AAL 331 Kingston final report
Join Date: Jul 2007
Location: Tanah Melayu
Age: 60
Posts: 57
Likes: 0
Received 0 Likes
on
0 Posts
History is always written by the conquerors. Heroics are always the domain of the braggarts.
They gave awards to the Transat hero who exacerbated the fuel leak problem for crunching the A330 onto Lajes; they awarded medals to murders who shot down Iran Air 655. Lots more if you care to research further.............
They gave awards to the Transat hero who exacerbated the fuel leak problem for crunching the A330 onto Lajes; they awarded medals to murders who shot down Iran Air 655. Lots more if you care to research further.............
Join Date: Apr 2003
Location: Europe
Posts: 3,039
Likes: 0
Received 0 Likes
on
0 Posts
PENCO, as before I agree that attitude is important (see Avoiding an overrun: what should be trained? also #9, #11, before that). However, I disagree with the view that the decision is always deliberate or something which without-fail can be controlled; the reasoning for this is described by others in HF guidance materials, and in particular ‘A Life in Error’ by James Reason – his latest (final) book which provides an excellent overview
Maybe it will. And on that basis I tend to agree with you. But it's a very big maybe!
Pilots think they can get away with a lot and the problem is that most of the time, they are right! You land long nine times and you think you can get away with it the tenth time. So on a dark and stormy tailwind night your brain will be so conditioned that you will ignore any further warnings about landing long unless..
Unless you are conditioned NEVER to land long. That's when attitude change comes in. Send out an email every single time a pilot lands long. Show him the FDM trace. Caution him about his actions. Tell him that, just as being unstable at 500, landing long is a big no-no under any circumstance.
Last edited by PENKO; 19th May 2014 at 12:47.
Accident investigation requires an impartial presentation of the occurrence without allocation either of pardon or blame; this report is a good example of this. It also identifies many safety weaknesses which can be addressed by a range of people at many operational levels, including individual enhancement as lessons to learn.
Will blaming fellow pilots help us learn; I doubt it. A more likely conclusion is that because ‘we think that we know' what happened (hindsight and a single focus on the outcome), ‘we’ won’t suffer the same, but how do we know that.
This view is similar to considering yourself to be invulnerable or being overconfident, both hazardous attitudes in aviation.
What surprises me is the number of contributors who present an old view of human error and accident causation, which I thought was to be changed with improved training in human factors and CRM. Are these HF initiatives failing to achieve their intent or is the teaching missing some important aspect.
‘Human desire’; try ‘goal’ or the objective of an activity. Seek a second opinion – change the witch doctor:
http://www.scribd.com/doc/224823088/...ective-Crew-DM
Human error
http://www.ctlab.org/documents/PerspOnHumErr.pdf
Will blaming fellow pilots help us learn; I doubt it. A more likely conclusion is that because ‘we think that we know' what happened (hindsight and a single focus on the outcome), ‘we’ won’t suffer the same, but how do we know that.
This view is similar to considering yourself to be invulnerable or being overconfident, both hazardous attitudes in aviation.
What surprises me is the number of contributors who present an old view of human error and accident causation, which I thought was to be changed with improved training in human factors and CRM. Are these HF initiatives failing to achieve their intent or is the teaching missing some important aspect.
‘Human desire’; try ‘goal’ or the objective of an activity. Seek a second opinion – change the witch doctor:
http://www.scribd.com/doc/224823088/...ective-Crew-DM
Human error
http://www.ctlab.org/documents/PerspOnHumErr.pdf
PENKO; a good philosophical question, one which I hope that regulators and safety experts are considering, because many people will place faith in automation without question.
IMHO well considered automation will make a difference, but perhaps not as much as might be expected. Humans tend to agree with computed solutions more than their own assessments, but with increasing conflict of cues, particularly visual input, automation might be ignored (the closer you get to the runway).
An EGPWS example. A sudden red warning challenges the belief of knowing where you are (what you are doing – which is 'correct' because you chose to do it), but with advanced amber alerting and terrain display the situation is placed in context, an alternative explanation. Here the system is decision-aiding opposed to decision-making. Of course there are situations where this information is not heeded; in these cases further automation might help. IIRC there was a limited trial where the EGPWS pull up warning was automated, either with the autopilot or just FD. In these instances the pilot was more reluctant to override/reverse the automated decision as this was a more significant challenge to their belief.
For systems such as ROPS, more consideration could be given to the advanced alerting (strategic) aspects, as these may have greater influence than a later (tactical) warning over the runway. This follows similar logic to getting pilots to think ahead, plan, brief, and consider a range of options. Thus as with EGPWS, adherence to procedures could be improved with earlier decision-aiding vs a later and possible challenging computed decision-making over the runway (‘shut up gringo’).
Another view of computer use is to enter the chosen landing data into the system, which might not be able to generate a more accurate solution than the crew, but might be able to rate the quality of decision against a range predetermined risks or vs previous performance in this situation – as discussed previously in this thread.
Automation can help us avoid situations where our weaknesses can be hazardous, but it cannot overcome or replace our weaknesses.
.
IMHO well considered automation will make a difference, but perhaps not as much as might be expected. Humans tend to agree with computed solutions more than their own assessments, but with increasing conflict of cues, particularly visual input, automation might be ignored (the closer you get to the runway).
An EGPWS example. A sudden red warning challenges the belief of knowing where you are (what you are doing – which is 'correct' because you chose to do it), but with advanced amber alerting and terrain display the situation is placed in context, an alternative explanation. Here the system is decision-aiding opposed to decision-making. Of course there are situations where this information is not heeded; in these cases further automation might help. IIRC there was a limited trial where the EGPWS pull up warning was automated, either with the autopilot or just FD. In these instances the pilot was more reluctant to override/reverse the automated decision as this was a more significant challenge to their belief.
For systems such as ROPS, more consideration could be given to the advanced alerting (strategic) aspects, as these may have greater influence than a later (tactical) warning over the runway. This follows similar logic to getting pilots to think ahead, plan, brief, and consider a range of options. Thus as with EGPWS, adherence to procedures could be improved with earlier decision-aiding vs a later and possible challenging computed decision-making over the runway (‘shut up gringo’).
Another view of computer use is to enter the chosen landing data into the system, which might not be able to generate a more accurate solution than the crew, but might be able to rate the quality of decision against a range predetermined risks or vs previous performance in this situation – as discussed previously in this thread.
Automation can help us avoid situations where our weaknesses can be hazardous, but it cannot overcome or replace our weaknesses.
.
Last edited by alf5071h; 19th May 2014 at 13:51.
Join Date: Sep 2013
Location: UK
Posts: 730
Likes: 0
Received 0 Likes
on
0 Posts
There is nothing new in this accident. The crew would have been aware of their baulked landing but ignored the repeated lessons of all those previous investigated accidents of the very same nature. So, forgive them if you want, but I won't. There has to be a line drawn somewhere, and if someone has a prang from genuine misinterpretation or confusion, then the investigation and follow up should be more sympathetic, but where wilful gross negligence is the causal factor, then they deserve a kick in the nuts.
Join Date: Mar 2009
Location: Phoenix, AZ USA
Age: 66
Posts: 0
Likes: 0
Received 0 Likes
on
0 Posts
Automation can help us avoid situations where our weaknesses can be hazardous, but it cannot overcome or replace our weaknesses.
That is a scary and absolutely incorrect statement.
Automation is designed to counter a perceived lack of aptitude, professionalism and experience. It breeds complacency and an acceptance of an inferior standard of conduct. The original idea of automation was the reduction of pilot workload in complex environments, not reduction in the skill of the aviator.
The simple truth is that the captain should have been fired and the conduct of the first officer reviewed to insure that he did in fact have the required understanding of his professional obligations. We need to go no farther then the accident up Canada where the first officer knew the captain was wrong and failed to force a go around...killing both himself and all souls. We're losing sight of the fact that the word professional is just as important as the word pilot. Just because you can fly doesn't mean you belong in the left hand seat of an airliner.
That is a scary and absolutely incorrect statement.
Automation is designed to counter a perceived lack of aptitude, professionalism and experience. It breeds complacency and an acceptance of an inferior standard of conduct. The original idea of automation was the reduction of pilot workload in complex environments, not reduction in the skill of the aviator.
The simple truth is that the captain should have been fired and the conduct of the first officer reviewed to insure that he did in fact have the required understanding of his professional obligations. We need to go no farther then the accident up Canada where the first officer knew the captain was wrong and failed to force a go around...killing both himself and all souls. We're losing sight of the fact that the word professional is just as important as the word pilot. Just because you can fly doesn't mean you belong in the left hand seat of an airliner.
Join Date: Jan 2014
Location: glendale
Posts: 819
Likes: 0
Received 0 Likes
on
0 Posts
I am amazed.
I would rather have a great "pilot/airplane/flying "mind than all the gadgets in the world
Why not teach pilots how to use their minds instead of their gadgets?
I would rather have a great "pilot/airplane/flying "mind than all the gadgets in the world
Why not teach pilots how to use their minds instead of their gadgets?
Join Date: Jan 2014
Location: glendale
Posts: 819
Likes: 0
Received 0 Likes
on
0 Posts
OK465
I guess I have to make it clearer for you.
But before I do, yes I have flown an ILS in weather. I flew in a plane.
So I suppose I don't advocate getting rid of all gadgets including such things as: engines, wings, flight controls, landing gear and so forth.
I like having a chair to sit in, inside a plane too.
So I guess I have to make something clear to you. I suppose I can fly, and have flown, just fine without a HUD. Or an attachment to the HUD telling me how much runway is remaining.
does that help you understand?
I guess I have to make it clearer for you.
But before I do, yes I have flown an ILS in weather. I flew in a plane.
So I suppose I don't advocate getting rid of all gadgets including such things as: engines, wings, flight controls, landing gear and so forth.
I like having a chair to sit in, inside a plane too.
So I guess I have to make something clear to you. I suppose I can fly, and have flown, just fine without a HUD. Or an attachment to the HUD telling me how much runway is remaining.
does that help you understand?
Join Date: Aug 2005
Location: fl
Posts: 2,525
Likes: 0
Received 0 Likes
on
0 Posts
Most all the pilots I went through my career with did just fine with no autopilot or if they flew a B737 200 as I did used it for climb, cruise and descent. As more and more automation became available some elected to use it to fly an ILS but most hand flew the ILS to maintain their currency so as not to rely on automation to fly their plane.
My airline did not require using automation unless the approach required it. That was ten years ago. Reading posts here I see some airlines require automation most of the time. A lot of foreign airlines start from ground zero teaching automation. Time will tell where this leads us.
My airline did not require using automation unless the approach required it. That was ten years ago. Reading posts here I see some airlines require automation most of the time. A lot of foreign airlines start from ground zero teaching automation. Time will tell where this leads us.
Will blaming fellow pilots help us learn; I doubt it. A more likely conclusion is that because ‘we think that we know' what happened (hindsight and a single focus on the outcome), ‘we’ won’t suffer the same, but how do we know that.
I read every one of them I could get my hands on and often vowed to myself, "I'll never make that stupid mistake". Guess what. It worked.
I "think I know" what happened in the AA accident and while there were many contributing factors, the single overwhelming reason these guys crashed (assuming the reports are even close to true) is that the pilot flew past half the runway before landing.
I'm quite sure Grampaw Pettibone wrote about this exact screw up more than once. Hindsight is 20/20 but it need not be hindsight associated with YOUR screw-up. Learning from pilots who made serious mistakes (like landing WAY too long) in the past is a good way to learn how to avoid making that mistake yourself. And I know that blaming the guys who screwed up in the past works, because while I have made countless landings in a variety of aircraft, I have NEVER flown past the first half of the runway before making one of those landings. Why? Because when I was just a youngster Grampaw Pettibone told me it was dangerous ............. and stupid.
Join Date: Jan 2014
Location: glendale
Posts: 819
Likes: 0
Received 0 Likes
on
0 Posts
mozella. bravo.
I had a math teacher in the 7th and 9th grades. same man. his most often made statement was: DO NOT FALL FOR TRAPS.
There are traps in flying. Knowing them, even by way of those who make mistakes, help us NOT FALL FOR TRAPS. Land in the first third, or the bonafide touchdown zone or get the heck out of there!
right on bubbers.
I had a math teacher in the 7th and 9th grades. same man. his most often made statement was: DO NOT FALL FOR TRAPS.
There are traps in flying. Knowing them, even by way of those who make mistakes, help us NOT FALL FOR TRAPS. Land in the first third, or the bonafide touchdown zone or get the heck out of there!
right on bubbers.
Guest
Join Date: Apr 2009
Location: On the Beach
Posts: 3,336
Likes: 0
Received 0 Likes
on
0 Posts
ok465:
Never have used one but I know enough about HUDs to know they are an awesome addition to the flight deck.
In the early 1970s the then-chairman of ALPA's All Weather Flying Committee tried to convince the FAA to mandate HUDs on transport category airplanes. He went to France and flew the HUDs available there at the time. He made a carefully organized and documented presentation to the suits at FAA Headquarters Flight Standards Service. They yawed and basically told him to wiz up a rope.
and I assume that if you were required by company SOP to use the HUD for every takeoff and landing and had done so during the accumulation of 5000+ hours on type....early in the game you would have used your mind to learn how to operate and utilize the HUD in an effective manner, just as you did when you upgraded to a digital watch and a VCR.
In the early 1970s the then-chairman of ALPA's All Weather Flying Committee tried to convince the FAA to mandate HUDs on transport category airplanes. He went to France and flew the HUDs available there at the time. He made a carefully organized and documented presentation to the suits at FAA Headquarters Flight Standards Service. They yawed and basically told him to wiz up a rope.
Join Date: Oct 2008
Location: NY
Posts: 38
Likes: 0
Received 0 Likes
on
0 Posts
This has been an interesting thread....
It's been a while since my 121 days, but if I recall, we couldn't take double penalties with respect to tailwind takeoffs and landings on contaminated runways. The latter mandated ops into the wind...
It's been a while since my 121 days, but if I recall, we couldn't take double penalties with respect to tailwind takeoffs and landings on contaminated runways. The latter mandated ops into the wind...
Join Date: May 2007
Location: NZ
Posts: 1
Likes: 0
Received 0 Likes
on
0 Posts
It's interesting the report doesn't really go into why the crew wern't aware of the RNAV approach when the plates were onboard and it was available for selection in the box. Eg were RNAV approaches widely used by the airline's pilots? Had the accident crew flown RNAV approaches at other airports? Were other carrier's regularly using the approach etc?
It seems this is somewhat glossed over. If the crew or their collegues at the time very rarly used RNAVs it might explain a little more why the ILS was deemed the only option.
It seems this is somewhat glossed over. If the crew or their collegues at the time very rarly used RNAVs it might explain a little more why the ILS was deemed the only option.
Never have used one but I know enough about HUDs to know they are an awesome addition to the flight deck.
In the early 1970s the then-chairman of ALPA's All Weather Flying Committee tried to convince the FAA to mandate HUDs on transport category airplanes. He went to France and flew the HUDs available there at the time. He made a carefully organized and documented presentation to the suits at FAA Headquarters Flight Standards Service. They yawed and basically told him to wiz up a rope.
In the early 1970s the then-chairman of ALPA's All Weather Flying Committee tried to convince the FAA to mandate HUDs on transport category airplanes. He went to France and flew the HUDs available there at the time. He made a carefully organized and documented presentation to the suits at FAA Headquarters Flight Standards Service. They yawed and basically told him to wiz up a rope.
A worthless distracting POS in rough weather and turbulence, light polluted fields and night and BS requirements to use it VFR. Great resource for weak crewmembers with little real experience before flying a transport jet.
Used an AA one into SJO Costa Rica at around 300/1. Following the HUD guidance took me past the touchdown zone.
Join Date: Sep 2010
Location: Double Oak, Texas
Age: 71
Posts: 180
Likes: 0
Received 0 Likes
on
0 Posts
Whatsa......
Is that 737 HUD able to recognize steeply sloped runways; i.e. The uphill rwy 07 at MROC? (Zero relative vertical velocity at 135 knots is somewhere around 175 fpm climb on runway 07 there)
Is that 737 HUD able to recognize steeply sloped runways; i.e. The uphill rwy 07 at MROC? (Zero relative vertical velocity at 135 knots is somewhere around 175 fpm climb on runway 07 there)
Guest
Join Date: Apr 2009
Location: On the Beach
Posts: 3,336
Likes: 0
Received 0 Likes
on
0 Posts
skyhibeaver:
The report states that AAL's ops specs authorize RNAV IAPs, that the crew was RNAV IAP qualified and possessed the RNAV chart. The report also states use of the RNAV Runway 30 IAP would have likely prevented the accident.
That raised the flag quite high. The investigators only had one interview opportunity. AAL may have not been all that open, either.
It's interesting the report doesn't really go into why the crew wern't aware of the RNAV approach when the plates were onboard and it was available for selection in the box. Eg were RNAV approaches widely used by the airline's pilots? Had the accident crew flown RNAV approaches at other airports? Were other carrier's regularly using the approach etc?
It seems this is somewhat glossed over. If the crew or their collegues at the time very rarly used RNAVs it might explain a little more why the ILS was deemed the only option.
It seems this is somewhat glossed over. If the crew or their collegues at the time very rarly used RNAVs it might explain a little more why the ILS was deemed the only option.
That raised the flag quite high. The investigators only had one interview opportunity. AAL may have not been all that open, either.
Join Date: Jan 2008
Location: The Colonies
Posts: 30
Likes: 0
Received 0 Likes
on
0 Posts
Stable conditions, low vis approaches and takeoffs, it's a great addition.
A worthless distracting POS in rough weather and turbulence, light
polluted fields and night and BS requirements to use it VFR. Great resource for
weak crewmembers with little real experience before flying a transport
jet.
Used an AA one into SJO Costa Rica at around 300/1. Following the
HUD guidance took me past the touchdown zone.
