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  • Skills, Training, CRM, Culture... Safety

    Things not mentioned in the title:

    Personality? Professionalism? Individual values? Responsibility? Sense of duty? ... Ethics anyone?

    This is one of my very rare and "obscure" threads where I really don't know where I am going. But try to follow me... if you can, because I can't.

    While this post goes around the Asian accident, I'm using it just an exucse to talk about a much deeper and fuzzy issue. That's why I put it out of the Asiana thread.

    Different posters compared the Asiana accident with Colgan, AF 447, KLM vs Pan-Am at Tenerife, Turkish...

    I don't know what was going on the minds of these three pilots at that time, but I don't think they are similar (maybe a bit with Turkish, but not too much).

    This accident, in my view, is more similar to the typical "busting minimums" one, or the "low semi-arobatic passes above my girlfried's house" type.

    Let's face it. Landing a perfectly functioning aircraft in severe daylight visual conditions with almost no wind or turbulence in a long, wide, sea-level, PAPI-equipped runway, is no feat. It is not in a J-3. It is not in a 777. It is not in the Concord, and it is even not in the worst glider of the Universe: the Space Shuttle.

    You don't need any special skill or training (other than being able to just fly the plane), it there are no tough judgement calls to be made, and CRM my ass, single pilot can do it with no sweat.

    I am 200% sure that any low time PPL or even a good simmer that takes the hobby seriously could have kept the glide slope and speed reasonably close to the target (the flare and touchdown part is more difficult, I concede)...

    ... IF ONLY THEY REALLY INTENDED TO DO IT.

    So, they passed through 500ft.
    The speed was not stabilized (and had never been during the approach).
    The glide slope was not stabilized (as and had never been during the approach).
    The thrust not in the "approach" range but at idle (as it had been during the whole approach).
    They had not even completed the landing checklist yet.

    And then, a voice calls "Five hundred".

    At this point, I bet that all of them thought "this is not ok, we are not meeting the stabilized approach criteria... in many ways, we are required to go around".

    But they didn't.

    It was not a tough judgement call. It was not that the approach had become stabilized at this point.
    The approach had never been stabilized.
    And they knew it.
    They had reached the stabilized approach gate.
    And they knew it.
    They should have gone around at that point.
    And they knew it. ALL OF THEM.
    But they didn't.

    Training can't solve that.
    Skills can't solve that.
    CRM can't solve that.

    This is the point of the additional words I added below the title.
    You can be an expert in all the airplane systems, be stick-n-rudder guy of superior quality, pass all checkrides ant training sessions with flying colors (because you are NOT so dumb to violate the procedures in an exam, are you?), and then, go and say "fuck all this BS, I am better than all that".

    Even a pristine safety culture can't ensure that it'll correct a naturally irresponsible person that lacks any commitment with duty.

    I concede that it can do something.
    I've worked in 2 factories (more, in fact, but these two come to the point).

    In one of them, people was very reluctant of using the PPE. "It's uncomfortable". "It interefre with my tasks". "I can't see the defects well with these safety googles". "They really don't work". were the typical excuses.

    In the other one, everybody used them without questions.

    The really interesting thing was the new hires.

    In the first one, they immediately voiced for the same excuses.
    In the other one, they used it without complains. Of course, saying that it is uncomfortable or that you can't work right with it is a lame excuses when everybody else is using it 8 hours per day with no complains or job-performance impact.

    I bet that, on average, the new guys were similar in both companies. So the reaction of a new hire to the EPPs was STRONGLY, CRITICALLY influenced by the company culture.

    Yet, even in the "good" company, there were rebels. Of course, they wouldn't last.

    My point, that I have raised before in this forum, is two fold:

    - No matter how much training and knowledge an airline (or the system) instill in a person, there will ALWAYS be cases of pilots that are willing to "know better" and knowingly do something they shouldn't.

    - If an airline is willing to cut corners, there will ALWAYS be a supply of pilots willing to work with that.

    Because of that, while we can blame the pilots individually for their dishonest behavior, that doesn't relieve the airlines of their responsibility. The airlines KNOW that these pilot exist, so they MUST do something about that.

    It's the airline's duty to either "cure" or "get rid" of the pilots that lack the necessary personality, as much as they do (or should do) regarding the skills.

    So, again, the solution is two-fold:

    - Strong safety culture, like in the "good" factory of my example.
    - A means to detect and get rid of the rebels.
    Both things are the TOP MANAGEMENT's responsibility.

    And please, before someone objects my appreciation of the Asiana accident, remember this is not the Asiana thread and that I used it only as an excuse to discuss the safety issues mentioned. So please follow me and assume for a minute that the behavior of the Asiana pilots was the one I described.

    --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
    --- Defend what you say with arguments, not by imposing your credentials ---

  • #2
    Originally posted by Gabriel View Post
    Things not mentioned in the title:

    Personality? Professionalism? Individual values? Responsibility? Sense of duty? ... Ethics anyone?

    This is one of my very rare and "obscure" threads where I really don't know where I am going. But try to follow me... if you can, because I can't.

    While this post goes around the Asian accident, I'm using it just an exucse to talk about a much deeper and fuzzy issue. That's why I put it out of the Asiana thread.

    Different posters compared the Asiana accident with Colgan, AF 447, KLM vs Pan-Am at Tenerife, Turkish...

    I don't know what was going on the minds of these three pilots at that time, but I don't think they are similar (maybe a bit with Turkish, but not too much).

    This accident, in my view, is more similar to the typical "busting minimums" one, or the "low semi-arobatic passes above my girlfried's house" type.

    Let's face it. Landing a perfectly functioning aircraft in severe daylight visual conditions with almost no wind or turbulence in a long, wide, sea-level, PAPI-equipped runway, is no feat. It is not in a J-3. It is not in a 777. It is not in the Concord, and it is even not in the worst glider of the Universe: the Space Shuttle.

    You don't need any special skill or training (other than being able to just fly the plane), it there are no tough judgement calls to be made, and CRM my ass, single pilot can do it with no sweat.

    I am 200% sure that any low time PPL or even a good simmer that takes the hobby seriously could have kept the glide slope and speed reasonably close to the target (the flare and touchdown part is more difficult, I concede)...

    ... IF ONLY THEY REALLY INTENDED TO DO IT.

    So, they passed through 500ft.
    The speed was not stabilized (and had never been during the approach).
    The glide slope was not stabilized (as and had never been during the approach).
    The thrust not in the "approach" range but at idle (as it had been during the whole approach).
    They had not even completed the landing checklist yet.

    And then, a voice calls "Five hundred".

    At this point, I bet that all of them thought "this is not ok, we are not meeting the stabilized approach criteria... in many ways, we are required to go around".

    But they didn't.

    It was not a tough judgement call. It was not that the approach had become stabilized at this point.
    The approach had never been stabilized.
    And they knew it.
    They had reached the stabilized approach gate.
    And they knew it.
    They should have gone around at that point.
    And they knew it. ALL OF THEM.
    But they didn't.

    Training can't solve that.
    Skills can't solve that.
    CRM can't solve that.

    This is the point of the additional words I added below the title.
    You can be an expert in all the airplane systems, be stick-n-rudder guy of superior quality, pass all checkrides ant training sessions with flying colors (because you are NOT so dumb to violate the procedures in an exam, are you?), and then, go and say "fuck all this BS, I am better than all that".

    Even a pristine safety culture can't ensure that it'll correct a naturally irresponsible person that lacks any commitment with duty.

    I concede that it can do something.
    I've worked in 2 factories (more, in fact, but these two come to the point).

    In one of them, people was very reluctant of using the PPE. "It's uncomfortable". "It interefre with my tasks". "I can't see the defects well with these safety googles". "They really don't work". were the typical excuses.

    In the other one, everybody used them without questions.

    The really interesting thing was the new hires.

    In the first one, they immediately voiced for the same excuses.
    In the other one, they used it without complains. Of course, saying that it is uncomfortable or that you can't work right with it is a lame excuses when everybody else is using it 8 hours per day with no complains or job-performance impact.

    I bet that, on average, the new guys were similar in both companies. So the reaction of a new hire to the EPPs was STRONGLY, CRITICALLY influenced by the company culture.

    Yet, even in the "good" company, there were rebels. Of course, they wouldn't last.

    My point, that I have raised before in this forum, is two fold:

    - No matter how much training and knowledge an airline (or the system) instill in a person, there will ALWAYS be cases of pilots that are willing to "know better" and knowingly do something they shouldn't.

    - If an airline is willing to cut corners, there will ALWAYS be a supply of pilots willing to work with that.

    Because of that, while we can blame the pilots individually for their dishonest behavior, that doesn't relieve the airlines of their responsibility. The airlines KNOW that these pilot exist, so they MUST do something about that.

    It's the airline's duty to either "cure" or "get rid" of the pilots that lack the necessary personality, as much as they do (or should do) regarding the skills.

    So, again, the solution is two-fold:

    - Strong safety culture, like in the "good" factory of my example.
    - A means to detect and get rid of the rebels.
    Both things are the TOP MANAGEMENT's responsibility.

    And please, before someone objects my appreciation of the Asiana accident, remember this is not the Asiana thread and that I used it only as an excuse to discuss the safety issues mentioned. So please follow me and assume for a minute that the behavior of the Asiana pilots was the one I described.

    Excellent post Gabriel, very well said and I concur 110%

    BB

    Comment


    • #3
      Originally posted by Gabriel View Post
      And then, a voice calls "Five hundred".

      At this point, I bet that all of them thought "this is not ok, we are not meeting the stabilized approach criteria... in many ways, we are required to go around".

      But they didn't.

      It was not a tough judgement call. It was not that the approach had become stabilized at this point.
      The approach had never been stabilized.
      And they knew it.
      They had reached the stabilized approach gate.
      And they knew it.
      They should have gone around at that point.
      And they knew it. ALL OF THEM.
      But they didn't.

      Training can't solve that.
      Skills can't solve that.
      CRM can't solve that.

      This is the point of the additional words I added below the title.
      You can be an expert in all the airplane systems, be stick-n-rudder guy of superior quality, pass all checkrides ant training sessions with flying colors (because you are NOT so dumb to violate the procedures in an exam, are you?), and then, go and say "fuck all this BS, I am better than all that".
      this can easily be construed as criminal negligence. perhaps not what you meant to point out, but i would also argue that the authorities should be charging people criminally in cases like your example. let a jury decide if what they did was simply poor training, poor skills, plain ol lazy-ass, or like you said, "i'm too good to worry about all this BS."

      Comment


      • #4
        Originally posted by BoeingBobby View Post
        Excellent post Gabriel, very well said and I concur 110%

        BB
        As do I...
        The "keep my tail out of trouble" disclaimer: Though I work in the airline industry, anything I post on here is my own speculation or opinion. Nothing I post is to be construed as "official" information from any air carrier or any other entity.

        Comment


        • #5
          Originally posted by Gabriel View Post
          Different posters compared the Asiana accident with Colgan, AF 447, KLM vs Pan-Am at Tenerife, Turkish...

          I don't know what was going on the minds of these three pilots at that time, but I don't think they are similar (maybe a bit with Turkish, but not too much).

          This accident, in my view, is more similar to the typical "busting minimums" one, or the "low semi-arobatic passes above my girlfried's house" type.
          I disagree with you there. I think this was a case of being caught out by stealth factor of the automation which is the result of not knowing the TYPE you are flying with on a system-interactions level. You didn't need to know this stuff of the Tomahawk or the DC-8 but on NG aircraft is it a vital part of the job. One area I would like to come back to—we've discussed this before—is that TRANSITIONAL regime between autoflight and manual instincts. It seems that a lot of accidents happen there, when the pilot is hand flying but still under the influence of automation (autothrottle, flight directors, pitch trim etc.). (I was thinking I should start a seperate thread dedicated to that discussion but I didn't want to create yet another place for everyone to argue about their qualifications and the value of ITS).

          Training can't solve that.
          Skills can't solve that.
          CRM can't solve that.

          So, again, the solution is two-fold:

          - Strong safety culture, like in the "good" factory of my example.
          - A means to detect and get rid of the rebels.
          I once went to the pistol range with a friend and his crazy uncle. After everybody has fired their rounds, everyone is required to clear the chambers, pulls the slides open and eject the clips on semi-autos and put the gun on the table. UNDER NO CIRCUMSTANCES CAN YOU TOUCH THE GUN WHILE ANYONE IS DOWNRANGE.

          Now, at one point, while people are retrieving their targets, the crazy uncle goes over to admire the my friend's new 9mm. Is is unloaded, the slide is open and the clip is ejected. There is no possible way it can fire a round, so HE PICKS IT UP.

          Someone yells PUT THE GUN DOWN!!. Everyone hits the deck. A chorus of voices are screaming at him to put the gun down. He shrugs, says something like "geez, it's obviously not loaded guys" and continues to hold the gun up until he is literally tackled by a guy behind him.

          This is because, in a good safety culture, when a slip can be fatal, certain rules are SUPERNATURALLY RESPECTED WITHOUT EXCEPTION.

          Busting minimums should be like this. Significantly missing a stabilization gate (well before the 500' one) should be like this. Having a hand on the thrust levers should be like this. And, with two or more pilots in the cockpit having this SUPERNATURAL RESPECT, it should work.

          So the problem as I see it is threefold:

          1) These things are not deeply enough impressed in training AND CULTURE throughout the industry (I think they are in certain companies).

          2) There is the problem of cockpit gradient, as well as the problem of letting things go due to good old fashioned airmanship (relax, old Chuck will have it back on the slope by the next gate...)

          3) Hiring pilot material int he first place. I agree with you completely here.

          Comment


          • #6
            Originally posted by TeeVee View Post
            this can easily be construed as criminal negligence. perhaps not what you meant to point out, but i would also argue that the authorities should be charging people criminally in cases like your example. let a jury decide if what they did was simply poor training, poor skills, plain ol lazy-ass, or like you said, "i'm too good to worry about all this BS."
            This is where part IV, sub-part g, section iii, paragraph 7 of my post comes into effect:

            Because of that, while we can blame the pilots individually for their dishonest behavior, that doesn't relieve the airlines of their responsibility. The airlines KNOW that these pilot exist, so they MUST do something about that.

            It's the airline's duty to either "cure" or "get rid" of the pilots that lack the necessary personality, as much as they do (or should do) regarding the skills.[...]Both things are the TOP MANAGEMENT's responsibility.
            I guess we can't charge the airline with criminal negligence. At least in Argentina you can't charge a legal entity with a criminal offense, because you can't jail it. So can we charge the Top Management (or better, the Top Managers) with criminal negligence? I guess not. Manslaughter maybe?

            Additional question: If the pilot know that he is violating the procedures, but he honestly thinks that what he is doing is safe (for example, he has done it hundreds of times before), is it still criminal negligence?

            Final question, what's the difference, in terms of the classification of the offense, between "I am required to lower the gear now... nah, I don't feel like doing it now, I'll do it later." ("plain ol lazy-ass") and "I am required to lower the gear now... nah, I can save a few pounds of fuel if I lower it later, it's still safe, especially with me behind the wheel" ("I'm too good to worry about all this BS.")?

            --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
            --- Defend what you say with arguments, not by imposing your credentials ---

            Comment


            • #7
              Originally posted by Gabriel View Post
              ............I guess we can't charge the airline with criminal negligence.............
              Some countries in Asia sometimes charge pilots with crimes (I used to have a ALPA list of those countries). Also France charged Continental over the Concorde crash.

              Se also here:

              Comment


              • #8
                Originally posted by Highkeas View Post
                Some countries in Asia sometimes charge pilots with crimes (I used to have a ALPA list of those countries). Also France charged Continental over the Concorde crash.

                Se also here:
                http://www.alpa.org/portals/alpa/mag...otsonTrial.pdf
                But I've said "charge the AIRLINE (or the top managers)". Not the pilots.

                --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                --- Defend what you say with arguments, not by imposing your credentials ---

                Comment


                • #9
                  Originally posted by Evan View Post
                  I disagree with you there. I think this was a case of being caught out by stealth factor of the automation which is the result of not knowing the TYPE you are flying with on a system-interactions level.
                  That too. If the autothrottle had worked in the way the pilots wrongly expected, this accident probably would not have happened.

                  Yet, they would have still violated the stabilized approach criteria, INTENTIONALLY. There is no room in my head for the idea that they didn't know that approach was not stabilized, or that they were crossing the stabilized approach gate, or that they were required to go around at this point.

                  The A/T not working as you expect can be the result of a number of possible causes, like technical problems, lack of understanding on how it works, or understanding it well but still configuring it incorrectly by mistake.

                  They might have been over-reliant on technology, and it certainly looks like they were. But that doesn't explain the intentional violation of the stabilized approach criteria. Complying with it would have also avoided this accident and in a more professional way than the autothrottle not happening to "fail" to their expectations.

                  --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                  --- Defend what you say with arguments, not by imposing your credentials ---

                  Comment


                  • #10
                    Originally posted by Gabriel View Post
                    They might have been over-reliant on technology, and it certainly looks like they were. But that doesn't explain the intentional violation of the stabilized approach criteria. Complying with it would have also avoided this accident and in a more professional way than the autothrottle not happening to "fail" to their expectations.
                    Naturally. There is no excuse no matter what the automation was doing. 1300fpm is unacceptable. You go around. Assuming you are flying the plane and aware of that. If you aren't, get a desk job..

                    And I wholeheartedly agree: management should no longer be allowed to blame the stooges they put in the cockpit.

                    Comment


                    • #11
                      If these guys had somehow pulled off this landing ( obviously earlier recognition of the situation ) Would anyone have ever heard a word about it ? How often does this go on ? How many times does a crew pull one out of their ass and all agree when they land this will be our secret to the grave ?

                      Comment


                      • #12
                        Originally posted by TheKiecker View Post
                        If these guys had somehow pulled off this landing ( obviously earlier recognition of the situation ) Would anyone have ever heard a word about it ? How often does this go on ? How many times does a crew pull one out of their ass and all agree when they land this will be our secret to the grave ?
                        FOQuA.
                        I hope that someone in the know can explain how it works.

                        --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                        --- Defend what you say with arguments, not by imposing your credentials ---

                        Comment


                        • #13
                          Reminds me of United 173 where the captain spent a bunch of time troubleshooting a landing gear issue and circling while running out of fuel. The other crew members knew it but didnt challenge the captain. Ultimately 10 people died in the crash. The pilot had lots of experience, but due to tunnel vision lost sight of the big picture. It was the end of his career and he had to live with those deaths for the rest of his life.

                          In the case of Asiana, I am sure they all knew they should have aborted the landing but nobody wanted to speak up and say they were wrong. I do believe a lot of this still persists and is far more likely to cause an accident than a mechanical issue, weather, or even ATC. I actually feel bad for these pilots because not only are their careers over, but the deaths and injuries caused by the accident will be with them for the rest of their lives. They didnt mean for this to happen but failing to speak up ended up costing lives. Cant imagine a worse nightmare for any pilot.

                          Comment


                          • #14
                            Failure to speak up?

                            What about the captain under training who was actually flying the plane? He didn't have to speak up. He had to go around.

                            And the training captain that was supervising the other guy? He didn't have to "speak up", he had to command a go around. He was the Pilot in Command for a reason. He was in the high side of the cockpit gradient.

                            --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                            --- Defend what you say with arguments, not by imposing your credentials ---

                            Comment


                            • #15
                              TeeVee

                              You would be hard pressed to make a case for criminal negligence. You need a few bigger smoking guns. Some examples:

                              The senior dispatcher and head bean counter send a memo or have a meeting with all of the Check Captains. In the meeting the tell the pilots to hammer it into the line crews that they MUST decrease the number of go arounds because perhaps .. the fuel consumed it hurting profits .. or ... "It's making us look bad in the statistics when they come out, KAL is whoopiing our asses and we need that market share, get the ON TIME numbers up at any cost"

                              Now as one poster who was an expat Sim Instructor detailed his history with a Korean carrier, and they could show a pattern of dismissal that operates without regard to safety but keeps perhaps 98% of new hires Korean in order to not have to recruit outside the culture, knowing this will have disastrous results eventually (a reasonable person would infer this) when despite the efforts of the Sim Instructors to bring them within reasonable industry standards, they engage in a pattern of dismissal.

                              There perhaps you have a criminal case. Because 4 guys screw the pooch in a cultural cluster fudge or because they have been overworked in not going to put them on the criminal dock.

                              Actually, it does seem that if put under the microscope if that culture of simulator training still exists (it probably does, I'll hazard that guess), it may bear looking into.
                              Live, from a grassy knoll somewhere near you.

                              Comment

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