Announcement

Collapse
No announcement yet.

ANA 737-700 close call on Sept 6 2011

Collapse
X
 
  • Filter
  • Time
  • Show
Clear All
new posts

  • #46
    How about a mild electric shock in the sims to properly condition what the check pilot misses?
    Live, from a grassy knoll somewhere near you.

    Comment


    • #47
      You've really given the case study for your own point Evan.

      You worked in an industry where getting your fingers in the wrong spot could have them disappearing, with a great safety culture and constant reminders of the danger. Yet STILL people working there were missing them.

      Thats the whole point - no matter how much you train something (such as looking when you're touching), humans are humans and will lapse. Even when the consequences are a missing finger. Even with a great safety culture.

      TeeVee, when manipulating the door switch the pilot is NOT supposed to be looking at the flight instruments. He is supposed to be looking behind him, at the TV in the back wall of the cockpit. Preferably for only a second or two. But, yes, sometimes delays happen, and you have to look for longer. You try to flick back to the instruments and back again to keep an eye on things. But you can lapse.

      Yes, this pilot should have picked up on what was happening. But he didn't. And that doesn't necessarily mean he's a bad pilot. It means he's human.

      Comment


      • #48
        Originally posted by TeeVee View Post
        immune? no. but i wouldn't do it. period. in 14 years of having people's lives in my hands, i never made a mistake out of lack of concentration or being distracted. how? i paid attention to the task at hand. sure, i had less things to monitor and not as many switches and buttons to play with. so yeah, not quite the best comparison.

        bottom line here is that this guy completely lost situational awareness as so many of you are so fond of saying.

        and if you read my half-joking post from earlier on, you'll note that i criticize boeing for the design of the knob as well. totally stupid design given its placement.
        More teen age, black and white mentality. But of course, Vnav doesn't know what he's talking about.
        Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

        Comment


        • #49
          Originally posted by 3WE View Post
          More teen age, black and white mentality. But of course, Vnav doesn't know what he's talking about.
          you can't help but attack the person, can you? since you have no real argument to make, you resort to this kind of nonsense.

          Comment


          • #50
            Originally posted by MCM View Post
            TeeVee, when manipulating the door switch the pilot is NOT supposed to be looking at the flight instruments. He is supposed to be looking behind him, at the TV in the back wall of the cockpit. Preferably for only a second or two. But, yes, sometimes delays happen, and you have to look for longer. You try to flick back to the instruments and back again to keep an eye on things. But you can lapse.

            Yes, this pilot should have picked up on what was happening. But he didn't. And that doesn't necessarily mean he's a bad pilot. It means he's human.
            so, ummm let's get this straight: you are supposed to physically turn to look at the door when unlocking it, but there is no need to look at the switch you're using to unlock the door which is why you are looking back to begin with? so looking to see who is comin through the door is more important than verifying that you yankin on the right dial?

            ok, maybe evan is right after all! the industry is doomed because it hasn't the foggiest clue how to set up proper regs.

            obviously the guy has some skills cuz he was able to recover the aircraft from a pretty crappy attitude and no one died. i think my point is that the kind of mistake he made should never happen. judging from the report's photos, the dials were sufficiently far apart and sufficiently physically different in shape so that he had to paying NO attention to what he was doing to make the mistake he did.

            Comment


            • #51
              once upon a time,

              a Delta 767 pilot taking off west from LAX had an eicas msg telling him his eecs are flaking on him. He moved his right hand toward the base of the throttle pedestal to press the two buttons that would disable them. But pilots are creatures of habit and his hand was also near the fuel control levers and he wrapped his fingers around both levers and cut off the fuel to both engines as he would do everytime he parked his aircraft. the crew managed to restart the engines about 50ft above the water and continue on to SFO.

              This goes to how one single action can have catastrophic consequences. The final solution was to move the eec switches above his head like on the 757.

              stuff happens.

              Comment


              • #52
                Originally posted by TeeVee View Post
                so, ummm let's get this straight: you are supposed to physically turn to look at the door when unlocking it, but there is no need to look at the switch you're using to unlock the door which is why you are looking back to begin with? so looking to see who is comin through the door is more important than verifying that you yankin on the right dial?
                Read again. MCM meant and said that you are not supposed to be looking at the FLIGHT instruments. You had said that he should have been looking at the instruments and hence realized that the plane was doing odd things (like banking, yawing and the control wheel turning) and MCM is replying to that.

                I think everybody here agree that this pilot should have visually checked what the hell was he grabbing before actioning it, and that it was a gross error that he didn't.

                --- 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


                • #53
                  Originally posted by MCM View Post
                  You've really given the case study for your own point Evan.

                  You worked in an industry where getting your fingers in the wrong spot could have them disappearing, with a great safety culture and constant reminders of the danger. Yet STILL people working there were missing them.
                  It was also an industry where people were not 'pilot material', and often not the brightest bulbs to begin with, and occasionally not even completely sober. More importantly, it was an industry where hundreds of lives were not as risk if you made a simple mistake. I don't underestimate the human factor aspect, but I think it is reasonable to expect an airline pilot to develop an instinct for following his hands to the controls with a constant sense of caution and responsibility. This, or course, is something that comes from a stronger education, and a stronger education will not come until a stronger regulation requires it.

                  We talk a lot about safety culture, but we also need to talk a lot about 'pilot material'. If you took a random sampling of fairly intelligent people, I think you would find that a certain minority have the ability to consistently apply a certain discipline to their actions. This should be a primary screening criteria for airline pilot training.

                  Even then, I realize, mistakes will occur, due to momentary brain-fart or fatigue. This is why control interface design is so critical. I see the guarded switch as the 'missing finger' in the cockpit. All you have to do is look at that guard to remind yourself that stupid errors occur and have grave consequences.

                  -------

                  Ok, so the new threat has been revealed. Now what?

                  Has Boeing moved or redesigned the door switch on existing aircraft? No.

                  Has the FAA required them to? No.

                  Has anything in the way of a bulletin been released about this? None that I can find.

                  Can this happen again on the 737NG? Absolutely.

                  What's being done to prevent it? Nothing I can think of.

                  Can this happen on an A320. Absolutely not.

                  Comment


                  • #54
                    Originally posted by Gabriel View Post
                    Read again. MCM meant and said that you are not supposed to be looking at the FLIGHT instruments. You had said that he should have been looking at the instruments and hence realized that the plane was doing odd things (like banking, yawing and the control wheel turning) and MCM is replying to that.

                    I think everybody here agree that this pilot should have visually checked what the hell was he grabbing before actioning it, and that it was a gross error that he didn't.

                    yup, he also said that the period of time he should be staring at some stupid camera was a second or two, leaving the rest of the time he wasn't looking at the flight instruments his bigger mistake.

                    i asked my friend why the cockpit door was opened from the inside since every plane has a keypad on the outside, which would allow the person leaving the cockpit to let themselves back in and avoid this ENTIRELY. now, wanna talk about stupidity? it's because someone may be able to see you input the code, thus later on gain entry using the code.

                    yeah, cuz it is just not possible for some jackass to have a knife at a FA throat around the corner and out of sight of the camera... this is some seriously asinine crap. who thinks this shit up?

                    Comment


                    • #55
                      Originally posted by Evan View Post
                      It was also an industry where people were not 'pilot material', and often not the brightest bulbs to begin with, and occasionally not even completely sober. More importantly, it was an industry where hundreds of lives were not as risk if you made a simple mistake. I don't underestimate the human factor aspect, but I think it is reasonable to expect an airline pilot to develop an instinct for following his hands to the controls with a constant sense of caution and responsibility. This, or course, is something that comes from a stronger education, and a stronger education will not come until a stronger regulation requires it.

                      We talk a lot about safety culture, but we also need to talk a lot about 'pilot material'. If you took a random sampling of fairly intelligent people, I think you would find that a certain minority have the ability to consistently apply a certain discipline to their actions. This should be a primary screening criteria for airline pilot training.

                      Even then, I realize, mistakes will occur, due to momentary brain-fart or fatigue. This is why control interface design is so critical. I see the guarded switch as the 'missing finger' in the cockpit. All you have to do is look at that guard to remind yourself that stupid errors occur and have grave consequences.

                      -------

                      Ok, so the new threat has been revealed. Now what?

                      Has Boeing moved or redesigned the door switch on existing aircraft? No.

                      Has the FAA required them to? No.

                      Has anything in the way of a bulletin been released about this? None that I can find.

                      Can this happen again on the 737NG? Absolutely.

                      What's being done to prevent it? Nothing I can think of.

                      Can this happen on an A320. Absolutely not.
                      aside from the obvious computer control issue, are there two dials on the airbus for the same controls? are they similar in shape and size? and where are they placed relative to each other?

                      Never mind, just found my answers. the door unlock is a push button of the momentary type, requiring it to be held down and the rudder trim is a dial.

                      Comment


                      • #56
                        To me, the "real threat" is that when we have the technology to prevent it, we allow these sorts of mistakes to cause an aircraft to leave its flight envelope.

                        You can redesign the buttons all you like - this is akin to reacting to a specific terrorist threat, like shoe bombs - the next mistake will be something else completely different, but just as asinine.

                        You can train the pilot to look at the nob all you like - for all we know, this pilot was staring at it the whole time. That is the nature of these lapses we all experience. Many times when a person is asked about why he pulled out in front of a motorcycle or other vehicle, the answer isn't that he didn't see it, it's that he saw it and still pulled out and has no idea why.

                        These lapses can occur with anyone, regardless of intelligence. Stereotypically, some of the most "absent-minded" people are brilliant college professors.

                        Comment


                        • #57
                          Originally posted by Fear_of_Flying View Post
                          These lapses can occur with anyone, regardless of intelligence. Stereotypically, some of the most "absent-minded" people are brilliant college professors.
                          Ok, this is a very interesting point. Brilliant college professors make terrible pilots. There is a bell curve of reliability to trained procedure. On the one side, you have morons. On the other, you have deeply intellectual minds that are always working on several channels of thought and lack the necessary focus. Somewhere in the middle is "pilot material". It's probably true that you can more easily train a monkey to do a simple task more reliably than an intellectual genius. The more "enlightened" the mind, the more "liberated" the behavior, the less likely it is to adhere to rote or routine or rules. So, ideally, pilots are very skilled and intelligent (both adhering to learned procedures from learned "instinct" and understanding the physics involved) but not overly intellectual and distracted by complex, divergent contemplation, or some rebellious philosophical expression of free will. Oh, man, am I going to get flamed for this...

                          Comment


                          • #58
                            A simple redesign of the shape of the button perhaps. It (by industry standards), is probably not warranted and there are few incidents that we are aware of but how many times "per shift", is that button used?
                            Live, from a grassy knoll somewhere near you.

                            Comment


                            • #59
                              Originally posted by guamainiac View Post
                              A simple redesign of the shape of the button perhaps. It (by industry standards), is probably not warranted and there are few incidents that we are aware of but how many times "per shift", is that button used?
                              I'm trying to think of a reason why a rotary switch would be used here, and I can think of exactly... none. This is a push-button solution. Maybe they had a bunch of extra rotary switches in inventory...?

                              The reason this wouldn't happen on the A320 is not just the pushbutton placed in a less bone-headed location. On the Airbus, the rudder trim is inhibited when the autopilot is active. Why does Boeing not do the same?

                              Comment


                              • #60
                                Originally posted by Evan View Post
                                I'm trying to think of a reason why a rotary switch would be used here, and I can think of exactly... none. This is a push-button solution. Maybe they had a bunch of extra rotary switches in inventory...?

                                The reason this wouldn't happen on the A320 is not just the pushbutton placed in a less bone-headed location. On the Airbus, the rudder trim is inhibited when the autopilot is active. Why does Boeing not do the same?
                                In the A320 the elevator is inhibited to exceed Alpha max.
                                In the A320 the elevator is inhibited to exceed 2.5Gs.
                                In the A320 the trim is automatic.
                                Why does Boeing not do the same with the 737?
                                I mean, Ok, strive for that (I wonder how it works in the 777 and 787) but remember that the 737 is a design more than 40 years old now and not fly by wire nor so computerized.

                                On the other hand, in the A320 you can't manually deploy the spoilers after landing. They automatically deploy when you touch down, provided that you didn't fail to idle both thrust levers. In the 737 you can and that alone could have saved a lot of lives in the A320 accident in Conghonas, Sao Paulo. Ok, that the pilot didn't forget to idle one of the thrust levers, or that he detected the problem during the landing roll, could have saved the too. But the same could be said about a 737 pilot not grabbing the wrong knob or detecting the mistake.

                                About the reason for the shape and location of the controls, it seems that Boeing has three positions: Auto, open and deny (pilots are very reserved about disclosing how the system works for obvious reasons, but one can guess more or less) And in any event, the cockpit is full of switches, levers, buttons and knobs so you really can't put all buttons far away from all other buttons, all knobs away from all other knobs and so on. And yet, who tells you that you won't push the wrong button instead of flipping the right switch?

                                "Flaps 15"
                                "Wait" (stands up, goes to reach behind the captains set) "Flaps 10"
                                "Gear down"
                                "In a second" (stands up again, goes to the forward galley) "Going down"
                                "Spoilers please"
                                "Right away" (stands up for a third time and runs to the aft lavatory) "Armed"
                                "Autobrakes"
                                "Yes sir" (stands up for a fourth time but the captain stops him)
                                "Where are you going? The autobrakes is in the overhead!"
                                "Oops, I was reaching behind the door for the landing lights, thanks Boeing for the new cockpit layout that prevents switchology errors"

                                --- 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

                                Working...
                                X