Landing Incident @ SFO

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Boris Badenov said:
OK, let's do a thought experiment, JC. That's reasonably non-confrontational, isn't it?

So. There's no longer such a thing as a "screw up". Or if there is, then certainly, those who have been victimized by the System and have commited these "screw ups" aren't worthy of being sent to hit the bricks and peddle their wares elsewhere. No! They've been failed by The System! There are no losers, just winners-in-waiting! There are only actions that are taken by people who are insufficiently trained. Which, presumably, can be corrected by right-thinking new-age "non-judgmental" training programs. Oh, you forgot where the airspeed indicator was? Gosh, guess we failed you again! Here you go, we'll put neon in the instrument. Bad pilot, BAD! Don't do it again! Here, have a chewtoy. GOOD pilot.

Forget about the people who die in agony in the back (they're just pax, after all...numbers! This is a numbers game!), let's talk about pilots. If nothing is your fault, then nothing is your responsability either. You're just another redundant component which might malfunction from time to time (hey, everyone does!). I think it's high time that we recognize that we have all the free will, aenima, and legitimacy of a broken sprocket. It's the new reality, and we'd best consign ourselves to it. Who's really flying this airplane? Uhm, not sure. The Safety Department? Dunno, NOT ME, anyway! I'm just here for the view and the free peanuts.
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I'm glad we have a safety department, but where I work, the Captain is ultimately responsible for the aircraft. (And if something happens, we'll BOTH be at the Big Brown Desk, with the question to the Captain being "Why did you do that?" and the question to me being "Why did you let him do that?", so yeah.)

But stop for a moment and consider this: It's entirely possible that you (1) screw up and (2) have been failed by the system, too. Because that's what a lot of accidents are about.

Consider Colgan 3407. The probable cause of the accident was the flight crew's inappropriate response to a stall warning. But WHY that crew committed that error is even more telling, and opened a whole can of worms about FAA air carrier oversight, the inadequate safety culture at Colgan, pilot qualification, and on and on. The immediate cause of the accident was the flight crew, but why that crew was placed into that aircraft, in those conditions, represented a failure of the safety system, and not JUST a failure of the crew. (Although the last line of defense was indeed woefully inadequate that night.)

Using your logic, all we'd have to do to prevent CJC3407 from happening again is to take all of us regional pukes into the simulator and retrain stall recoveries -- but that's stopping the accident chain right before the accident happens, and fails to address all the other things that happened.

I don't want to repeat what many others have hashed out here, but you really should read Just Culture. It is in no way an attempt to duck responsibility (the opening story of a nurse who incorrectly prepares a lidocaine solution for a neo-natal patient due to confusing instructions from the attending and confusing paperwork is an interesting story of how both an individual actor and The System can both drop the ball), but it reinforces the fact that there really are few simple, open-and-shut accidents.
 
Hacker15e said:
I think that there's a happy middle ground that, for some reason in this thread gets ignored.

Certainly there can be systems that can be at fault...but there can also just be pilots who don't perform, too. I really don't understand why people are so polarized in one corner or the other -- we have to be willing to look at ALL the possible root causes, either systemic or in personal performance, if we care about excellence and safety.
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When we should be looking at the situation without bias and unemotionally discussing the event, we're all getting wrapped up like emotional 14 year girls and 8 year old boys fighting over the last Big Red Ball.

Sometimes it's ok to be a cold, heartless, unemotional Vulcan.
 
Derg said:
When we should be looking at the situation without bias and unemotionally discussing the event, we're all getting wrapped up like emotional 14 year girls and 8 year old boys fighting over the last Big Red Ball.

Sometimes it's ok to be a cold, heartless, unemotional Vulcan.
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You pointy bastard.
 
Hacker15e said:
I think that there's a happy middle ground that, for some reason in this thread gets ignored.
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My sense in making the post above was that I was responding to a polarized view, not that I was presenting one. Obviously, it's very useful to make use of every source of data available on why pilots screw up. But the guys at the pointy end are still, in anything resembling a sane world, responsible for what happens to their aircraft. The PIC is the final authority. It's black and white. Yes, of course, obviously, make use of whatever sources of information are available to understand why bad stuff happens. I'm confused that this even needs to be said, as I don't think anyone was arguing against it.
 
Boris Badenov said:
OK, let's do a thought experiment, JC. That's reasonably non-confrontational, isn't it?

So. There's no longer such a thing as a "screw up". Or if there is, then certainly, those who have been victimized by the System and have commited these "screw ups" aren't worthy of being sent to hit the bricks and peddle their wares elsewhere. No! They've been failed by The System! There are no losers, just winners-in-waiting! There are only actions that are taken by people who are insufficiently trained. Which, presumably, can be corrected by right-thinking new-age "non-judgmental" training programs. Oh, you forgot where the airspeed indicator was? Gosh, guess we failed you again! Here you go, we'll put neon in the instrument. Bad pilot, BAD! Don't do it again! Here, have a chewtoy. GOOD pilot.

Forget about the people who die in agony in the back (they're just pax, after all...numbers! This is a numbers game!), let's talk about pilots. If nothing is your fault, then nothing is your responsability either. You're just another redundant component which might malfunction from time to time (hey, everyone does!). I think it's high time that we recognize that we have all the free will, anima, and legitimacy of a broken sprocket. It's the new reality, and we'd best consign ourselves to it. Who's really flying this airplane? Uhm, not sure. The Safety Department? Dunno, NOT ME, anyway! I'm just here for the view and the free peanuts.
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There are those that will argue that this post is unduly punitive and against a "culture of safety" and they will also tell you that you are a menace to everything in the sky, including birds (true).

I would argue that is not true and that you aren't "anti-safety" but "pro-responsibility". And, to those out there in 121 shaking your heads that we down here in the herd just don't get it - perhaps we don't. It also goes to my post earlier about diminishing returns/how much more safe can you make it. The human aspect creates great outcomes (Sully, Al Haynes, many others). The same human aspect can create dreadful outcomes (This, Colgan, etc). At some point, unless there is a clear trend developing (and perhaps there is - airspeed control), maybe you just have to take the good with the bad. If you went back to 1970 and were tasked with created a "system" for safety, and after doing so you could point to zero major airline wrecks over a 12 year period - would you take it? Airplane wrecks at this level are so incredibly rare the overwhelming likelihood of a crash is pilot error. Can you ever fully eliminate that?
 
TFaudree_ERAU said:
As long as you wear your orange safety vest during walk-around, the world is a safer place.
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Their ramp, their rules. I got bitched out for taking a photo of the plane I was flying when security flipped their lid in Bucharest.

Sometimes it is what it is.
 
WacoFan said:
There are those that will argue that this post is unduly punitive and against a "culture of safety" and they will also tell you that you are a menace to everything in the sky, including birds (true).

I would argue that is not true and that you aren't "anti-safety" but "pro-responsibility". And, to those out there in 121 shaking your heads that we down here in the herd just don't get it - perhaps we don't. It also goes to my post earlier about diminishing returns/how much more safe can you make it. The human aspect creates great outcomes (Sully, Al Haynes, many others). The same human aspect can create dreadful outcomes (This, Colgan, etc). At some point, unless there is a clear trend developing (and perhaps there is - airspeed control), maybe you just have to take the good with the bad. If you went back to 1970 and were tasked with created a "system" for safety, and after doing so you could point to zero major airline wrecks over a 12 year period - would you take it? Airplane wrecks at this level are so incredibly rare the overwhelming likelihood of a crash is pilot error. Can you ever fully eliminate that?
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Not without eliminating pilots, and that creates even more substandard outcomes.
 
Autothrust Blue said:
Not without eliminating pilots, and that creates even more substandard outcomes.
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That's my point. At what point have you over-automated, over "safety stuff" to the point where you start to potentially also mitigate the "good" human aspects (Sully, etc)? Can you ever get to that point?
 
WacoFan said:
That's my point. At what point have you over-automated, over "safety stuff" to the point where you start to potentially also mitigate the "good" human aspects (Sully, etc)? Can you ever get to that point?
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I've had conversations with 'bus drivers that go something along the lines of "yeah, they actually want us to hand fly the airplane more often now" - so yes, I'd say it's definitely possible to get to that point.
 
We went from a phase of "heads down in the books and the FMS/let the automation do the work" where the accountants got ahold of the training program (bad), then FOQA data showed a marked spike in certain situations, now we've swung to the "hands on throttle and stick"/FD's off occasionally/know how to hamfist your way through a visual approach.
 
pullup said:
This is where you and I differ. I put on my big boy pants and read your responses, I actually agree with quite a bit of what you say. I hope you report your blood pressure medicine usage.
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If you really 'put your big boy pants on' then how do you think about your idol and his lack of maturity in his posts such we saw in post 1167?
 
I'm not sure why you guys think that just culture is about removing responsibility.

There are a few videos that I found today. If you're interested in understanding what just culture really is as well as what it is not, take a look at www.justculture.org. Under the media link, there are some videos.

We can start a new thread to address "Just Culture" if you like, but I think we should drop it on this thread. Really though, a web board is no place to hash out a completely different point of view. It's just too geared towards short responses and quips, and less toward genuine discussion and arguments.

Autothrust Blue made an excellent post, by the way.
 
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