from the last paragraph.
​​​​​​While this is hardly controversial, it might be worth considering the formal and informal norms in a given company.
The formal norms are a written policy, SOP, rules, etc. The informal norms are the unwritten rules, incentives, and 'reputation points added and subtracted' based on various decisions made. ​
How many of you have been in companies where the informal norms and the formal norms (policy) didn't quite match? (*There is a current thread on R&N in re Easy Jet that seems to cover this mismatch a bit regarding sickness...)
Can anyone comment from their own experience in this airline? (PIA)

Have they posted the full cvr transcript leading up to this accident yet?

I'm afraid there'll be long wait: CAA published the Preleminary Report within the usual month after start of investigation. At the end of this report they refer to the final report draft process. Expect Final Report no earlier than 1 year after.

Of course leaks are not totally ruled out. And possibly govt/parliament asks for another interim report.

On practical terms the final report will be of limited added benefit. What is known so far has already painted a complete enough picture to see what happened, the crew crashed a functional aircraft on their own.

The particular and perplexing sequence is something a crime-story novelist could have come up without much creativity at all, simply by combining elements from historical accidents. Probably even from the last decade, the age of information.

Besides, researching the hows and whys is not the reason for the investigation in the first place. Going back to the definitions, the sole purpose is preventing a re-occurrence by defining and implementing mitigation measures (which might also come in simple terms of re-focusing on safety targets already known before).

The pertinent questions, after the full report is out, would be (random order):

1) What could the ATC possibly do to break-up an identical chain of events the next time?
2) What could the aircraft / engine manufacturers possibly do to break-up an identical chain of events the next time?
3) What could the first officer possibly do to break-up an identical chain of events the next time?
4) What could the captain possibly do to break-up an identical chain of events the next time?
5) What could the airline operations managers possibly do to break-up an identical chain of events the next time?
6) What could the airline S&Q managers possibly do to break-up an identical chain of events the next time?
7) What could the CAA possibly do to break-up an identical chain of events the next time?

My suggestion is the understanding today is on a sufficient level to get moving on each of the separate points above. On top of which: The existence of an SMS system utilizing FDM / FOQA elements, long mandatory for airlines such as PIA themselves, would had prevented this completely unnecessary loss of life.

A fish starts stinking from the head. So you missed in your numbers the PIA top management. That a captain gets away with those sort of cowboy approaches is the direct consequence of top management style. If every manager looks the other way, will, at a certain point, lead to this outcome. That the CRM did not work and the Co was not preventing this has the same reason.
Number 1 and 2 is a distraction and has no relevance.
7 should have pulled the AOC long ago.

Yes, the whole thing is skewed on all fronts. I deleted parts here and there to regain a bit of clarity for the original message - there is no need to wait for the final report before fixing things.

You are correct in what you say. 1) Will be researched and some tweaks found, 2) come up with "no tangible solution available".

Why 7 did not act as you describe goes beyond what can be achieved from within the industry :sad:. Specifically EASA did find "no-go" issues with the airline before the crash.

On a positive note: They started to admit this and talk about it. Step one to improve things. We have had non-qualified pilots flying for a living in other places of the world before. So the overall problem must be solved. If you look at how you can track your cars previous owners's repairs and mileage over time maybe some sort of shared pilot logbook database (without certain details) could be helpful to verify qualification, experience and checks?

Having had the dubious benefit of working in this area of the world, anyone here will tell you that this is the narrative always spun after a catastrophic event, if any are expecting a KAL type damascus conversion here they'll be sorely disappointed, it will (after suitable cosmetic alterations and bare faced lies) be business as usual, or at least as much as they can get away with.

Unfortunately, this will continue until position in society and money are not factors in who gets to manage a company or pilot an aircraft. It should be knowledge, skill and capability that matter. It requires a cultural shift that will happen, eventually, I hope. This in no way takes away from the fact that there are good pilots in these environments, but not all, and that's the problem.

Flight Data oversight.......?
 

Maybe this has been mentioned before but one of the most troubling aspects of the crash for me is almost certainly (yet to be confirmed) the likely lack of flight data oversight. It seems obvious to me that the crew knew that they would not be pinged by flight data monitoring. That is to say the such a cavalier approach could be flown with no adherence to conventional flight envelopes that would surely be at least loosely spelled out in company procedures let alone the complete failure to satisfy the stable approach criteria. They must have known that there was never going to be blow back over this, perhaps this will be shown to be incorrect but I have my doubts, this can’t be the first time these guys flew like this.

Where I operate, you can be sure that should you get an EGPWS hard alert, or caution for that matter or a GEAR NOT DOWN alert and fail to bug out, you will get a phone call. You’ll need to submit a report either way and if you don’t.......once again, you’ll get a phone call. It’s a double edge sword of flying with big brother in the jump seat at all times and yet knowing that your colleagues and family are much safer whenever they step on board. Seems to have served us very well over time.

I wonder if Airbus and Boeing might consider pushing regulators to step up random audits of flight data, it would at least be in the interests of underwriters if no one else.

Thoughts?

Could not agree more. I would guess there are still a lot of places where a Go-Around would be a call into the office, but an unstable approach would not because of a lack of monitoring. My company gives me a lot of leeway, and I like that, but in recurrent we will see examples of people taking it too far. It does help to know there is no punishment for screwing up the approach if you pull the plug in time.

That is the most constructive suggested response to this tragedy yet.
It also helps address the problem of CRM when there are social gradients in the cockpit, because the junior individual can correct the more senior by referring to the risk of the data audit.

There is a reason that limits are set, either by the manufacturer or the operator. If you operate outside of the limits, and are routinely allowed to get away with it, this is the outcome. Poor skills, poor CRM, poor oversight, poor outcome.

TACA 110
 

TACA110 is indeed an interesting video, The Gimli glider (B767) and an air Transat A300/330 have also done the same. Perhaps this is not what was being referred to?

Interesting point Willie Nelson. It could be a possibility that FDA is not properly monitored or followed up, hence the violation of all possible stabilization criteria becoming something usual: the popular normalization of deviation. Certainly something for investigators to make a question or two.

However, it seems as if the problem goes up higher than a simple flight safety/standards department. Taking from what others have said here before, it could go as high as the government; the whole system maybe permeated by obliteration of rules

When can we expect the official reports ?

pvapproach

No, and they do not have to either. Maybe on the final report . we'll see


fitliker :

You mean the final report ?Sometimes between 1 and 5 years from now.I would guess.

Escape Path

Absolutely the problem goes higher, as EDLB puts it: “A fish starts stinking from the head” but you can cut to the chase by looking at the company’s safety management system directors and their direct reports when looking for who had control of the culture. For example if there’s a record of discussion as to how a flight data audit program might be designed, managed and who has oversight of it.

As the preamble on all crash comics always state, it’s not as important at least initially, to state who dropped the ball as It is to find how it was dropped. I have no doubt that Personal/ corporate liability tends to ultimately become self evident after that.

My outfit runs a pretty tight SMS involving a high level data oversight program and a closed loop incident oversight process with regular LOS audits (line observation safety audits) with very well trained staff for these purposes. We learned from previous incidents and it’s served us well.

I’m doubtful the PIA culture or regulatory oversight for that matter could be sufficiently remediated to be honest but looking at their full safety management system would be one of the most productive lines of inquiry from a root cause analysis perspective.

ATC Watcher

A former colleague bought himself a new VisonJet with the the autoland (Safe Return) feature

There's a number of youTube clips on the Garmin Emergency Autoland flight trials - worth checking out.

Easy for me to say in retirement, but the transition from augmented to autonomous flight control is not as far away as we might think

As more and more human factors accident are discovered it's natural to think of replacing them. After all humans are in the cockpit only because machines can't do it.