Subject: Re: Analysis of Cali accident
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Dear Martin :
Thank you very much for your thoughtfull view on the Cali accident and
interesting information of an analysis by Peter Ladkin. I agree with the
results of the investigations made for the Cali accident by several aviation
specialists including yourself, but still doubt whether these indepth analyses
are truly instructive and useful for people routinely working in the
operational environments. For them to enter into a mentally stressful situation
is an "usual business"(even if it is not so frequent) and cannot be completely
avoided because flying an airplane is in itself a very risky business for human
beings. They may make so many errors in the course of struggling with the
troubles because of their limited performance in high workload situations.
Although the CRM training for reducing human errors in such situations is being
developed and improved, it would not be effective for eliminating all the human
errors involved. The target of the training, therefore, must be narrowed down
to some limited number of critical and significant human errors selected with
human factors and risk management considerations. In this meaning, I cited a
"moving map" issue( psychologically a so-called "figure-ground" problem ) as a
most vital issue experienced in the Cali accident. If the crew were aware of a
flight path desplay which was directed to the undesired location, they could
have successfully escaped from the "Collision Course". As I mentioned earlier,
difficulty in observing a moving map desplay in highly stressed condition( and
even in lower workload condition ) have been experienced in the Exxon Valdez
accident at Alaska. The reason why I am sticking to this issue is that I would
like to say the newly proposed EGPWS( Enhanced GPWS ) might not work
effectively as expected especially in highly stressed conditions like the Cali
case because the EGPWS is essentially the same as a rader(moving map) display.
I believe any complacency associated with incorpolating the EGPWS could be
effectively avoided by instructing the flight crew about the limitations and
weakness of the display system.
Hideatke Sakuma, JAL
> Dear Mr. Sakuma,
> Thank you very much for your inspiring ideas about the Cali-accident.
> After reading the CVR of the last 30 min. of the flight, my opinion is that
> the first part in the error chain was accepting the straight-in-approach
> without really thinking about the oncoming flight-deck-duties that were
> associated with the amended clearance (get out the other appr.-charts,
> reprogram the FMC, rebriefing of the procedure, recheck
> A/C-configuration,...). There was not enough time left to perform all those
> duties properly.
> Contributing to the acceptance of this clearance was probably subtle
> pressure to minimize delay (that`s what we all are doing all the time and is
> expected by our company).
> After the decision to accept RW 19 the "big picture" of both pilots narrowed
> to a "small tunnel" and the problems with the FMC and map-display that you
> mentioned contributed to the oncoming errors.
> The decision to accept RW 19 caused mental stress to both pilots, thereby
> reducing their situational awareness (of flight path and obstacle
> clearance).
> Another psychological fact is proven again: as soon as a decision is taken,
> we try to stick to this decision and look for facts supporting it and ignore
> facts, that do not support our decision.
> Maybe also "regression" was somehow involved in the accident sequence:
> mental stress causes us to regret to attitudes and actions learned earlier,
> although they are not appropriate in the actual situation; flying in radar
> environment most of the time and accepting direct routings is "usual
> business" in our part of the world, but it was not appropriate in the
> situation of AA 965. Maybe the stressful situation caused the "Regression"
> to the feeling of operating in a radar-environment (as they did most of the
> time).
> I found a very interesting analysis of the Cali-accident yesterday, maybe
> you are intersted (if you don`t know it already):
> try http://mek.ml.org/~ladkin/Incidents/Cali/calirep.html
> Thank you very much for your help, I hope to hear from you again!
> Martin Pletzer
> Tyrolean Airways CRM-Coordinator
> Austria
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