic safety culture is not terribly well informed.
The facts should be known soon enough. But the possibilities include:
1. Something on the airplane failing....brand new plane and not much indication in that direction.
2. Act of God, weather exceeding the capability of the aircraft....cannot be excluded, but unlikely to be the only cause
3. Pilot error.....never very palatable for fellow pilots, but more often than not a factor
If there was pilot error combined with deficiencies in safety culture then the cost of insurance for their huge new fleet will probably increase. Given nobody was killed it will not be such a big insurance event. However it is indicative of what could happen.
Hopefully this will make the management of Lionair and other airlines, who consider pilots an expensive and largely avoidable cost, stop and rethink how they recruit, train and retain their pilots.
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Rain
The CVR should be able to pick up the sound of the rain to prove or disprove some reports of a wall of water.
IF the noise of the rain was of a high decibel level, we may also find out that the crew may have had trouble talking to each other with proper flight discipline lost.
IF the noise of the rain was of a high decibel level, we may also find out that the crew may have had trouble talking to each other with proper flight discipline lost.
"Mildly" Eccentric Stardriver
Just watched "Children of the Magenta Line". That should be required viewing on all training courses on a modern aircraft. In my last job we had a lot of
P2F First Officers, which made us effectively unpaid line trainers (although I have to say that since these were not strictly company employees, we had a "spare" FO sitting down the back). Even flying over Europe a question such as "if an engine failed now, where would you go, and why?" could leave them floundering. I never tried "if I were to die now...? The answer would probably have given me sleepless nights. Enough thread drift, just wanted to put my bit in.
P2F First Officers, which made us effectively unpaid line trainers (although I have to say that since these were not strictly company employees, we had a "spare" FO sitting down the back). Even flying over Europe a question such as "if an engine failed now, where would you go, and why?" could leave them floundering. I never tried "if I were to die now...? The answer would probably have given me sleepless nights. Enough thread drift, just wanted to put my bit in.
The CVR should be able to pick up the sound of the rain to prove or disprove some reports of a wall of water.
IF the noise of the rain was of a high decibel level, we may also find out that the crew may have had trouble talking to each other with proper flight discipline lost.
IF the noise of the rain was of a high decibel level, we may also find out that the crew may have had trouble talking to each other with proper flight discipline lost.
On past engine wash outs it wasn't the rain that you hear on the CVR it was the hail.
Rain alone is not the problem as it gets centrifuged out the fan, The problem is the inertia of the hail which overcomes the centrifuging effect.
In order to do it with water alone you would need extremely low engine rpm and a rain storm of the likes never documented in a flight encounter.
I don't mind all these various what-if theories being expounded here as long as we accept the investigation findings when they are released.
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lompaseo
who said anything about an ''engine wash out''? I said we would hear rain on the CVR if it was of such amazing intenstiy as to be classified as a ''wall of water''.
We would also hear the windshield wipers going like HELL.
I've been in the cockpit of a 737 while it was raining (not hailing) and the noise level was higher than normal...adding the windshield wipers and even a hollar for rainboe would add to the noise.
lets not read too much into a simple statement.
this would be an excellent accident to have a cockpit VIDEO recorder to aid in investigation.
who said anything about an ''engine wash out''? I said we would hear rain on the CVR if it was of such amazing intenstiy as to be classified as a ''wall of water''.
We would also hear the windshield wipers going like HELL.
I've been in the cockpit of a 737 while it was raining (not hailing) and the noise level was higher than normal...adding the windshield wipers and even a hollar for rainboe would add to the noise.
lets not read too much into a simple statement.
this would be an excellent accident to have a cockpit VIDEO recorder to aid in investigation.
If this is infact true, then that explains a lot of things. And IF true, how then can a 2000 hour FO not understand the consequences of doing such a thing, so low to the surface and at a relatively low airspeed?
Just watched "Children of the Magenta Line". That should be required viewing on all training courses on a modern aircraft.
Even on the so called 'advanced' microlights - LSA's in USAspeak - that I now instruct on, many are coming fitted with TV screen style, Glass Cockpit, instrumentation, and students spend far too much time gazing at the picture - actually trying to find the basic information like airspeed and altitude from amongst the mass of largely uneccessary information that is also there - and not enough time looking out of the window, some even bring their own iPad loaded with some sort of Magenta Line navigation software.
Our CAA Rules for microlights only require a means of determining Airspeed, Height and Magnetic Heading, so with all this superflous electronic information we are already breeding a new generation of pilots, and many of our students start their eventual airline career on these little aeroplanes, dependant on all this electronic gadgetry.
I refuse to allow iPads when I fly with them, and am clearly regarded as a Mean Old Fart. I also ban cellphones now, after one student started texting his girl friend whilst taxying back in, before completing the After Landing Checks ! Perhaps I am a MOF ? See if I care.
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Its been reported that the cpt had a training background but is he a company trainer ? The F/O has 2000 hrs , assume he started with company as P2f at 200 hrs then he may be coming up for a command himself . Maybe there was some command training or command potential checking going on ? Be interesting to read if there where any CRM issues that contributed to the outcome .
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Even on the so called 'advanced' microlights - LSA's in USAspeak - that I now instruct on, many are coming fitted with TV screen style, Glass Cockpit, instrumentation, and students spend far too much time gazing at the picture - actually trying to find the basic information like airspeed and altitude from amongst the mass of largely uneccessary information that is also there...
I refuse to allow iPads when I fly with them, and am clearly regarded as a Mean Old Fart. I also ban cellphones now, after one student started texting his girl friend whilst taxying back in, before completing the After Landing Checks ! Perhaps I am a MOF ?
Look, as I understand it the "Magenta Children" meme is basically a treatise on *automation* dependence, not an avenue for bashing modern avionics in general. A PFD - even on a microlight - is just a modern iteration of the old-fashioned gauges. If you only want it used as such, then there's nothing stopping you.
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dozy...
I'm in the airline industry...all the colgan FO had to do was call in sick. granted, an outfit like colgan might have tried to fire her, but it was her choice to fly.
and that is what leadership is all about.
I will also say this...after commuting from San Francisco to Boston, I learned early on that I had better get there in time to have 12 hours in a hotel before reporting for duty...and it cost ME money.
I'm in the airline industry...all the colgan FO had to do was call in sick. granted, an outfit like colgan might have tried to fire her, but it was her choice to fly.
and that is what leadership is all about.
I will also say this...after commuting from San Francisco to Boston, I learned early on that I had better get there in time to have 12 hours in a hotel before reporting for duty...and it cost ME money.
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and that is what leadership is all about.
In any case, the illness and commuting fatigue factors combine into a potentially deadly whole if you consider that with a flu virus you can feel fine when you sign on and deadhead from Seattle, but feel like death when you get off at Newark.
Of course, you can call in sick at Newark, but then we're back to coercion because you not only have to pay your own accommodation costs - being very far from home - but you'll probably have to front any further transport costs to get you back home and lose money on your flight time. That's on top of the question you raised of whether doing so would risk your job.
I will also say this...after commuting from San Francisco to Boston, I learned early on that I had better get there in time to have 12 hours in a hotel before reporting for duty...and it cost ME money.
Last edited by DozyWannabe; 18th Apr 2013 at 01:04.
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sevenstroke:
I guess it would have cost her money, too, which I doubt she had.
I got displaced from LAX to STL for 4 months in 1983. I went over the day before for an 18 hour, or so, layover on my dime.
Even then, it finally caused me issues, which proved what I knew all long, that I couldn't commute from LAX to JFK to fly the "coveted" international (when it was far more limited.)
I will also say this...after commuting from San Francisco to Boston, I learned early on that I had better get there in time to have 12 hours in a hotel before reporting for duty...and it cost ME money.
I got displaced from LAX to STL for 4 months in 1983. I went over the day before for an 18 hour, or so, layover on my dime.
Even then, it finally caused me issues, which proved what I knew all long, that I couldn't commute from LAX to JFK to fly the "coveted" international (when it was far more limited.)
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dozzy...I suspect that you really don't know flying well.
the FO made a choice of living in SEA and flying out of EWR...and if it didn't work for her, she could have gotten a ''crash pad'' instead of living at home...or she could have waited for a job with another airline in SEA.
I remember what I went through when i worked for regional airlines...and I remember quitting one that had the habit of flying over gross weight.
You rarely ''get it all''...if I got it all I would have had a job in SFO instead of BOS...but I knew what it would cost me in terms of money, relationships and everything else under the sun.
AND if she was so sick, why was she well enough to explain in some detail how she had an "IN" at another larger airline and would likely get on there while the crew was flying through the night?
No Dozzy...the world of the pilot is pretty well known by the time you have as many hours as she had.
aterpster...I understand...I also know how I gave up a captain slot at a regionalairline in MSP to stay closer to home for money, family and other situations.
money...its all about money...choices...that's what flying is.
the FO made a choice of living in SEA and flying out of EWR...and if it didn't work for her, she could have gotten a ''crash pad'' instead of living at home...or she could have waited for a job with another airline in SEA.
I remember what I went through when i worked for regional airlines...and I remember quitting one that had the habit of flying over gross weight.
You rarely ''get it all''...if I got it all I would have had a job in SFO instead of BOS...but I knew what it would cost me in terms of money, relationships and everything else under the sun.
AND if she was so sick, why was she well enough to explain in some detail how she had an "IN" at another larger airline and would likely get on there while the crew was flying through the night?
No Dozzy...the world of the pilot is pretty well known by the time you have as many hours as she had.
aterpster...I understand...I also know how I gave up a captain slot at a regionalairline in MSP to stay closer to home for money, family and other situations.
money...its all about money...choices...that's what flying is.
Dozy, ExSp33b1rd, the problem is way deeper than gazing at the guages for information.
We have slowly built a virtual world in which software and the enticing and even intoxicating, (in-toxic-ating, if we take the root word) images formed by billions of pixels may just present information but this way of replicating the outside world is making a fundamental shift in psychological and sensory perceptions; they have grown into substitutes for what is going on outside the cockpit. We accept that what we see on the screen is not only more accessible but "more" accurate. Prior to automation it was easy to perceive that what was presented on the guages coincided with the world beyond the cockpit. Today most "piloting" is done "inside the cockpit", (so to speak) and because cockpit information is so rich, so ergonomically good and reliable, the need to "verify coincident information", (by which I mean, attend to understanding what is going on outside...beginning with the wings and engines and extending to weather systems), is less.
Steam guages always elicited a slight suspicion not wholly justified, because they got very good but remained unchanged until the early '80's. But the nature of reading, interpreting and flying the "group of six" is fundamentally (and philosophically, if anyone cares) different in the way our mental model of the outside world is structured and reified.
The effect is a disconnect between what is merely seen outside the cockpit and what is psychologically perceived outside the cockpit.
Many Old Farts, (and I'm one of 'em) may struggle with this notion and even dismiss it, but in my view no one under the age of 30 probably would. In fact, it is likely that none of this is visible to them - they are "in the river" so to speak and can't see the movement that has occurred in the tools of their trade.
Under the heading of, "I'll see it when I believe it . . ." we we old farts see the world fundamentally different. It is why skills, particularly manual skills, are yielding psychological space to skills which require the manipulation of a virtual world which more thoroughly than ever, is the model of reality we carry in our heads.
One is never in a cockpit, one is in a virtual reality, the presentation of which is on screen. That is a state of mind that a group-of-six could not possibly achieve. "Virtual Reality" is actually an oxymoron but fewer and fewer intuitively know this, (or experience the difference that makes a difference).
I know this is a topic for another thread and my apologies for the momentary thread drift. But there is a qualitative difference in recent accidents even just within the field of human factors and it shows up primarily in CFIT and LOC accidents. Control is lost or a CFIT occurs in perfectly serviceable aircraft because the real reality when the virtual reality implodes when the screen reality for some technical reason, disappears. I think this is what is going on when we speak of "children of the magenta line"; - there is simply less experience in reality to fall back on when the software or the guages quit.
The F/O on the Colgan Q400 accident at Buffalo was texting on the taxi-out. It's what people under 30 do and it was "normal" for her. The sad thing is, no one at her airline told her how to be a professional airline pilot and her captain just let her continue. We have to teach those who don't know that aviation still kills regardless of how much information we have on our guages or screens or tablets.
So ExSp33b1rd, well done and good for you for keeping the iPads, cell phones and other 'virtuality'-creating devices out of the cockpit, at least until your students understand that an accident is not virtual.
PJ2
We have slowly built a virtual world in which software and the enticing and even intoxicating, (in-toxic-ating, if we take the root word) images formed by billions of pixels may just present information but this way of replicating the outside world is making a fundamental shift in psychological and sensory perceptions; they have grown into substitutes for what is going on outside the cockpit. We accept that what we see on the screen is not only more accessible but "more" accurate. Prior to automation it was easy to perceive that what was presented on the guages coincided with the world beyond the cockpit. Today most "piloting" is done "inside the cockpit", (so to speak) and because cockpit information is so rich, so ergonomically good and reliable, the need to "verify coincident information", (by which I mean, attend to understanding what is going on outside...beginning with the wings and engines and extending to weather systems), is less.
Steam guages always elicited a slight suspicion not wholly justified, because they got very good but remained unchanged until the early '80's. But the nature of reading, interpreting and flying the "group of six" is fundamentally (and philosophically, if anyone cares) different in the way our mental model of the outside world is structured and reified.
The effect is a disconnect between what is merely seen outside the cockpit and what is psychologically perceived outside the cockpit.
Many Old Farts, (and I'm one of 'em) may struggle with this notion and even dismiss it, but in my view no one under the age of 30 probably would. In fact, it is likely that none of this is visible to them - they are "in the river" so to speak and can't see the movement that has occurred in the tools of their trade.
Under the heading of, "I'll see it when I believe it . . ." we we old farts see the world fundamentally different. It is why skills, particularly manual skills, are yielding psychological space to skills which require the manipulation of a virtual world which more thoroughly than ever, is the model of reality we carry in our heads.
One is never in a cockpit, one is in a virtual reality, the presentation of which is on screen. That is a state of mind that a group-of-six could not possibly achieve. "Virtual Reality" is actually an oxymoron but fewer and fewer intuitively know this, (or experience the difference that makes a difference).
I know this is a topic for another thread and my apologies for the momentary thread drift. But there is a qualitative difference in recent accidents even just within the field of human factors and it shows up primarily in CFIT and LOC accidents. Control is lost or a CFIT occurs in perfectly serviceable aircraft because the real reality when the virtual reality implodes when the screen reality for some technical reason, disappears. I think this is what is going on when we speak of "children of the magenta line"; - there is simply less experience in reality to fall back on when the software or the guages quit.
The F/O on the Colgan Q400 accident at Buffalo was texting on the taxi-out. It's what people under 30 do and it was "normal" for her. The sad thing is, no one at her airline told her how to be a professional airline pilot and her captain just let her continue. We have to teach those who don't know that aviation still kills regardless of how much information we have on our guages or screens or tablets.
So ExSp33b1rd, well done and good for you for keeping the iPads, cell phones and other 'virtuality'-creating devices out of the cockpit, at least until your students understand that an accident is not virtual.
PJ2
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@PJ2: Very interesting stuff, and food for thought. I'd like to ruminate for a bit and reply properly tomorrow, but I'm not sure this thread is the place to do it, as we're off in the long grass topic-wise. Your post might be worth a thread of its own in fact...
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Hi,
One interesting thing is how you can learn to write
There are currently two ways (since the invention of the typewriter .. now shelved and replaced by mechanical keyboard or touchpad)
Can a child learn to write using only the keyboard
Or you can learn to write with a pencil
Whoever has learned to write with a pencil can easily immediately write with a keyboard
Whoever has learned to write with a keyboard will be a lot of trouble to write with a pencil
To meditate ....
One interesting thing is how you can learn to write
There are currently two ways (since the invention of the typewriter .. now shelved and replaced by mechanical keyboard or touchpad)
Can a child learn to write using only the keyboard
Or you can learn to write with a pencil
Whoever has learned to write with a pencil can easily immediately write with a keyboard
Whoever has learned to write with a keyboard will be a lot of trouble to write with a pencil
To meditate ....
Last edited by jcjeant; 18th Apr 2013 at 02:07.