A350 pilot startled by windshear alarm
@Bengerman
How many circuits, landings and take-offs did we do for our initial flight training in a C172 - just one of each?
How many times do musicians practise a musical piece before performing it - just the once?
How many times do athletes, tennis players, footballers, sports people practise their skills before a competition - just the once?
How many circuits, landings and take-offs did we do for our initial flight training in a C172 - just one of each?
How many times do musicians practise a musical piece before performing it - just the once?
How many times do athletes, tennis players, footballers, sports people practise their skills before a competition - just the once?
Last edited by Uplinker; 21st Jul 2021 at 09:39.
Join Date: Aug 2000
Location: Near Stuttgart, Germany
Posts: 1,095
Likes: 0
Received 1 Like
on
1 Post
Yes. But all the rehearsals are done in vain if the artist suffers an attack of stage fright. And this is what happened here. That was a crew of very experienced pilots, who without any doubt knew very well how to properly fly a go-around. Practised it hundreds of times both in the simulator and in real life. But for some reason the pilot flying "froze" at the cotrols and the pilot monitoring didn't notice that condition right away. Would a more thorough briefing have prevented this "freezing"? How thorough would that briefing need to be? There is so much that can go wrong, briefing it all would take longer than the flight itself...
Only half a speed-brake
The reports does not explain how well they knew to fly a go-around. On the contrary, it does show they were not proficient to execute one in complex circumstances. Neither of the two situations you describe should have been allowed to happen, that's why standards exist. Passing the grade in the SIM but failing to perform when the day comes reeks of a dysfunctional training system, where the objective is not well understood.
Responsible reaction needs to take form of a preventive measure that - if sent back in time and applied to the incident crew involved - would had prevent the situation. In thorough agreement with your implied "but you cannot change a man or ultimately predict his reactions once he snaps", it's either the hardware, training or procedures that need focus.
+ Aircraft is capable of executing it on it's own, just keep the AP on.
+ The SOP for G/A works well and cannot be made any more simple. TOGA+flaps. Read FMA and adjust the targets, then gear up and call ATC.
+ If the situation stinks of going missed, perhaps a mini review is prudent. I started doing exactly that after the last one.
+ Training change is possible in two ways, more exercises or stricter evaluation.
Which one is it?
My money is on what sonicbum suggested. But most definitely they have not practised it hundred times in simulators or real life. "Done quite a number in the SIM, but never a real one on the type." - sounds more like it.
https://www.bea.aero/fileadmin/user_...20-0065.en.pdf
Responsible reaction needs to take form of a preventive measure that - if sent back in time and applied to the incident crew involved - would had prevent the situation. In thorough agreement with your implied "but you cannot change a man or ultimately predict his reactions once he snaps", it's either the hardware, training or procedures that need focus.
+ Aircraft is capable of executing it on it's own, just keep the AP on.
+ The SOP for G/A works well and cannot be made any more simple. TOGA+flaps. Read FMA and adjust the targets, then gear up and call ATC.
+ If the situation stinks of going missed, perhaps a mini review is prudent. I started doing exactly that after the last one.
+ Training change is possible in two ways, more exercises or stricter evaluation.
Which one is it?
My money is on what sonicbum suggested. But most definitely they have not practised it hundred times in simulators or real life. "Done quite a number in the SIM, but never a real one on the type." - sounds more like it.
https://www.bea.aero/fileadmin/user_...20-0065.en.pdf
Last edited by FlightDetent; 20th Jul 2021 at 22:52.
Join Date: Sep 2011
Location: earth
Posts: 1,098
Likes: 0
Received 0 Likes
on
0 Posts
Joe le Taxi
Absolutely agree!
Those new pilots have been deprived of adequate training. The new syllabi for these new gen pilots, cost reduced beyond reason, address almost exclusively the cerebrum. SOP, procedures by memory items, QRH and so forth. The cerebrum can easily freeze in startle situations (qed by many recent incidents) and is not best suited to find the appropriate intellectual procedure in due time. The genuine basic formation though implies the cerebellum as well. This part is much less prone to freezing, but can only perform some basic functions without much intellectual thought. It is well developed in birds and there might be a reason. In startle situations they instinctively fly up and when safe their cerebrum takes it from there --> Pitch and power, when safe add appropriate procedures.
This can only be achieved by in field basic training. The modern CBT and SIM training will never achieve it adequately. If the argument is cost or environmental impact, then think: Basic training can be nicely done with new electrical training aircraft. They are affordable, underpowered, fly close to the ground and have little range. Exactly what sharpens the basic flying instincts of newbees and might be needed in startle situations.
There is no replacement for such skills. All the other necessary skills in modern aircraft and today's environment can then be acquired virtually.
Absolutely agree!
Those new pilots have been deprived of adequate training. The new syllabi for these new gen pilots, cost reduced beyond reason, address almost exclusively the cerebrum. SOP, procedures by memory items, QRH and so forth. The cerebrum can easily freeze in startle situations (qed by many recent incidents) and is not best suited to find the appropriate intellectual procedure in due time. The genuine basic formation though implies the cerebellum as well. This part is much less prone to freezing, but can only perform some basic functions without much intellectual thought. It is well developed in birds and there might be a reason. In startle situations they instinctively fly up and when safe their cerebrum takes it from there --> Pitch and power, when safe add appropriate procedures.
This can only be achieved by in field basic training. The modern CBT and SIM training will never achieve it adequately. If the argument is cost or environmental impact, then think: Basic training can be nicely done with new electrical training aircraft. They are affordable, underpowered, fly close to the ground and have little range. Exactly what sharpens the basic flying instincts of newbees and might be needed in startle situations.
There is no replacement for such skills. All the other necessary skills in modern aircraft and today's environment can then be acquired virtually.
@what next,
Yes, a long, tedious briefing before push-back or TOD, detailing actions for every eventuality is counter-productive, I agree - the recipient's eyes will glaze over and they will switch off.
But if it appears that a memory drill might be necessary in the very near future, no harm in voicing it and even running through the actions before doing it if there is time. And this will absolutely prevent startle and stage fright........and cock-ups !
If I am going from end stop to end stop on the side-stick during a turbulent approach, but PM cannot see this and I am keeping the aircraft's attitude fairly stable, I will nevertheless say, "hmmm, we might have to go-around in a minute". Then at least PM is on the same page with me.
Yes, a long, tedious briefing before push-back or TOD, detailing actions for every eventuality is counter-productive, I agree - the recipient's eyes will glaze over and they will switch off.
But if it appears that a memory drill might be necessary in the very near future, no harm in voicing it and even running through the actions before doing it if there is time. And this will absolutely prevent startle and stage fright........and cock-ups !
If I am going from end stop to end stop on the side-stick during a turbulent approach, but PM cannot see this and I am keeping the aircraft's attitude fairly stable, I will nevertheless say, "hmmm, we might have to go-around in a minute". Then at least PM is on the same page with me.
Re: “The report does not explain … …, it does show they were not proficient to execute one in complex circumstances.” #123
This covers many aspects of this incident;
The difficulty in explaining complex situations; - often it is impossible to explain human behaviour, there will not be a single view which satisfies everyone.
There was no ‘showing’ - reasoned argument about proficiency; only that actions (with hindsight), were not as expected for the situation.
It is very difficult to change the human condition, easier to change the situational circumstance, which is what the report concluded.
There will always be errors; their relevance depends on the consequences. Forgetting - unaware that the AP was disengaged is labeled ‘error’; a human limitation, which in isolation was not critical. However, the consequence of adjusting to the ‘error’ resulted in ‘an undesired state’ - Level Bust - the hazard.
The report recommends reviewing the ‘complex circumstances’ of the missed approach requirements - GA altitude and routing; not proficiency or training.
Tacitly the report recognises that there are limits to human performance, which in a very safe industry might defy intervention focused on the human, e.g. training; alternatively changing the situations to be managed could help avoid a similar incident.
This covers many aspects of this incident;
The difficulty in explaining complex situations; - often it is impossible to explain human behaviour, there will not be a single view which satisfies everyone.
There was no ‘showing’ - reasoned argument about proficiency; only that actions (with hindsight), were not as expected for the situation.
It is very difficult to change the human condition, easier to change the situational circumstance, which is what the report concluded.
There will always be errors; their relevance depends on the consequences. Forgetting - unaware that the AP was disengaged is labeled ‘error’; a human limitation, which in isolation was not critical. However, the consequence of adjusting to the ‘error’ resulted in ‘an undesired state’ - Level Bust - the hazard.
The report recommends reviewing the ‘complex circumstances’ of the missed approach requirements - GA altitude and routing; not proficiency or training.
Tacitly the report recognises that there are limits to human performance, which in a very safe industry might defy intervention focused on the human, e.g. training; alternatively changing the situations to be managed could help avoid a similar incident.
swh
Having never flown an airbus so no idea how the manuals are structured.
its a manoeuvre that needs to be flown from memory. It’s technically not a memory item on a Boeing either. But I wouldn’t open the QRH to brief myself on the manoeuvre if I got a wind shear warning.
Having never flown an airbus so no idea how the manuals are structured.
its a manoeuvre that needs to be flown from memory. It’s technically not a memory item on a Boeing either. But I wouldn’t open the QRH to brief myself on the manoeuvre if I got a wind shear warning.
Rebel PPRuNer
Join Date: Aug 2000
Location: Toronto, Canada (formerly EICK)
Age: 50
Posts: 2,834
Likes: 0
Received 0 Likes
on
0 Posts
FDR available but CVR not, and the BEA report does not specify why - perhaps the common reason that the aircraft was not held out of service and it was overwritten. That’s unfortunate, given the circumstances, no? The CVR would not have filled in all the gaps left by the FDR but it would have helped corroborate the interviews - especially if there was a significant lapse of time before these occurred also.
