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The ones that got away

Old 13th Jul 2013, 02:55
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The ones that got away

Perhaps if Asiana 214 had an extra 10knots. This debacle would have passed unnoticed. The crew would have had retired to their beers in the hotel and the Intructor pilot would have gone on to pass his wisdom (or lack of it) to other pilots. The Capt under training would have checked out and may crash another day with worst consequences.
How many other incidents I can think off where 'what ifs' would have made it an 'uneventful, unnoticed flight'. eg: What if AF358 had another five hundred feet stopping distance in Toronto. It would have been another thathad got away with it.
Airport authorities should have approach exceedance alerts whereby crew are immediately grounded pending investigation should they attempt unstabilised final approaches pushing for a lucky outcome. With todays technology, this can be easily done.

Last edited by Hardbutt; 13th Jul 2013 at 05:47.
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Old 13th Jul 2013, 06:16
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Rubbish.

We have a little thing call a QAR. This data is downloaded after every flight and if the crew go outside certain criteria it is red flagged for investigation under strict protocols.

We can run but we most certainly can't hide.

Next.
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Old 13th Jul 2013, 06:56
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What a shame. The OP started well and then very quickly went to pot. It would be a shame if the original precept was lost or dismissed because of the rubbish solution proposed.

As nitpicker330 says there are tools like QAR, and some similar ideas for ground systems, that produce routine operation data that can be analysed for trends and undesirable occurrences and, if necessary, can prompt further reasoned investigation. What needs to be promoted is the proper use of these tools - not to strike the fear of God into a crew or a controller who may exceed some parameter. And for the whole thing to be subject to proper oversight of an operator's use of the tools.

Sadly, from my experience (albeit limited from the airborne side of things) is that the tools often are not well used, the results incorrectly used, and the supervisory agencies do little to address this. Result - some very useful bits of kit are falling into disrepute and are their use is untrusted.

The use of tools like this is going hand-in-hand with training that teaches people that in this situation you do that - removing the value of proper use of professional skills and judgement - and leading some to think that exceedance of any parameter is automatically wrong. The old 'uns amongst can see where this is headed with examples in several recent aircraft accidents. And, sadly, we are headed down the same route with ATC.
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Old 13th Jul 2013, 10:34
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Old 13th Jul 2013, 13:13
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The ones that didn't get away

In the past it was believed that by simply following rules or SOP’s everything would be fine. It was the role of the Quality department to monitor that everyone followed the rules. However the rules could not cover all eventualities.

As human beings we will always make mistakes. Our SOP’s will attempt to limit the affects these may have on our performance, however distractions, interruptions, technical issues, fatigue or any combination of other factors will invariably lead to some sort of issues.

The occurrences that you mention are exactly that, OCCURRENCES which further develop into INCIDENTS and eventually ACCIDENTS. Therefore about three years ago ICAO mandated that airlines set up Safety Management Systems to try to pro-actively predict THREATS which might in the future lead to accidents or incidents. These would have to be weeded out. Just like the reason model of holes in Swiss cheese lining up, an attempt would be made to assess and categorize each THREAT and perform a risk assessment on it in or to TRAP, MITIGATE, or AVIOD these issues.

Using the iceberg model it was determined OCCURRENCES amounted to 99.5%, INCIDENTS accounted for 0.49% and, ACCIDENTS 0.01%, based on ASR’s filed by 121/135 operators to the FAA in 2000.

As SMS is a very new concept, many airlines do not fully know how to utilize it yet. What makes an SMS system work is the amount of data available to try and detect dangerous trends. As mentioned above FDM, FOQA, QAR will help identify some trends but may not pick some things up. Another common trend is to have safety audits, but once again it is difficult to cast a wide enough net to pick up real threats. In order to assist with gathering safety information some airlines have setup telephone hotlines, confidential reporting systems or even web forums.

Most important however for this system to work is to have a NON PUNITIVE REPORTING SYSTEM and an OPEN and FAIR company culture. Only when you start to share those experiences where you think you had a close shave can other people start to benefit from your experience as well as finding way to rectify the situation in the future.

If people simply decide to go for a pint and forget about the issue after one such close shave then that is a shame, as useful information that could have helped someone else will get lost. In some cases it may not be fully lost as it works its’ way around the airline on the grapevine with people say “watch out here, as this happened to me…”

If this were the case however that would be a clear indication that the message from the Safety department isn’t getting through or that the company must make a greater effort to create an open working environment, as the company are often the ones who have the correct tools to try and fix issues.
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Old 14th Jul 2013, 06:07
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Nitpicker330.
If they had 10knots or 10 feet extra, and the company downloaded the landing data later, what would have been their response if any et all?
No aircraft should be betting on a lucky landing on an unstabilised short final. If a punitive stick was waiting on engine shutdown if the numbers were grossly busted, the 'save face' or 'Im a ace' types would have hit the TOGA button.

Last edited by Hardbutt; 14th Jul 2013 at 06:15.
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Old 14th Jul 2013, 07:33
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Harbutt - it is worth noting that an 'extra 10kts' would have left them 20kts slow I believe and the FOQA should pick that up. Likewise AF358 where touchdown and handling were wrong I believe.
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Old 21st Jul 2013, 03:05
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You could always do it the navy way and have a man standing at deck (runway) edge ready to give a wave off if an abnormal approach is detected (high or low on glideslope, slow or high speed).



To all the pros, just joking.

Last edited by Brian Abraham; 21st Jul 2013 at 03:06.
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