A very interesting MOST experience. And an excellent example of how we can
dig ourselves deeply into problems by following a poor judgment chain, and
avoiding the management process. Management should have started during the
Preflight Briefing where the rules of management were identified and put in
place. Limiting ourselves to at this operational scenario, however, we should
have seen some management activities immediately after the warning light
illuminated, and at the very latest, right after the go-around. At that time,
the PIC should have assumed the leadership to deal with the problems at hand.
When the PIC failed to assume such leadership, the responsibility to initiate
the management procedures falls to the SIC. Apparently the SIC took no
action, and thus it was a crew failure.
The management actions here must consist of observable parts (procedures)
that work together (as a coherent management system) to produce the best
possible decisions. In evaluating crew performance, we simply look for these
procedures, which are required of all crewmembers. They are quite simple to
evaluate -- yes or no (just like SOPs for, say engine start up -- either the
crew used the approved procedure or they didn't). They failed to use the
proper procedures (assuming that you had specific management procedures), nor
did they satisfy their Professional Responsibilities (another key aspect to
our management system). Just because the flight did not crash does not mean
the management was successful. In this case it was a crew failure.
Skip Mudge
CMR