Air Niugini Aircraft crash, Truk Lagoon
M R,
My less than overt point is that we often think that others know what is mean and understood. So as much as you might think (assume) that I will know something, might the crew have believed that many of the issues now identified with hindsight were acceptable to their way of thinking at that time.
The difficult task now is in unraveling why there should have been such a difference and what we can learn from this.
Opposed to declaring that the apparent failure to heed warnings and alerts is unbelievable (our way of thinking), we should reconsider that hearing is the first sense to degrade with increasing workload, together with the issues of fixation etc, as discussed the report (HF 2.3.1.), and that with many complacent historical items, all combined at an inopportune time.
Why should such contributions exist, and why was the combination so critical at that time. What might we do about these.
My less than overt point is that we often think that others know what is mean and understood. So as much as you might think (assume) that I will know something, might the crew have believed that many of the issues now identified with hindsight were acceptable to their way of thinking at that time.
The difficult task now is in unraveling why there should have been such a difference and what we can learn from this.
Opposed to declaring that the apparent failure to heed warnings and alerts is unbelievable (our way of thinking), we should reconsider that hearing is the first sense to degrade with increasing workload, together with the issues of fixation etc, as discussed the report (HF 2.3.1.), and that with many complacent historical items, all combined at an inopportune time.
Why should such contributions exist, and why was the combination so critical at that time. What might we do about these.
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I don’t understand. The report states that the crew did not have sufficient duty-free time. Off duty at 11pm, on duty at 750 am. So only 8:50 “off duty”, when they should have had 10:00. 1:10 short.
Yet under the human factors section, the “expert” states that fatigue was not a factor. Surely if you don’t achieve the required rest time under the regulations, fatigue is most certainly at least a factor? Otherwise, why bother having flight time limitations?
The report even outlines some symptoms of being distracted, which fit this crew’s actions pretty well, like task fixation and ignoring repeated GPWS alerts.
Yet under the human factors section, the “expert” states that fatigue was not a factor. Surely if you don’t achieve the required rest time under the regulations, fatigue is most certainly at least a factor? Otherwise, why bother having flight time limitations?
The report even outlines some symptoms of being distracted, which fit this crew’s actions pretty well, like task fixation and ignoring repeated GPWS alerts.
Aside from the blindingly obvious. Having watched the cockpit video the pilot seems to be continuously arm wrestling the controls in all directions, are all those vigorous and frequent control inputs really necessary to land a 737? Even if flying through a bit of a rain squall. Can't help but think he's working too hard on that, needlessly, and losing oversight of what's really important. I've seen a few helicopter pilots fly like that. Get them to take their hands off the controls and it will fly much better.
What happened is clear not least because of the video. Why it happened is less so. As an experienced captain on type I would venture a few comments. At first sight the crew were qualified and in terms of total flight time very experienced. However there was quite a marked cockpit gradient. What I mean by this is that the Australian co-pilot only had a few hundred hours on type while the local captain had 19,000 hours total time. This would not be the first time that a junior pilot was slow to speak up. Interestingly about 15,000 of the captain's hours appear to have been as co-pilot, which in a hiring interview would at least raise questions. Based on his performance on this and the previous flight we might reasonably speculate as to the reason why. The co-pilot did make the very reasonable suggestion that flaps 40 would be a good idea. With a potentially wet runway just over 1800 metres in length it is surprising that the captain was planning for anything else.
The 737 on a normal day is a very easy airplane to fly. With a short runway and a non precision approach in poor weather it needs another level of skill. The reconstruction shows very well the initial approach as just another day at the office. Bit of weather ahead, but the captain says they will break out in time, which is a pretty clear case of confirmation bias. If he had asked the co-pilot what he thought and whether they should hold for the weather to move away, he might well have got a different answer. Precisely because flying has become so routine there is a great tendency to continue. Doing something different is much less comfortable than just carrying on even with sink rate warnings etc. Alarmingly this is one of several very similar events I can think of with the 737. The Bali crash and the St Maarten Westjet event are two obvious examples. A particular issue is a high mda where you decide to continue and as per Boeing procedures click off the autopilot and autothrottle. At this point when you lose sight of the runway your actions should be clear, go-around. Flying a light aircraft you add power and in this case turn left towards the missed approach. In the Boeing you are in much less familiar territory and doing something many people very rarely do in real life, flying the aircraft without guidance or automatics.
There are of course many honourable exceptions to the rule. But as instructors know the weak pilots are the last ones to want to demonstrate their weaknesses and practice on line, even if the company allows it, which is of course another issue. There are a surprising number of large airlines who discourage switching off some or all of the automatics. The high cost of simulator time also means that these skills are often not the focus of valuable checking time. I would suggest that there would be a good market for a lower cost simulation alternative where manual flight could be regularly practised to achieve true competence on a regular basis.
The 737 on a normal day is a very easy airplane to fly. With a short runway and a non precision approach in poor weather it needs another level of skill. The reconstruction shows very well the initial approach as just another day at the office. Bit of weather ahead, but the captain says they will break out in time, which is a pretty clear case of confirmation bias. If he had asked the co-pilot what he thought and whether they should hold for the weather to move away, he might well have got a different answer. Precisely because flying has become so routine there is a great tendency to continue. Doing something different is much less comfortable than just carrying on even with sink rate warnings etc. Alarmingly this is one of several very similar events I can think of with the 737. The Bali crash and the St Maarten Westjet event are two obvious examples. A particular issue is a high mda where you decide to continue and as per Boeing procedures click off the autopilot and autothrottle. At this point when you lose sight of the runway your actions should be clear, go-around. Flying a light aircraft you add power and in this case turn left towards the missed approach. In the Boeing you are in much less familiar territory and doing something many people very rarely do in real life, flying the aircraft without guidance or automatics.
There are of course many honourable exceptions to the rule. But as instructors know the weak pilots are the last ones to want to demonstrate their weaknesses and practice on line, even if the company allows it, which is of course another issue. There are a surprising number of large airlines who discourage switching off some or all of the automatics. The high cost of simulator time also means that these skills are often not the focus of valuable checking time. I would suggest that there would be a good market for a lower cost simulation alternative where manual flight could be regularly practised to achieve true competence on a regular basis.
The high cost of simulator time also means that these skills are often not the focus of valuable checking time. I would suggest that there would be a good market for a lower cost simulation alternative where manual flight could be regularly practised to achieve true competence on a regular basis.
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Air Niugini said it would continue investigating the crash, agreeing that it was a case of "human factors" and not pilot error that contributed to the crash."What we have to understand here is the pilots didn't purposely fly that plane into the water," Air Niugini's managing director Alan Milne told reporters, after the findings were handed down.He said both were experienced pilots, and something else "was a factor there that all came together to make that accident happen".
Well that's a huge relief. The crew are off the hook. At least we now know the pilots didn't deliberately fly the 737 into the water. The airline agreed it wasn't pilot error, either. That left Human Factors and something else was a factor. The dreaded something else. Time perhaps to resurrect Agatha Christie's detective, Hercule Poirot to solve the case of the missing factor? .
Well that's a huge relief. The crew are off the hook. At least we now know the pilots didn't deliberately fly the 737 into the water. The airline agreed it wasn't pilot error, either. That left Human Factors and something else was a factor. The dreaded something else. Time perhaps to resurrect Agatha Christie's detective, Hercule Poirot to solve the case of the missing factor? .
