> This is a test. This past week I was conducted a Facilitator Training
> session. When we got to the section where the students present CRM lessons,
> and lead debates, one insightful student brought this case study to the class.
> He asked everyone to read it, and then he refered to it as he presented his
> assigned lesson. It even caused me to lean back and ponder somewhat.
> I'd like to present this short story, and ask if anyone in the group
> recognizes the event.
> It does relate to the discussion of "error management" by organizations, and
> teamwork by the crew involved.
>
> CASE STUDY
> The mishap crew was making their first transoceanic crossing for a
> commercial carrier in a newly introduced equipment type. The equipment was
> considered to be the most technologically advanced to date.
> The captain had approximately 40 years experience and was consistently
> chosen by the carrier to perform command duties when new equipment was
> acquired. He was respected by his peers. Crewmembers characterized him as "low
> key" and "firm, but fair". Prior to this incident, his safety record was
> spotless.
> All other crewmembers aboard were highly experienced and respected members
> of the company. None had been directly involved in any major incidents.
> The equipement in use had been involved in a "normal" course of
> Operational Test and Evaluation according to records. Subsequent investigation
> called the quality of the OT & E process and findings into question. Comm/Nav
> equipment was "state of the art". All required equipment was aboard, in
> accordance with policies and regulations, except for one navaid that was
> determined to be non-mission essential.
> Enroute weather indicated conditions were favorable for icing. Reports
> received from other carriers confirmed icing conditions.
> Manifested passengers included several Distinguished Visitors, including
> the president of the carrier.
> During departure, a "minor incident" occurred that caused no damage and
> was judged to have no bearing on the mishap. Departure was on schedule.
>
> Which event was this?
>
> Greg Deen
> Raytheon
Titanic?