Yesterday you wrote:
<<Bob Helmriech's "Fifth Generation" describes an attitude of management
that is forgiving of "error" (since human error is inevitable), but not
forgiving of "violations." With this premise, answer me this:
A pilot gets "task saturated" during a rushed approach. His first
attempt to land is high and hot, so, at the suggestion of a crewmember, he
goes around and transisitions into a visual pattern (the weather is OK).
During the visual pattern, he uses airspeeds and flaps settings that are
different than prescribed in the flight manual. His turn to final is high,
close, overshooting, and hot again. He states "we'll use half flaps so I can
get it down", which of course is opposite of basic pilotage. He touches down
quite long, excessively fast, and as a result the aircraft breaks up leaving
the aerodrome boundry.
I think it fair to say that the pilot did not begin the day planning to
botch the landing, but he got overwhelmed by the arrival challenge.
"Error" which should be forgiven? or
"Violation" (of flight manual directives) which should receive
discipline?
Should the PIC and crew be treated different, or the same?
What's your vote?>>
As a guy that is working on your case study on that same circumstance, let me
offer an opinion. I have read the accident report, discussed the fateful
landing with experts both in and out of the "corporate" culture, and
conducted a couple of seminars with experienced pilots on the same aircraft
type. The consus is that there were errors of both commission and omission.
To make an error is human to forgive, divine is what some one said once. I
wonder what experience or philosophy offers about violations. About ignorance
it is said that it is no excuse.
When does an error become a violation? First, I do not think that this pilot
had the basic airmanship skills required to land the aircraft on the airfield
in question. Second, I do not think that anyone on his crew, including the
other pilot (also qualified as an aircraft commander or captain) had those
skills. Third, Did the corporate system know that they had put a "weak" link
into that kind of position?
If the regulatory or policy guidance stipulates a given configuration for a
certain kind of landing, and the crew ignores or violates the guidance, is
that an error or a violation?
As you mention the pilot probably did not intend to run off the end of the
runway when he started the day. Likewise, the other pilot probably did not
think they were in trouble for the landing, even when the incorrect flap
setting was selected. He may well have not known the difference either.
Surely, someone in the management chain knew the pilot's capabilities or lack
thereof. If not, then the error was not in the cockpit. If so, ditto. Again
though if the policy or regulatory guidance is that the crew have certain
capabilities to do a particular mission, but are assigned the mission in
spite of a lack of the capabilities, is that an error or a violation? And
whose?
I suspect the corporate system that put the "weak" crew into the position is
much more a cause than the crew involved.
However, your question still raises the issue of corporate versus individual
responsibility. Good catch.
Dave Wilson
HTI