Landing Incident @ SFO

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seagull said:
Remember that old "definition of insanity", trying to do the same thing over and over and expecting different results?
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I respect your expeirence, but from my perspective, it seems like instituting yet another "train to proficency" program is the repetition of past behavior. It seems incredibly unlikely to me that it's impossible to recruit pilots who simply don't "woopsie" and forget the freaking power levers, whatever their training, whatever their recent experience. I do not accept that we're all so stupid that we forget that the wing doesn't work if it's not going fast enough. I mean, honestly...how does that happen to someone who's "basically a good pilot"? What does "basically a good pilot" even MEAN if we're willing to assign the sobriquet to someone who allows the plane to stop flying because, uh, I dunno, "woopsie"? I submit to you that the truth is that no one reading this thread really thinks that this could happen to them. And I hope rightfully so.
 
Boris Badenov said:
Plane crashes? My fault, until proven otherwise. I accept that, as did generations of aviators before me. Why is this suddenly declasse? Because I assure you, we're not helping ourselves by pointing in every imaginable direction when bad things happen. Quite the opposite.
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That's why I read NTSB accident reports backwards. When I know the conclusion, I can ignore the part of the narrative that describes what the pilot had for breakfast.
 
The old insanity is the new sanity.

I'll stick to being a stubborn old bastard and skip the new age reading list. I'll only let my children participate in sports that keep score and I'll not make excuses when I make mistakes or act stupid.

Sent from my DROID RAZR using Tapatalk 2
 
Boris Badenov said:
I respect your expeirence, but from my perspective, it seems like instituting yet another "train to proficency" program is the repetition of past behavior. It seems incredibly unlikely to me that it's impossible to recruit pilots who simply don't "woopsie" and forget the freaking power levers, whatever their training, whatever their recent experience. I do not accept that we're all so stupid that we forget that the wing doesn't work if it's not going fast enough. I mean, honestly...how does that happen to someone who's "basically a good pilot"? What does "basically a good pilot" even MEAN if we're willing to assign the sobriquet to someone who allows the plane to stop flying because, uh, I dunno, "woopsie"? I submit to you that the truth is that no one reading this thread really thinks that this could happen to them. And I hope rightfully so.
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Let's take this in another direction, then: How would you handle a pilot who, as with my example, drags the tailskid on landing on a calm, clear, VMC day (and no, I've never done it!)?

Thought experiment! :)
 
Pilot Fighter said:
That's why I read NTSB accident reports backwards. When I know the conclusion, I can ignore the part of the narrative that describes what the pilot had for breakfast.
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They've made it easier for you, there's usually an executive summary and probable cause statement in the first few pages. Just read that and skip the tens or hundreds of pages of analysis. ;)
 
dasleben said:
Let's take this in another direction, then: How would you handle a pilot who, as with my example, drags the tailskid on landing on a calm, clear, VMC day (and no, I've never done it!)?

Thought experiment! :)
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"So what happened, dude? (And don't lie to me, otherwise, you're definitely out on your ass.)"
 
Boris Badenov said:
I respect your expeirence, but from my perspective, it seems like instituting yet another "train to proficency" program is the repetition of past behavior. It seems incredibly unlikely to me that it's impossible to recruit pilots who simply don't "woopsie" and forget the freaking power levers, whatever their training, whatever their recent experience. I do not accept that we're all so stupid that we forget that the wing doesn't work if it's not going fast enough. I mean, honestly...how does that happen to someone who's "basically a good pilot"? What does "basically a good pilot" even MEAN if we're willing to assign the sobriquet to someone who allows the plane to stop flying because, uh, I dunno, "woopsie"? I submit to you that the truth is that no one reading this thread really thinks that this could happen to them. And I hope rightfully so.
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This has nothing to do with abdicating responsibility, in fact, it is the opposite, as those that design the system also are responsible. The point of accident/incident investigation is to prevent future accidents. Just hammering someone for missing something that we set them up to miss is, in and of itself, abdicating responsibility for those in the command chain. As the front-line sharp-end operator, we need to do everything we can to operate safely, but we still depend on others to ensure that our aircraft was designed in an airworthy way, that they designed the procedures we use in a way that won't create an accident, etc.

If you hit some trees on a low visibility approach at night that were not included in the survey of the approach procedure design, are you still responsible?
 
seagull said:
I think the problem is that I am looking to prevent future accidents/events, rather than worry so much about who goes to jail for the previous ones. If putting people in jail does NOTHING to stop a future accident and actually creates an environment where those that were in control of the policies that set up an environment making that error more likely, get off with NO penalties, then why would you do it?

Remember that old "definition of insanity", trying to do the same thing over and over and expecting different results?
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THIS.

The problem, or misunderstanding here, seems to be that Just Culture isn't so much a look back after an accident as if it's some sort of get out of jail free card. It's more a look forward to gather data (through the ASAP reports, for example) and find trends in order to prevent an accident.

We're all sitting here looking back at this accident, so it's not like a Just Culture safety mindset says, "It was the system's fault, we should have known those poor guys couldn't fly a visual (if that's what it turns out to be)." In fact, I don't really see where a Just Culture has much to do at all with accident investigation.

The "Get out of jail free card," so to speak, is when you observe something or do something that did NOT result in an accident and you report it to your Manager of Safety so that the Safety Committee can gather evidence and look at the aggregate of reports coming in and notice trends. So when someone reports that they flew an approach but after landing and thinking through it, they felt pretty behind the airplane, and come to think of it, we probably should have gone around because in reality it was unstabilized. If the Safety Committee gets a bunch of reports like this and notices a trend, they might say, "You know what? Our long haul pilots seem to have trouble with visual approaches. We need to address this." This is all hypothetical of course.

A Just Culture addresses this (in an ideal world) before the accident happens. An Unjust Culture (or whatever you call the antithesis) finds this trend out after 300 people are dead, after lots of digging and interviews, and it turns out that there was no reporting going on because everyone was scared they'd get in trouble if they reported they screwed something up in the slightest.

Please don't get the idea that a Just Culture absolves individuals of responsibility after an accident. Heck, at my organization, which thrives on this model of safety, we've fired more than one pilot that I know of after an accident (or else removed them from the flight line).
 
RedBaron2000 said:
THIS.

The problem, or misunderstanding here, seems to be that Just Culture isn't so much a look back after an accident as if it's some sort of get out of jail free card. It's more a look forward to gather data (through the ASAP reports, for example) and find trends in order to prevent an accident.

We're all sitting here looking back at this accident, so it's not like a Just Culture safety mindset says, "It was the system's fault, we should have known those poor guys couldn't fly a visual (if that's what it turns out to be)." In fact, I don't really see where a Just Culture has much to do at all with accident investigation.
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There is something gravely wrong with the training, qualification and proficiency systems if that's how this shakes out.
 
Seggy said:
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?
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Um, firstly how does his actions have anything to do with me? Secondly, that was funny. Why are you afraid to laugh?
 
Boris Badenov

Let me give you a real-life example (this actually happened).

At an unnamed airline (not my current one), there was once a crew who accidentally used paperwork that was 40,000 lbs in error. The paperwork showed them with a takeoff weight of 210,000#, when in fact they were at 250,000#. While enroute on a 6 hour leg, they were finding their fuel scores were consistently getting worse, over-burning to the point that they were concerned about having enough fuel to make it to the destination (not to mention the alternate). The PIC made the correct decision to divert the aircraft to uplift more fuel; the airplane took a 2-3 hour delay, but they safely made it to the destination.

The aftermath was that the Captain was fired, and both FOs were put back on probation. Yes, the person responsible made a mistake, and he paid for it with his job. In your eyes, that's justice served, right?

Actually, no. The firing of that Captain was about the worst thing anyone could have ever done. With that, the company sent a clear message to the pilot group that any mistakes would be met with termination. The next time a jet took off overweight, nobody would say anything. The paperwork would be "fixed," so that any audit would keep the pilots out of trouble. Entire stacks of paperwork disappeared. People would push bad fuel situations even further, knowing what might happen to their careers if they were terminated. Thankfully, the latter never ended in tragedy.

This is an example of an Unjust Culture. This was not a made up situation. Firing the Captain without fixing the problem only created a more hazardous environment, which is why this industry is trending toward Just Culture in terms of safety. seagull said it better than I: It's not about punishment, it's about preventing future accidents.
 
dasleben said:
Boris Badenov

Let me give you a real-life example (this actually happened).

At an unnamed airline (not my current one), there was once a crew who accidentally used paperwork that was 40,000 lbs in error. The paperwork showed them with a takeoff weight of 210,000#, when in fact they were at 250,000#. While enroute on a 6 hour leg, they were finding their fuel scores were consistently getting worse, over-burning to the point that they were concerned about having enough fuel to make it to the destination (not to mention the alternate). The PIC made the correct decision to divert the aircraft to uplift more fuel; the airplane took a 2-3 hour delay, but they safely made it to the destination.

The aftermath was that the Captain was fired, and both FOs were put back on probation. Yes, the person responsible made a mistake, and he paid for it with his job. In your eyes, that's justice served, right?

Actually, no. The firing of that Captain was about the worst thing anyone could have ever done. With that, the company sent a clear message to the pilot group that any mistakes would be met with termination. The next time a jet took off overweight, nobody would say anything. The paperwork would be "fixed," so that any audit would keep the pilots out of trouble. Entire stacks of paperwork disappeared. People would push bad fuel situations even further, knowing what might happen to their careers if they were terminated. Thankfully, the latter never ended in tragedy.

This is an example of an Unjust Culture. This was not a made up situation. Firing the Captain without fixing the problem only created a more hazardous environment, which is why this industry is trending toward Just Culture in terms of safety. seagull said it better than I: It's not about punishment, it's about preventing future accidents.
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Great example. And this is how it's often done in many parts of Asia. Stuff gets pencil whipped all the time, flying gets pushed for fear of being penalized.

The bottom line is this: Do you want to work at a place that encourages reporting of safety related issues, or do you want to work at a place where people cover up their errors for fear of getting fired? Which is the safer place?
 
pullup said:
Um, firstly how does his actions have anything to do with me? Secondly, that was funny. Why are you afraid to laugh?
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Telling someone to 'stroke out' isn't funny.
 
Seggy said:
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?
Click to expand...

WacoFan said:
And you're always (or even frequently) the very picture of maturity?
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pullup said:
Um, firstly how does his actions have anything to do with me? Secondly, that was funny. Why are you afraid to laugh?
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You know... Nobody really gives a flying fornication about ya'lls little pissing match right now.

Adults are trying to have a conversation... mmmkaay?
 
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