Re: 3407 Strikes a Cord Redux/Whatever you guys are arguing
I love this thread! :cwm27:
KillTron I must give it to you. You are either really good at messing with us or are just really dense and arrogant.
When will you admit that there was more to it than two complacent pilots? Training, Fatigue, and Pilot Pushing being a few issues that come to mind?? I don't think anyone said that the pilots didn't make mistakes. What we are saying is that the reasons the mistakes were made were due to the factors that the company could have controlled. They were fatigued, inadequately trained on the type of aircraft they were piloting, and the weather was crap and at their current capacity (see fatigued) there was too much stuff going on at once. There were several links in the proverbial chain that led up to this and I know that inadequate training and a lack of rest were two big ones that were at the beginning.
The company /training programs would be tertiary factors, and fatigue would be a secondary factor. IMHO, this accident isn't a single point failure event though, hence to me, the error chain wouldn't really apply. Using the swiss cheese model, several factors....some mentioned here....were constantly trying to get through the layers of cheese, and a few got through. You have to work backward from there though. Starting at the accident and working backwards, it's apparent there were breakdowns in basic airmanship. Why that happened was possibly due to either loss of SA as a whole, breakdown in CRM, fixation on other parts of the aircraft or happenings outside the aircraft, or misprioritization (or possibly all four). The inattention to the aircraft speed seems to been the catalyst to the situation of stall and stall recovery techniques, etc. I don't believe the crew was complacent, I think they ran into a situation they may not have dealt with before (ice), fixated on it and lost SA (airspeed missed at level off), then reacted incorrectly due to either misdiagnosing the situation and applying the wrong corrective action based on that misdiagnosis, or correct diagnosis and still wrong reaction.
Do you really think that if they were well rested and properly trained that this accident would have still happened?
Sure it could've. Again, using the swiss cheese model (no single point or "chain" failure....ie- one didn't have to happen in order to allow the other), there were many factors trying to make it through the swiss cheese layers. Well rested...that question can't be answered, as we don't know exactly how much rest they truly had or their alertness level. Properly trained could be more easily addressed. But the airmanship failures that began the physical actions of the aircraft, as noted on the FDR, put the proverbial roller coaster in motion, ultimately ending the plane up in the ground.
Ill even go as far back as to training before Colgan. Maybe there is an underlying issue with the initial training that these pilots received, I dunno. Did these two ever flight instruct or fly freight? There is alot to be said about having someone try to kill you every day for 1000 hours as a flight instructor.
You need to stop looking at what the pilots did to cause the accident and try to look at why the pilots did what they did in that situation.
The BL is though, that two pilots flew a (by all accounts) perfectly good plane into the ground. You have to look at the what in order to answer the why, and from there start with the basics and work to the complex. There are tons of factors in this accident; and going by the primary/secondary/tertiary classifications of cause; the primary would involve the crews direct actions or inactions...the airmanship; secondary would answer the why that caused them to likely do what they did; and tertiary would be factors that contribute, but didn't have a direct action in the accident....ie- management and training. Management/training department weren't in the cockpit manipulating the controls, so they're not going to be above tertiary. Keeping all this in mind, then we can place factors in their proper classification.
Not supporting one side or another here, as I have no dog in this fight....apart from the investigative concepts aspect of this. But have been watching this self-licking ice cream cone argument going round and round page after page.
FTW
