Too many cooks!

It is a two man cockpit, for heavens sake. Let them work accordingly. If you bring in the incoming crew (you barely ever meet them), the augmenting crew (their in everyone's way, having no place to go), any administrator (that couldn't be bothered by anything else but the next cricket match) or any kind of remote computer/laptop/calculator/adminstrators handheld prodigy, with programming that defies Windows 95 with a 386 processor, then you're heading the wrong way.
Too many cooks simply spoil the meal, especially those who know little about real cooking, if you get my drift.

It should be entrirely left up to the two operating pilots with the final loadsheet, provided mostly 10-15 minutes before ETD. The TO calculation should be done together and only then, with the actual loadsheet and the actual numbers and (most probably) actual runway and its conditions. That may sound late, but having done all the preflight preparations, the last 10 minutes should be calm and reserved for these crucial calculations and inputs, and subsequently adequate and specific briefing. The operating pilots should throw out ANYBODY during this phase, even including the augmenting Captain who has 30000 hours more on his cap, is TRE and comes from the land that invented better North Atlantic crossings than Lufthansa.
Any calculations and endless briefing-blahblahs done before are useless and dangerously mind pre-setting, as we subconsciously tend to thinks "it's already done".

I tend to go for fighting distractions, as a main ennemy before take-off.

As it appears in this incident, some distraction was "self induced and augmented" and might have accelerated resignation. We will see ....

Good point.
Has anyone ever actually done a study on that?
What % of Part 121 flights have more than the normal crew compliment v's what % of Part 121 aircraft involved in a major incident have more than a normal compliment.
I would guess about 10% of flights I do have someone extra on the Flight deck yet it seems that about 30% - 50% of accidents I hear about have someone extra on.
Anyone know the stats?

Finger Trouble- How costly it can be on a modern aircraft
 

I was waiting for some sort of reliable data from investigation to emerge before posting this story. Though the enquiry report is not published yet, the scenario of a mix up of a "2" and "3" looks most realistic.
I am with aviation for nearly 4 decades. I relate an incident that I recall very vividly which can high-light the perils of finger trouble on a modern aircraft and how pilots of yesteryears had a better knack of spotting gross errors.
It was a 747-200, 3 man crew, and I was in the cockpit (I am not a pilot). During take off preparation the 3rd crew, Flight Engineer prepared a Take off card with speeds V1, Vr, etc and kept on the pedestal. This was the norm in the airline I was working at that time. The pilot in command while setting the white bugs on his airspeed indicator, paused, gave back the card to the FE and said "Re-check, these are wrong". The First officer had already set the bugs on his side and did not see the error. The FE , re-checked the speeds, and corrected the error. There was an 11 knots error and by this time he was sweating profusely, which I remember very well. He told me later in the flight, "if the Captain reports the matter he will be fu****". A few weeks later I found out that the incident was indeed reported by the Captain, the FE was grounded and send for retraining.
A question will arise for many present day pilots, "How did the captain spot the error"? Well the year was 1982, when computers were not available and crew had a fair idea of these important figures for a particular flight. They flew one type of aircraft.
In today's scenario, everything in the cockpit is automated. The Laptop calculated figures are entered in FMC CDU, are automatically set on the PFD for V1 speeds etc for both pilots. Pilots have less chance of detecting the error, as they fly A330 one day and A345 the very next. One flight can be on a short 2 hour sector and the next can be a 14 hr one on A340. The errors from finger trouble are rarely reported and highlighted only when disasters occur.
I feel sorry for the crew. One single mistake can ruin an impeccable career. In EK407 case the error nearly killed them and the paxs. Probably could have killed off the airline as well. Any airline would have punished them unfortunately the same way (Except the highly unionized ones)
Human factors could be the main cause, but for such gross errors, you pay with your job. That is life for a pilot, I suppose. Hope the crew had no mortgage on Dubai property as well, in whcih case their next shock will be when they go to close their Bank accounts!!

That would be the baggage handlers then. Or maybe PPRUNE. Funnily nobody mentioned flaps yet...

There was still enough automation in those days to make errors. Consider KAL007 in 1983 when a simple mistake concerning the autopilot and INS inputs had catastrophic implications.

As I understood it (correct me if I'm wrong) KAL007 deliberately cut the corner as KAL had done for some time in order to save fuel.
On that fateful day, the Russians were conducting tests at Kamchatka Base and were on high alert, hence the response.

In other words there was no entry error. The INS story was a cover-up

Mentioned earlier.
Excellent safeguards on the BUS in that matter.

KAL007 cuts cormer
 

Correct me if I'm wrong but wasn't there a pay insentive at that airline, if you saved fuel you received a bonus?

tbaylx, what you say is right and that this should be a leaning experience for the industry as a whole. Sacking people is not a means to an end. All that i am saying is that this thread is full of strange and imaginative reasons why the aircraft left a lot of aluminium on the runway at melbourne. As the investigation is pointing towards the wrong infromation being put into the computer ( to suggest any sort of cover up or conspiracy only insults the professionals working in this industry). I have been in engineering for 35 years and have never sacked anyone for putting there hand up for making a mistake. We are all in this industry together lets keep it professional and safe for our customers. thanks guys.

Sounds like the old saying, The only silly mistake or silly question is the one thats has not been answered or learned. !!!

It can prove to be a very good/cheap way of learning and saving lots of money and face. !!!

Anyone that withholds said information should think of the next event and how they will feel. ????

But for the above to work, all operators should be on a learning curve full time.......

A simple mistake concerning the figures into an Ins, although not in the cockpit, resulted in Erebus.

Pool! Spot on.

In an earlier post I mentioned the 767 that had ZFW instead of TOW in the TODC.
After that they introduced a feature that compared the TOW with the flight number. If the numbers were not in accordance with a set parameter you had to recheck and confirm the numbers.
When the A340 entered service they opted not to have this. Ended with an "EK407" in PVG 2005.

Until I have a better system I do my own check. I check the TOW at the briefing and calculate the expected V2. If the FMC calculated one differs I investigate. Many pilots use this but it is not learned during training. Wonder why? Would be very useful for new crewmembers.

No it didn't.
That was one factor in the accident.
Like most accidents there were several factors that, if any one of them had been removed, the accident would not have occurred.

One could just as easily say " A simple error of judgement , going below the company VMC minima of 6000ft, resulted in Erebus"

But that would be equally inaccurate.

Air NZ & Erebus
 

As framer has said, the change to an INS coordinate made by AirNZ navigation staff was one factor which contributed to the loss of the DC10 and all on board. Descending below the area MSA whilst believing to be visual, but in fact being in "white out" conditions, was just as much to blame. Having flown into the nearby McMurdo Base a number of times in the previous summer (1978),and having been thoroughly briefed beforehand an the perils of "white out", we maintained a regular sked with McMurdo en-route. If the trend was favouring a "white out" happening we would return to Christchurch before PNR. Incidentally, the McMurdo Rescue Crews were fearful of an accident involving a sight-seeing polar flight. They knew that even if the impact was survived they did not have the resources to conduct a rescue of such magnitude, especially as most on those flights would have been in light clothing and would quickly succumb to the extreme low temperature.

KAL007

I thought they were off course for the entire journey due to incorrect INS inputs made prior to departure from Anchorage. In any event, 'cutting corners' should not have taken the aircraft over the Kamchatka Peninsula.

Chart



http://en.wikipedia.org/wiki/File:KA_Flight_007.gif

With the greatest of respect, Tyres...
 

You're fundamentally correct, of course, but as always this mistake was only ONE of what became the long chain of errors, assumptions, oversights and second-guessing which led to a totally avoidable accident.

Big question, of course, is whether it was
-finger trouble or
-using wrong figure from loadsheet, or
-insert in wrong place or
-zillions of other possibilities,
that caused this incident?

Always wondered with my own company why the layout of our ACARS loadsheet wasn't changed (e.g. separate header with just figures used for input), same for layout on FMS performance page, etc...

I feel sorry for the crew they had to resign, but now they can give honest feedback (f.i. if they think that factors like schedule contributed) with no pressure from anybody. This will hopefully lead to useful feedback/recommendations.

So much for the "Just Reporting Culture" we should all aspire to
 

Two careers and family lives shattered - all for a possible finger input or other unintentional human error.

This should have been addressed/reported as part of a Just Culture policy, encouraging full and open reporting, ASAPs voluntarily filed, learn from what happened, apply lessons learned, share the information gained openly, train to proficiency if determined to be appropriate by the Event Review Committee, and move on.

Two "resignations" make the owners happy I guess, and they will sleep well tonight. But if I am going to be fired, sorry - resign, for an honest non premeditated error, I will not be offering any debrief information to help determine what happened. Why should I hand them the gun?

Just assuming here ofcourse, it is sad to realise that it happened before, will happen again, while it can be easily avoided.

Separate loadsheet header, dual entry (from both pilots) in FMS, etc...

Quite right Endeby-Browne
 

I'm editing myself for relevance or lack of it :)

Oilhead,
I agree with you and have to say I'm very disappointed by the apparent lack of support by their colleagues on these threads.
I just hope its not representative of how they are actually being treated in DXB:confused:

Well, it took me less than five minutes to pull these out:

Posted mostly from EK crew I believe. There are more.



And the following might explain why there are relatively few posts like the above amongst the 30+/- pages:

In my airline, we prepare our T/OFF Perf. Page with the Estimated Take-Off Weight of our OFP while we have time and are not in a hurry to close doors.

We get an EZFW from our operations in order to correct our Fuel numbers (normally the maintenance guy is waiting for Captains finnal decision to complete the refueling process, that has stoped 2 tons before the initial estimated figure) as soon as we get to the aircraft. That estimate will show us a weight trend (compared to the TOW of the OFP).

When the Load Sheet arrives, the Captain dictates to the Co-Pilot the actual numbers. Actual numbers are therefore compared with the ones we have on our OFP and the Co-Pilot annouces to the Captain when entering the Actual ZFW on the FMGC, that we are "x Tons" below or above the EZFW of the Flight Plan. He goes to the RTOW's and finds the new V1, Vr, V2 and FLEX.

Closes the RTOW Book and hands it to the Captain. The Captain gives him a copy of the Load Sheet and finds his own speeds and Flex on the RTOW to compare with the ones just entered on the FMGC by the F/O.

During our Take-Off briefing we positively identify the aircraft we are flying that day. We fly 3 different types (lato sense) of aircraft: A340-300 and A330 PW or GE equipped (Different weights, different engines). As a general rule, it is a good help to check for two or three limitation items like MTOW, Max EGT, if that particular bird has Brake-Fans (or not) if it has Fuel Dump (or not). It helps you to sit in the right aircraft.

I understand that there is no panacea to avoid accidents. I'm very sorry for our colleagues.

brokenenglish,
Yes, there is a few in 638 posts. It would be nice to hear of a groundswell of support to keep them employed!:confused:

It would be a fine thing but any worthwhile action would likely lead to further job losses.

I guess you're not familiar with how things work in the Middle East. But your location suggests you are familiar with the 49ers.


Not everyone takes the moderate view however, the following was posted by a Training Captain at said airline on page 19 of this thread:

Two more comments from earlier in the tread that I think many EK pilots would agree with.

and

Msitakes (like that one) can ruin a career.
 

Probably one of the most powerful learning techniques is putting a good man in front of a group of peers and have him explain how he came to make a mistake. Organize a structured discussion on the contributing factors and possible mitigating measures. We then all walk away more aware and safer.
Lifting the maker of an honest mistake out of the system and dumping him/her by the wayside will have no beneficial effects whatsoever. Quite the contrary. It demonstrates short term focus and a lack of vision and commitment to systematically improve an operation. Not to mention the destruction of a transparent reporting culture.

Michael Birbeck - quite right and well put.

For airlines to sack/force pilots involved in incidents such as this to resign will do nothing. Perhaps this is the aviation equivalent of lashing a muslim woman because she has been seen in the company of another man. Primitive and ultimately ineffective.

Certainly some retraining and perhaps even disciplinary action may be justified but how will sweeping this matter under the carpet by terminating those involved in any way rectify human-factors based errors?

It never will and employers who use such tactics are simpletons.

Unfortunately their human factors based errors (poorly planned expansion, dismal fuel hedging plans, engaging in illegal freight cartels etc)rarely physically injure people, these employers just tootle off to the next company willing to pay impressive bonuses etc.

About time sime mature and forward-looking tactics were used to try to counter such errors rather than this primitive foolishness.

I've often wondered if they do injure people .
Here's one example, if an airline schedules a half hour turn-around that can't be met due to taxi times etc, and the crew are always under pressure to depart on time, and one day a crew make a mistake entering data or taxiing or selecting flap or whatever.....isn't that directly a result of poor management? ie if they had an extra 15mins up their sleeve they most certainly wouldn't have felt rushed etc. I think that the workload and pressures in this job are increasing, while the working conditions and remuneration are slipping, and pilots being pilots, cover it up as best they can in their natural desire to perform efficiently.

I tend to feel the same way that there are accidents, and there are accidents. Yet in the drive to remain united as a pilot group, there is pressure to stay with the party line that this could have happened to anyone, therefore the pilots should remain onboard.

As pilots, does anyone seriously expect to remain part of the team if allowing a breakdown in procedure and safety resulting in not just a gross error, which is pardonable, but damage, which is not?

Wilful errors are violations of law. We're not talking about those, which are instances that usually validate instant dismissal. Next down the chain are unwitting errors, which are just that. They are not violations, and would not validate instant dismissal.

Nonetheless, unwitting errors made by a new First Officer are unacceptable in the grading system we use, and will inhibit a First Officer's promotion. We all know this to be true. Been there, done that perhaps.

I suspect we all agree that this was an unwitting error, by a crew, not an individual, and the issue of how it transpired is becoming a question of systemic error or operator error.

For those not in the know, systemic errors are system-based, suggesting the system needs to be changed to capture the error. Operator errors, on the other hand, require further training. Or not, if the error is gross enough.

'There go I but for the grace of God' as a logical approach to this issue just doesn't cut it for me. 'I could have made a mistake like this' is also limited in usefulness. Both are perfectly true statements, but they are not the basis of training a pilot group to ensure accidents don't happen.

!!!! does happen.

In the Turkish accident thread, few of the more experienced pilots suggest allowing the pilots in that accident, were they alive, the privilege of retaining their jobs. Why was this accident any different? How? It wasn't systemic, but operator-induced.

Pilots have a very big responsibility involving, amongst many other things, ensuring all errors along the chain are captured and either mitigated or erased so as to have little or no impact on the safety of the operation. That's a big task, and if it means taking off 22 minutes late, so be it.

In the rough and tumble of life, to ignore this truth (at least as I see it) is to ignore reality and, to follow on, what comes with it.

Don't lose sight of the ball.

I could agree with the above, however up to a certain point only.
Operator error is certainly present here, but to dismiss systemic error is wrong. As long as only the first and most serious error is looked at, the dismissal of the crew might be sustained. But we have to look further and check if any systemic error contributed or lead to the operators one.
Not pretending all the factors contributed here, we nevertheless have to check:
- fatigue
- distraction in cockpit preparation
- bad place/rest/implementation management for augmenting crew
- company stress (multiple factors)
- MFF problems
- (others I might forgot)

If eventually there are contributing factors, then not only the crew have to brunt consequences, but the company just as much.
If there is no other outcome than losing collegues, if there is no improvement of some blatant shortcomings of EK, then all will remain a farce. One we have seen too many times alredha, ehh, sorry, already.

You are perfectly correct.

There are many issues involved, and I'm not aware of the intrinsic complications in the EK operation over and above what is obvious. It is very hard, perhaps impossible, for an outsider to make an assessment of the what, where, how and why of this accident. However, there has been an accident.

Whether or not external issues are involved is perhaps where the upcoming Commander's meeting for EK dudes might provide a useful forum. Certainly more so than this one. I hope they are in a position to take up arms against what seems to be a common foe for all pilots in that company, not just Commanders.

It appears, repeating, appears to be an operator error. If that were the case, dismissal is what I would prepare for. The horror of being in such a position must be pretty tough. Which is probably why there's been a lot of responses on the forum. Who would want that to be thrown on a friend or colleague?

No-one, which brings to mind some final points, for me at least:

1. Don't misunderstand the risks involved in being a pilot.

2. Recognise the absolutely critical nature of takeoffs and landings.

3. Force yourself to be sharp in those phases, even if fatigued.

4. Rid the flight deck of identifiable distractions, period.

5. Rest well as you can in the cruise.

I've re-read my last post and hope it's not taken out of context.

My focus is on how I will capture the errors on my next start up, taxi out, departure, climb, cruise, descent, landing and shutdown at the gate.

Regarding doctors, bankers & other professionals: guess you may be right in that sense.

yep-you got the gist of what I am saying.
I think it's an interesting mix of culture, machine and money at the moment.
As I imminently approach an Airbus conversion, I'm even more interested when Mr Cock-up comes knocking!
Just because -I don't have the warm blanket of familiarity to protect me.
And, sorry, we are now way off thread....
Vino

Lets say crew noticed problem during the early part of the take off run and applied TOGA or stopped and aircraft was not damaged.

1. would they have been sacked/asked to leave ?

I think some of the last 10 posts or so have the correct views on learning and not having the blame culture.

Blame culture just watches time pass by, every event that is not reported and thus not understood/learnt is just the sort of building blocks needed to have a (Blame Culture) Accident.

F1 champ Lewis trashed my car | The Sun |News

The above link shows even the best of us can get it wrong from time to time !

MB,

you mencioned the tragic Glen Stewart case.

Does anyone have a copy of the excellent "Pilot" magazine article on his story?

Cheers

Bla bla bla... what a lot of fertilizer in this thread. Expert my.....bla bla bla
Bottom line is.
One pilot made a calculation mistake
The other didnt catch it.
6 or 7 people in the cockpit IS distracting..
At high speed they realized it.
Their flying skills and experience safe their lives...and a bunch of others.
Anyone could the made the first mistake.
Not all pilots could have safed it afterwards.
Hope they left with big cheques in their pockets to keep quite

Good wind and gods speed to the crew.....