IV-6936 MD83 overrun at Mahshahr, Iran
de minimus non curat lex
Thread Starter
IV-6936 MD83 overrun at Mahshahr, Iran
Fortunately this accident did not involve loss of life on 27/1/2020 despite ending up on a dual carriageway adjacent to the airport, as it was not a ‘Table Top’ airfield.
Reported on AVHerald.com following Iran‘s AIB report.
Once again, similar to IX 1344, a tailwind landing flown by a very experienced elderly male Captain with a very inexperienced FO, ignoring various aircraft generated alerts, and essentially operating as ‘single crew’ style. The FO was essentially afraid to pipe up. Probably Culture was an issue as well?
Another testosterone fuelled macho style of flying resulting in a crash, as was PIA 8303.
I do wonder if a women had been in the LHS of these aircraft if the accidents would have occurred?
I am trying to think when the last public transport accident occurred with a women in the LHS?
SWA 1380 demonstrated that a critical emergency with an uncontained engine ‘explosion’ and rapid decompression was extremely well handled despite aircraft damage with a women in the LHS.
Perhaps more women in the LHS might reduce accidents, as despite conventional CRM training they continue to occur with monotonous regularity.
Reported on AVHerald.com following Iran‘s AIB report.
Once again, similar to IX 1344, a tailwind landing flown by a very experienced elderly male Captain with a very inexperienced FO, ignoring various aircraft generated alerts, and essentially operating as ‘single crew’ style. The FO was essentially afraid to pipe up. Probably Culture was an issue as well?
Another testosterone fuelled macho style of flying resulting in a crash, as was PIA 8303.
I do wonder if a women had been in the LHS of these aircraft if the accidents would have occurred?
I am trying to think when the last public transport accident occurred with a women in the LHS?
SWA 1380 demonstrated that a critical emergency with an uncontained engine ‘explosion’ and rapid decompression was extremely well handled despite aircraft damage with a women in the LHS.
Perhaps more women in the LHS might reduce accidents, as despite conventional CRM training they continue to occur with monotonous regularity.
I think the reason there are not more accidents with female LHS is there is still a disgustingly low proportion of pilots that are female, let alone in the LHS.
One of the COVID side effects is the job losses will hit the younger pilots more than the older ones due to seniority still playing a big role, and those younger pilots are more likely to be women than the older generation. It’s a real shame, more diversity is still desperately needed in this industry.
One of the COVID side effects is the job losses will hit the younger pilots more than the older ones due to seniority still playing a big role, and those younger pilots are more likely to be women than the older generation. It’s a real shame, more diversity is still desperately needed in this industry.
The Landing Briefing is The Flight plan for the Mind.
parkfell, what is the point of this thread ?
An unjustified, unsubstantiated view of individuals, age, experience, or culture; just to make the headlines. Or by introducing a gender debate start a 'meaningless' discussion; unless you seek more 'name in headlines' being one of those who commented in Av Herald.
There are lessons to be learnt from this accident, not necessarily as identified in the final report - an example of a good investigation determining what happened, but not necessarily why (limitations of ICAO requirements, particularly for HF).
Points for discussion and learning could start with the preflight organisation 'abnormalities'.
Possibly an influence on what appeared to be a rushed descent - trying to make up time; the lack of pre landing briefing with opportunity to reconsider landing performance, and have a plan from which deviations might be identified by the PM.
The inappropriate responses to EGPWS Alerts and a Pull UP Warning is an HF lesson for everyone - if only the issues could be identified.
Also, another example of the expectation that CRM and Intervention will always identify adverse situations, and that all decisions are expected to be good; and if not then 'more training required'.
Professional discussion of the above could have significant safety benefit - before considering unstable tailwind approaches, fast and long touchdowns.
Final Report https://www.cao.ir/web/accidents/rep...pjRE9nPT0=.pdf
An unjustified, unsubstantiated view of individuals, age, experience, or culture; just to make the headlines. Or by introducing a gender debate start a 'meaningless' discussion; unless you seek more 'name in headlines' being one of those who commented in Av Herald.
There are lessons to be learnt from this accident, not necessarily as identified in the final report - an example of a good investigation determining what happened, but not necessarily why (limitations of ICAO requirements, particularly for HF).
Points for discussion and learning could start with the preflight organisation 'abnormalities'.
Possibly an influence on what appeared to be a rushed descent - trying to make up time; the lack of pre landing briefing with opportunity to reconsider landing performance, and have a plan from which deviations might be identified by the PM.
The inappropriate responses to EGPWS Alerts and a Pull UP Warning is an HF lesson for everyone - if only the issues could be identified.
Also, another example of the expectation that CRM and Intervention will always identify adverse situations, and that all decisions are expected to be good; and if not then 'more training required'.
Professional discussion of the above could have significant safety benefit - before considering unstable tailwind approaches, fast and long touchdowns.
Final Report https://www.cao.ir/web/accidents/rep...pjRE9nPT0=.pdf
PPRuNe Handmaiden
I'll sleep on this question. I have an early show tomorrow.
It is an interesting question but as VariablePitchP has said, there is a big disparaty between the numbers of female pilots to male pilots. That's not changing any time soon.
Are women less likely to do a rash action in the flight deck? Maybe? But no one knows at this point in time. There's just not enough of us to do a valid comparison.
About the only event I can think of is the QF B744 Bangkok golf course redesign versus the QF B743 captained by a woman who decided to go around during the approach before the ill fated QF B744. Naturally, there's a lot more to it than sex differences between the captains.
Personally, I'd say there's more cultural/fleet culture/background/experience that influences behaviour at this level than sex.
It is an interesting question but as VariablePitchP has said, there is a big disparaty between the numbers of female pilots to male pilots. That's not changing any time soon.
Are women less likely to do a rash action in the flight deck? Maybe? But no one knows at this point in time. There's just not enough of us to do a valid comparison.
About the only event I can think of is the QF B744 Bangkok golf course redesign versus the QF B743 captained by a woman who decided to go around during the approach before the ill fated QF B744. Naturally, there's a lot more to it than sex differences between the captains.
Personally, I'd say there's more cultural/fleet culture/background/experience that influences behaviour at this level than sex.
de minimus non curat lex
Thread Starter
Safetypee
Thank you for providing the actual report which adds to the collection of reading material for those starting their multi crew training and others, when the training machine eventually gets going again.
The point I was attempting to make is that there is something going on in the minds of these accident Captains which appeared to prevent them from abandoning the approach and going around.
Just what is it that inhibits them from following what they know to be the SOP for an obvious unstable approach ? What are the common threads? Why this overwhelming desire to land when all the indications to the readers of these accident reports would say things are really not at all good. Does some abnormality of the mind occur at a critical point?
IV-6936 ~ The flight deck gradient is obvious. The report indicates a history of unstable approaches by the Captain which might indicate overall competence? Perhaps if the standard route without the ACC shortcut had been followed sufficient track miles might well have helped. Declining ability due to age?
What we don’t know were the conversations immediately after the event, when the magnitude of what had happened was sinking in. To be that fly on the wall for the subsequent meetings with the investigating team and the company.
Anecdotal evidence will continue to be built up as to why “press on itis” is a common theme. And as Redsnail has pointed out insufficient women to get a reliable statistical sample. Just ‘a feeling’ on my part....
Thank you for providing the actual report which adds to the collection of reading material for those starting their multi crew training and others, when the training machine eventually gets going again.
The point I was attempting to make is that there is something going on in the minds of these accident Captains which appeared to prevent them from abandoning the approach and going around.
Just what is it that inhibits them from following what they know to be the SOP for an obvious unstable approach ? What are the common threads? Why this overwhelming desire to land when all the indications to the readers of these accident reports would say things are really not at all good. Does some abnormality of the mind occur at a critical point?
IV-6936 ~ The flight deck gradient is obvious. The report indicates a history of unstable approaches by the Captain which might indicate overall competence? Perhaps if the standard route without the ACC shortcut had been followed sufficient track miles might well have helped. Declining ability due to age?
What we don’t know were the conversations immediately after the event, when the magnitude of what had happened was sinking in. To be that fly on the wall for the subsequent meetings with the investigating team and the company.
Anecdotal evidence will continue to be built up as to why “press on itis” is a common theme. And as Redsnail has pointed out insufficient women to get a reliable statistical sample. Just ‘a feeling’ on my part....
Last edited by parkfell; 3rd Sep 2020 at 08:58. Reason: added to final paragraph
parkfell, 
"… there is something going on in the minds of these accident Captains which appeared to prevent them from …"
A key question; however we must not differentiate 'these' individuals from everyone else - including ourselves, who make similar decisions each day, generally with successful outcomes.
- "… what is it that inhibits them from following what they know to be the SOP for an obvious unstable approach ?
- What are the common threads?
- Why this overwhelming desire to land when all the indications to the readers of these accident reports would say things are really not at all good."
These points hinge on hindsight - our judgement after the fact:
- We cannot judge what the crew knew, or with knowledge, were able to recall it at that time.
- Nor might we identify commonalities, and particularly the human tendency to 'see' patterns where there are none. At best we might identify associations from a few accidents, but unlikely to have sufficient proof to justify widespread action. An alternative is to evaluate all operations, considering the range behaviours which result in success, but again after the fact; and who decides what is good or not, and how.
- The desire to land, often described as plan continuation bias, and again only identified with hindsight, has generated a range of academic views. One issue is that soft science (HF) depends on judgement, whereas people generally require 'fact'; if not from hard science, then facts as individually 'created'; our view, subject to our biases, culture, education, and experiences.
Orasanu and Martin provide a useful, simplified view of decision 'error'. *
There are more recent academic views, but with little practical advice to help improve aviation safety.
As I recall, one view suggests that the cognitive incentive required to change an inappropriate course of action requires an opposing incentive nine times greater. e.g. the mental gain in choosing to land straight in, saving time and fuel, tailwind, unstable, fast, - because these have been successful on many previous occasions; has to be opposed by a perception of risk nine times stronger in those situations which can result in an accident.
Thus the need for safety focus on procedural deviation, situation assessment, and knowledge of risk in decision making (education, training). Also checks on organisational influences, rota change, disruption, time and fuel pressure.
The industry must clearly restate the risks during landing, false perceptions of tradeoffs, safety margins, etc; landing briefing, accuracy and application of landing performance data.
Also, review implementation of safety strategies; e.g. current focus on LOC avoidance and practical recovery procedures vs landing accidents have no recovery procedure, only avoidance.
And reconsider risk; LOC has resulted to more fatalities (historical), but future risk often overlooks the remedial actions - AF 447, 737 Max, technical changes; thus projecting future fatalities on history would not be appropriate risk assessment. Whereas landing overruns have a similarly high historical risk (number of events), but without any practical mitigation the accidents could be repeated in similar situations, higher risk as the number events and fatalities cannot be prejudged. Safety action relies on frail human judgement.
** http://www.pacdeff.com/pdfs/Errors%2...n%20Making.pdf
"… there is something going on in the minds of these accident Captains which appeared to prevent them from …"
A key question; however we must not differentiate 'these' individuals from everyone else - including ourselves, who make similar decisions each day, generally with successful outcomes.
- "… what is it that inhibits them from following what they know to be the SOP for an obvious unstable approach ?
- What are the common threads?
- Why this overwhelming desire to land when all the indications to the readers of these accident reports would say things are really not at all good."
These points hinge on hindsight - our judgement after the fact:
- We cannot judge what the crew knew, or with knowledge, were able to recall it at that time.
- Nor might we identify commonalities, and particularly the human tendency to 'see' patterns where there are none. At best we might identify associations from a few accidents, but unlikely to have sufficient proof to justify widespread action. An alternative is to evaluate all operations, considering the range behaviours which result in success, but again after the fact; and who decides what is good or not, and how.
- The desire to land, often described as plan continuation bias, and again only identified with hindsight, has generated a range of academic views. One issue is that soft science (HF) depends on judgement, whereas people generally require 'fact'; if not from hard science, then facts as individually 'created'; our view, subject to our biases, culture, education, and experiences.
Orasanu and Martin provide a useful, simplified view of decision 'error'. *
There are more recent academic views, but with little practical advice to help improve aviation safety.
As I recall, one view suggests that the cognitive incentive required to change an inappropriate course of action requires an opposing incentive nine times greater. e.g. the mental gain in choosing to land straight in, saving time and fuel, tailwind, unstable, fast, - because these have been successful on many previous occasions; has to be opposed by a perception of risk nine times stronger in those situations which can result in an accident.
Thus the need for safety focus on procedural deviation, situation assessment, and knowledge of risk in decision making (education, training). Also checks on organisational influences, rota change, disruption, time and fuel pressure.
The industry must clearly restate the risks during landing, false perceptions of tradeoffs, safety margins, etc; landing briefing, accuracy and application of landing performance data.
Also, review implementation of safety strategies; e.g. current focus on LOC avoidance and practical recovery procedures vs landing accidents have no recovery procedure, only avoidance.
And reconsider risk; LOC has resulted to more fatalities (historical), but future risk often overlooks the remedial actions - AF 447, 737 Max, technical changes; thus projecting future fatalities on history would not be appropriate risk assessment. Whereas landing overruns have a similarly high historical risk (number of events), but without any practical mitigation the accidents could be repeated in similar situations, higher risk as the number events and fatalities cannot be prejudged. Safety action relies on frail human judgement.
** http://www.pacdeff.com/pdfs/Errors%2...n%20Making.pdf
de minimus non curat lex
Thread Starter
Theoretical considerations are all fine and dandy, and even if you spent time with the serial offenders explaining the potential risks they run, I suspect it would only have limited effect on them, for a limited time, before they would revert to type.
It is the new recruits in the RHS who I feel sorry for. I wonder if they know just what they are letting themselves in for?
What would possibly concentrate the mind would be robust SMS management and spelling out in unequivocal terms the employment sanctions the company would impose when unsafe practices took place.
Just how you integrate this into ‘Cultural’ considerations is something else, together with the role of the Regulator?
EASA has made it clear to PIA what is expected of them before the EU airspace ban is lifted.
More than a single Munro to climb.
It is the new recruits in the RHS who I feel sorry for. I wonder if they know just what they are letting themselves in for?
What would possibly concentrate the mind would be robust SMS management and spelling out in unequivocal terms the employment sanctions the company would impose when unsafe practices took place.
Just how you integrate this into ‘Cultural’ considerations is something else, together with the role of the Regulator?
EASA has made it clear to PIA what is expected of them before the EU airspace ban is lifted.
More than a single Munro to climb.
