Re: Error or Violation?

Andre Berger (aberger_at_innet.be)
Thu, 3 Jul 1997 07:52:54 +0200


Hello CRMers,

> A pilot gets "task saturated" during a rushed approach.
Error: needs training in how to manage stress and workload to avoid being
task saturated.
Error: accepts rushed approach without going around immediately when seeing
that the approach is rushed.

> His first
> attempt to land is high and hot, so, at the suggestion of a crewmember,
he
> goes around and transitions into a visual pattern (the weather is OK).
Good.

> During the visual pattern, he uses airspeeds and flaps settings that are
> different than prescribed in the flight manual.
Error or good judgment, difficult to say. Most visual patterns in flight
manuals are designed for touch and goes, not for use after a go around from
an instrument approach.

> His turn to final is high,
> close, overshooting, and hot again.
Error.

> He states "we'll use half flaps so I can
> get it down", which of course is opposite of basic pilotage.
Incompetence. Probably poor training.

> He touches down
> quite long, excessively fast,
Violation: needs disciplinary action for PIC and crew because of not going
around again.

> and as a result the aircraft breaks up leaving
> the aerodrome boundary.

Or how a combination of errors, incompetence and violation of rules leads
to an accident.
As a manager, I would react with:
1. Tolerance to the errors and give special training to avoid these in the
future (e.g. LOFT scenario).
2. Retraining for the basic pilotage errors. Review with the training
manager to see how it is possible that a PIC makes a basic pilotage
mistake. May be a training problem, aircrew selection problem or not.
3. Take disciplinary action against the PIC, F/O (and S/O if on board). If
breaking a plane (and possibly killing a few pax) in such a way does not
require disciplinary action, what else would?

Kind regards,

Andre Berger
E-mail: aberger_at_innet.be
Website: http://www.linepilot.org