EasyJet A319 lands on closed Runway at Pisa 30/12
Well said, seen the box...
Quote from Wageslave:
"Talk of holes in the cheese strike me as being a bit by the by in this case. Holes require errors elsewhere and I don't see "errors" in the info given elsewhere."
In which case, why did you continue to expend several hundred words listing them all? There's a hint of old-school elitism in any implication that the pilots' layer of swiss-cheese should be uniquely impervious. If there are holes in several other layers, as your and others' comments imply, customer airlines need to put pressure on the Italian authorities: not simply admit 100% liability on behalf of a crew.
Quote:
"I know full well that pilots are never wrong according to many here, especially after they have made a grave error. That just cannot be true, and a bit more eyes wide open reality/honesty in these matters may not be a bad thing."
Wrong. The default situation with us is that we accept prime responsibility for any error. I think that all the pilots (and ex-pilots, like myself) posting here so far have been simply pointing out the possible extenuating circumstances. Pilots do not need to have traps set for them: being human they are perfectly capable of making their own mistakes - and learning accordingly.
Quote from Wageslave:
"Talk of holes in the cheese strike me as being a bit by the by in this case. Holes require errors elsewhere and I don't see "errors" in the info given elsewhere."
In which case, why did you continue to expend several hundred words listing them all? There's a hint of old-school elitism in any implication that the pilots' layer of swiss-cheese should be uniquely impervious. If there are holes in several other layers, as your and others' comments imply, customer airlines need to put pressure on the Italian authorities: not simply admit 100% liability on behalf of a crew.
Quote:
"I know full well that pilots are never wrong according to many here, especially after they have made a grave error. That just cannot be true, and a bit more eyes wide open reality/honesty in these matters may not be a bad thing."
Wrong. The default situation with us is that we accept prime responsibility for any error. I think that all the pilots (and ex-pilots, like myself) posting here so far have been simply pointing out the possible extenuating circumstances. Pilots do not need to have traps set for them: being human they are perfectly capable of making their own mistakes - and learning accordingly.
Chris, not much logic in those arguments I fear. I expended words to describe why they are NOT holes in the cheese as was clearly stated, and no mention of the pilots' layers being impervious. How did you infer that?
We accept responsibility as individuals, yes, but again I wasn't referring to that, as clearly stated. I was referring to the extraordinary reluctance on PPRuNe of accepting that accident pilots could have made cardinal error/s and finding a plethora of marginally connected extraneous events that could conceivably have had a minor bearing on the matter and using them to try to exonerate or ameliorate the pilot's actions. Its the elephant in the room syndrome and is present in almost every accident or incident topic on this forum.
We accept responsibility as individuals, yes, but again I wasn't referring to that, as clearly stated. I was referring to the extraordinary reluctance on PPRuNe of accepting that accident pilots could have made cardinal error/s and finding a plethora of marginally connected extraneous events that could conceivably have had a minor bearing on the matter and using them to try to exonerate or ameliorate the pilot's actions. Its the elephant in the room syndrome and is present in almost every accident or incident topic on this forum.
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I was referring to the extraordinary reluctance on PPRuNe of accepting that accident pilots could have made cardinal error/s and finding a plethora of marginally connected extraneous events that could conceivably have had a minor bearing on the matter and using them to try to exonerate or ameliorate the pilot's actions.
Yes, of course the crew made an error. However, had the NOTAM been presented in a clearer and more easily digestible format, had the airfield information been available earlier, had (making an assumption that they had some bearing on the incident) Pisa's ATC procedures been of a better standard: the error chain would have most likely been broken and the incident would not have occurred.
As I'm sure you're aware, the primary purpose of any investigation in an aviation context is not to apportion blame, but to prevent further accidents and incidents. By your logic displayed here, whenever there's an incident which has a human factors element to it, the investigation should simply conclude that the crew made an error, without bothering to look into the contributory factors. Why then bother having an investigation?
seen the box, tell me, had they read the NOTAM correctly is it likely they would have landed on the wrong runway, yes or no?
Last edited by seen_the_box; 3rd Jan 2016 at 18:21. Reason: Spelling error
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Wageslave - for what it is worth, my observations of PPRuNe are that pilots go into attack-dog mode very quickly with other pilots and are almost invariably at the 'it would never happen to me' end of the scale. The case in question here will no doubt be investigated meticulously by easyJet, the AAIB the Italian authorities and anyone who can claim an interest in the issue, however small.
It is also reasonable to say that very few pilots go to work with the intention of making a significant error of judgement. Therefore, when mistakes are made, there will be no one more upset at something going wrong than the individuals involved. Given that we can usually agree that the pilots in any incident wanted to do the right thing, and yet did not do so, it is entirely appropriate to try and understand the procedures and processes in place at the time to ascertain why an event took place that no one every wanted to happen. That means looking at all factors, however innocuous they might appear, to try and understand what led to an error occurring. In most cases somehow a series of errors and coincidences take place which make a particular crew on a particular day at a particular airport do the wrong thing. Leaving no stone unturned to work out why would seem a sensible way forward to me.
It is also reasonable to say that very few pilots go to work with the intention of making a significant error of judgement. Therefore, when mistakes are made, there will be no one more upset at something going wrong than the individuals involved. Given that we can usually agree that the pilots in any incident wanted to do the right thing, and yet did not do so, it is entirely appropriate to try and understand the procedures and processes in place at the time to ascertain why an event took place that no one every wanted to happen. That means looking at all factors, however innocuous they might appear, to try and understand what led to an error occurring. In most cases somehow a series of errors and coincidences take place which make a particular crew on a particular day at a particular airport do the wrong thing. Leaving no stone unturned to work out why would seem a sensible way forward to me.
Last edited by Count of Monte Bisto; 4th Jan 2016 at 20:08. Reason: Typo
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Count of Monte Bisto you are very right on the subject of pilots claiming that they would never make such mishaps in the event of an incident. There are two types of pilots; those it has happened to and those it will happen to, if not carefully guarded against.
Hello Chris Scott. It is very hard to have a fair intellectual battle with an unarmed man but you leave me little choice. The entire post made by seen the box is irrelevant, unsubstantiated personal opinion or just plain wrong. Sorry you wish to align yourself with such inept logic.
Seen the box seems to have so misread my post that he writes that I don't accept that errors happen, or that breaking the error chain "will" (note not "may) break it despite my clearly describing errors, error chains and how to break them. This is the sloppiest and most negligent answer I've seen for a while here - pure unwarranted assumption, or worse.
His second para is also devoid of logic and contains mere surmise; "Had" all sorts of random things happened other results "Might" have occurred. This is an "argument" akin to predicting the football pools by reading tea leaves. The correct position, I say again, is that "had they correctly read the NOTAM" they would have had reason to question an incorrect clearance if one was ever given. If so they apparently did not question it. Further if no incorrect landing runway was given by ATC then ipso facto they just landed on the wrong one. Either way ATC can have had no significant part in determining which runway was landed on unless incorrect readbacks were made. The result was determined by an assumption of the duty runway based, probably, on habit, experience, call it what you will unaffected by NOTAM or ATC. No amount of better quality ATC will remedy that.
His third para is a pastiche of irrationality and misinformation (my logic suggests nothing of what he infers) presented to look as though I had said it, not he. That is dishonest.
To continue by saying that if anyone is arrogant enough....and I emphasise "anyone"- then he would not fly with me is a non sequitur almost beyond belief. Why would he not fly with me if anyone else was arrogant? Or is he just ungrammatically accusing me of some imagined arrogance in taking this stance that he has invented? Because I most certainly did not take or present it. That is not only dishonest, it is a pathetic and weak attempt at slander and merely serves to further discredit his totally worthless "logic". It also describes all too well his staggering arrogance and unprofessionalism at making unwarranted and purely invented assumptions against someone he does not know. I am not impressed.
I have no quarrel with what the count said, it seems almost the same as my position and I agree with it, though I'd like to pay more attention to whys and wherefores of the fundamental error and less to presenting "extenuating circumstances" that played no part in leading to it at all, and are therefore not extenuating circumstances.
If someone is so certain that 07L is the duty runway and not 07R yet still lands on it despite being told 07R the problem is hardly with ATC - is it???
If he believed it was 07R as NOTAMed but was unexpectedly told 07L he would query the deviation from NOTAM rather than just land as previously assumed wouldn't he? How can ATC or ATIS/lack of be responsible for that?
The question is surely how such well trained pilots bamboozle themselves into missing critical NOTAMs relating to fundamental gotchas at well known trap-locations, not mere detail of whether the trap location had an ATIS or spoke the Queen's English. Its much deeper and more fundamental than that. Sure, the detail needs sorting out but it isn't the elephant in the room. Let's address that first?
Seen the box seems to have so misread my post that he writes that I don't accept that errors happen, or that breaking the error chain "will" (note not "may) break it despite my clearly describing errors, error chains and how to break them. This is the sloppiest and most negligent answer I've seen for a while here - pure unwarranted assumption, or worse.
His second para is also devoid of logic and contains mere surmise; "Had" all sorts of random things happened other results "Might" have occurred. This is an "argument" akin to predicting the football pools by reading tea leaves. The correct position, I say again, is that "had they correctly read the NOTAM" they would have had reason to question an incorrect clearance if one was ever given. If so they apparently did not question it. Further if no incorrect landing runway was given by ATC then ipso facto they just landed on the wrong one. Either way ATC can have had no significant part in determining which runway was landed on unless incorrect readbacks were made. The result was determined by an assumption of the duty runway based, probably, on habit, experience, call it what you will unaffected by NOTAM or ATC. No amount of better quality ATC will remedy that.
His third para is a pastiche of irrationality and misinformation (my logic suggests nothing of what he infers) presented to look as though I had said it, not he. That is dishonest.
To continue by saying that if anyone is arrogant enough....and I emphasise "anyone"- then he would not fly with me is a non sequitur almost beyond belief. Why would he not fly with me if anyone else was arrogant? Or is he just ungrammatically accusing me of some imagined arrogance in taking this stance that he has invented? Because I most certainly did not take or present it. That is not only dishonest, it is a pathetic and weak attempt at slander and merely serves to further discredit his totally worthless "logic". It also describes all too well his staggering arrogance and unprofessionalism at making unwarranted and purely invented assumptions against someone he does not know. I am not impressed.
I have no quarrel with what the count said, it seems almost the same as my position and I agree with it, though I'd like to pay more attention to whys and wherefores of the fundamental error and less to presenting "extenuating circumstances" that played no part in leading to it at all, and are therefore not extenuating circumstances.
If someone is so certain that 07L is the duty runway and not 07R yet still lands on it despite being told 07R the problem is hardly with ATC - is it???
If he believed it was 07R as NOTAMed but was unexpectedly told 07L he would query the deviation from NOTAM rather than just land as previously assumed wouldn't he? How can ATC or ATIS/lack of be responsible for that?
The question is surely how such well trained pilots bamboozle themselves into missing critical NOTAMs relating to fundamental gotchas at well known trap-locations, not mere detail of whether the trap location had an ATIS or spoke the Queen's English. Its much deeper and more fundamental than that. Sure, the detail needs sorting out but it isn't the elephant in the room. Let's address that first?
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pisa runways
It will be interesting to learn how many times the pilots had been into Pisa.
seeing an airfield on a little chart and simulated on a computer aint the same as looking at it in the raw. and how long do you get to do that on the approach, at low level and with a very slantwise view? not very long.
getting a bit tetchy on here. why not save that for after we know the actual course of events when by the sound of it, a lot of humble pie may be flying around.
seeing an airfield on a little chart and simulated on a computer aint the same as looking at it in the raw. and how long do you get to do that on the approach, at low level and with a very slantwise view? not very long.
getting a bit tetchy on here. why not save that for after we know the actual course of events when by the sound of it, a lot of humble pie may be flying around.
Without in any way wishing to ally myself with Wageslave's "little moment"...
I am troubled by a piece pf phrasing that pops up in a couple of posts.
That is a low-rent, low-bar, passive standard. A five-year-old can get into a cockpit without "the intention of making an error."
A pilot needs a more assertive attitude: "Today, the world will throw all kinds of $%*# at me - the NOTAMs will be unintelligible, ATC will be obtuse, other pilots will cut corners, the electrons will go haywire, the weather will conspire against me, the bits of cement will be indistinguishable, and I'm not too sure about the guy/gal in the other seat - but I will overcome all obstacles, prevail, and finish the job competently and safely!"
That does not mean one has to be cynical or bitter or scared (skeptical, yes) - one can be a "happy warrior," taking joy in every successful ploy to outwit The Hunter (Fate). And when one arrives safely, and looks back on a flight where, in fact, most things went right, say "Hunh! That was actually a pretty good day!"
I am troubled by a piece pf phrasing that pops up in a couple of posts.
s_t_b - "Nobody (intentional acts of destruction aside) sets out routinely to cause an incident or accident."
CoMB - "It is also reasonable to say that very few pilots go to work with the intention of making a significant error of judgement."
CoMB - "It is also reasonable to say that very few pilots go to work with the intention of making a significant error of judgement."
A pilot needs a more assertive attitude: "Today, the world will throw all kinds of $%*# at me - the NOTAMs will be unintelligible, ATC will be obtuse, other pilots will cut corners, the electrons will go haywire, the weather will conspire against me, the bits of cement will be indistinguishable, and I'm not too sure about the guy/gal in the other seat - but I will overcome all obstacles, prevail, and finish the job competently and safely!"
That does not mean one has to be cynical or bitter or scared (skeptical, yes) - one can be a "happy warrior," taking joy in every successful ploy to outwit The Hunter (Fate). And when one arrives safely, and looks back on a flight where, in fact, most things went right, say "Hunh! That was actually a pretty good day!"
Originally Posted by pattern_is_full
Without in any way wishing to ally myself with Wageslave's "little moment"...
I am troubled by a piece pf phrasing that pops up in a couple of posts.
Quote:
s_t_b - "Nobody (intentional acts of destruction aside) sets out routinely to cause an incident or accident."
CoMB - "It is also reasonable to say that very few pilots go to work with the intention of making a significant error of judgement."
That is a low-rent, low-bar, passive standard. A five-year-old can get into a cockpit without "the intention of making an error."
A pilot needs a more assertive attitude: "Today, the world will throw all kinds of $%*# at me - the NOTAMs will be unintelligible, ATC will be obtuse, other pilots will cut corners, the electrons will go haywire, the weather will conspire against me, the bits of cement will be indistinguishable, and I'm not too sure about the guy/gal in the other seat - but I will overcome all obstacles, prevail, and finish the job competently and safely!"
That does not mean one has to be cynical or bitter or scared (skeptical, yes) - one can be a "happy warrior," taking joy in every successful ploy to outwit The Hunter (Fate). And when one arrives safely, and looks back on a flight where, in fact, most things went right, say "Hunh! That was actually a pretty good day!"
I am troubled by a piece pf phrasing that pops up in a couple of posts.
Quote:
s_t_b - "Nobody (intentional acts of destruction aside) sets out routinely to cause an incident or accident."
CoMB - "It is also reasonable to say that very few pilots go to work with the intention of making a significant error of judgement."
That is a low-rent, low-bar, passive standard. A five-year-old can get into a cockpit without "the intention of making an error."
A pilot needs a more assertive attitude: "Today, the world will throw all kinds of $%*# at me - the NOTAMs will be unintelligible, ATC will be obtuse, other pilots will cut corners, the electrons will go haywire, the weather will conspire against me, the bits of cement will be indistinguishable, and I'm not too sure about the guy/gal in the other seat - but I will overcome all obstacles, prevail, and finish the job competently and safely!"
That does not mean one has to be cynical or bitter or scared (skeptical, yes) - one can be a "happy warrior," taking joy in every successful ploy to outwit The Hunter (Fate). And when one arrives safely, and looks back on a flight where, in fact, most things went right, say "Hunh! That was actually a pretty good day!"
If it was an isolated incident it could be apportioned (not completely) to crew error as a result of any number of factors such as complacency or fatigue.
But multiple crews made that same approach, they can't all have made the same mistake by chance, there must have been something like a glaring lack of clarity in the NOTAMS or some such.
People have been saying that crews are routinely landing on that runway in normal ops so have got into the habit of that runway and are used to it... but if the crew could fall into that trap... why not ATC?! They're surely much more used to 04R, so isn't it equally likely, if not more so, that in the briefest moment of complacency or distraction they said 04R instead of 04L?
The number of times I hear crew around the south coast in private aircraft talking to ATC with a company callsign before remembering they're not at work... isn't a brain fart like that equally as possible in Pisa?
Last edited by LlamaFarmer; 4th Jan 2016 at 22:33.
I see "failures" such as this as a system failure.
If you're playing football and your team loses 30 goals to nil then you wouldn't blame it all on the goalkeeper. (Although you might sack the manager).
I am totally with this "attitude". However therein lies part of the dilemma. As pilots our mindset is (naturally) mission orientated but if we all refused to operate to certain airports you can bet your bottom dollar that matters such as no ATIS, poor ATC, inadequate NOTAMS etc would be sorted at the drop of a hat.
If you're playing football and your team loses 30 goals to nil then you wouldn't blame it all on the goalkeeper. (Although you might sack the manager).
A pilot needs a more assertive attitude: "Today, the world will throw all kinds of $%*# at me - the NOTAMs will be unintelligible, ATC will be obtuse, other pilots will cut corners, the electrons will go haywire, the weather will conspire against me, the bits of cement will be indistinguishable, and I'm not too sure about the guy/gal in the other seat - but I will overcome all obstacles, prevail, and finish the job competently and safely!"
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I tried swallowing the Oxford Dictionary (original version, not the dumbed down one) for breakfast but much prefer me toast 'n' butter. I also had a quick go at the Times criptic but got no further than clue one. I guess I was clueless. I am breaking all me New Year Resolutions which included avoiding social yuckspeak and must use three , commonly used , to illustrate what happened here (at Pisa)............ Look,........ AT THE END OF THE DAY.............HE DID WHAT HE DOES...........AND IT IS WHAT IT IS. Blimey Wageslave, geeeza break. Do you write Notams for a hobby ?
Only half a speed-brake
Valid NOTAM:
In a previous life I took part in reverse engineering 
a NOTAM-highlighting system for an electronic briefing tool. With such solution, it is inevitable that pilots will de-focus from the non-highlighted notams. That left me feeling uneasy as a designer and an operator and we did not stop until a really smart algorithm had been devised.
The original notam does not provide enough clues for software recognition of its importance.
Does EZY use any sort of notam highligting in their EFBs, which I understand are rather elaborate?
Q) LIMM/QMRXX/IV/NBO /A /000/999/4341N01024E
A) LIRP
B) 16/01/03 09:49 C) 16/01/31 10:00
E) RUNWAY 04R/22L CLSD. AVBL AS TWY ONLY. RUNWAY 04L/22R AVBL AS RWY IN USE. RMK 1: TRAFFIC MAY BE SUBJ DLA. RMK 2: DRG TAX OPS MAY BE NECESSARY TO CROSS ACTIVE RUNWAY IN ORDER TO PREVENT RWY INCURSION FLW STRICTLY ATC INSTRUCTIONS. REF AIP AD 2 LIRP 2-1
A) LIRP
B) 16/01/03 09:49 C) 16/01/31 10:00
E) RUNWAY 04R/22L CLSD. AVBL AS TWY ONLY. RUNWAY 04L/22R AVBL AS RWY IN USE. RMK 1: TRAFFIC MAY BE SUBJ DLA. RMK 2: DRG TAX OPS MAY BE NECESSARY TO CROSS ACTIVE RUNWAY IN ORDER TO PREVENT RWY INCURSION FLW STRICTLY ATC INSTRUCTIONS. REF AIP AD 2 LIRP 2-1
a NOTAM-highlighting system for an electronic briefing tool. With such solution, it is inevitable that pilots will de-focus from the non-highlighted notams. That left me feeling uneasy as a designer and an operator and we did not stop until a really smart algorithm had been devised.The original notam does not provide enough clues for software recognition of its importance.
B6654/15 - RUNWAY 04R/22L AVBL AS TWY ONLY. RUNWAY 04L/22R AVBL AS RWY IN USE. RMK1:TRAFFIC MAY BE SUBJ DLA RMK2: TAX OPS MAY BE NECESSARY TO CROSS ACTIVE RUNWAY IN ORDER TO PREVENT RWY INCURSION FLW STRICTLY ATC INSTRUCTION. REF AIP AD 2 LIRP 2-1. 23 DEC 15:44 2015 UNTIL 31 JAN 23:59 2016 ESTIMATED.
Valid NOTAM: In a previous life I took part in reverse engineering a NOTAM-highlighting system for an electronic briefing tool. With such solution, it is inevitable that pilots will de-focus from the non-highlighted notams. That left me feeling uneasy as a designer and an operator and we did not stop until a really smart algorithm had been devised.
The original notam does not provide enough clues for software recognition of its importance. Does EZY use any sort of notam highligting in their EFBs, which I understand are rather elaborate?
a NOTAM-highlighting system for an electronic briefing tool. With such solution, it is inevitable that pilots will de-focus from the non-highlighted notams. That left me feeling uneasy as a designer and an operator and we did not stop until a really smart algorithm had been devised.The original notam does not provide enough clues for software recognition of its importance. Does EZY use any sort of notam highligting in their EFBs, which I understand are rather elaborate?