It isn't the automation, it is the Pilot Monitoring, CRM and Culture

Polar742 said:
Sorry, that's the best I can attempt to convert what's in my melon. It's very conceptual that you're looking for what's the common omission versus hard evidence.
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@MikeD, I think you are looking a little to deep into this. @Polar742 hits the nail on the head here.

The single pilot example doesn't help out at all here. The bottom line is they weren't single pilot, they made a mistake as a crew, and the goal is how do you prevent another crew from making that mistake again.
 
I think this is a great topic of discussion. Most accidents in the past few years haven't been mechanical in nature and all lean towards something human going wrong in the cockpit. I get the cultural view but how do regulators break through those particular barriers to improve how things are being handed in the cockpit? I know they somehow did it with Korean Air but forcing them to keep that hierarchy crap out of the airplane by introducing CRM. It seems it worked, kinda, maybe, who really knows. It just seems like a very tough "habit" to break or curve for that matter. Maybe US pilots are reverting back to those old habits?
 
SeanD said:
Maybe US pilots are reverting back to those old habits?
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If, in point of fact, these incidents can all be traced back to complacency, I don't think there's anything new or old about it, it's just human nature. I think the interesting thing to discuss (which Seggy has been talking about for a long time, to his credit) is how to approach the question systematically. Ie. What level of automation/SOP/hierarchical dependence gives the best result vs. our natural predisposition to get "in the groove" and fail to notice indications that things aren't "just another day at work". I'd make an argument that there's a sweet spot somewhere between "kick the tires and light the fires" and "plug in the computer, read the checklist, and everything will be fine". In any case, it is definitely a great topic for discussion.
 
Boris Badenov said:
If, in point of fact, these incidents can all be traced back to complacency, I don't think there's anything new or old about it, it's just human nature. I think the interesting thing to discuss (which Seggy has been talking about for a long time, to his credit) is how to approach the question systematically. Ie. What level of automation/SOP/hierarchical dependence gives the best result vs. our natural predisposition to get "in the groove" and fail to notice indications that things aren't "just another day at work". I'd make an argument that there's a sweet spot somewhere between "kick the tires and light the fires" and "plug in the computer, read the checklist, and everything will be fine". In any case, it is definitely a great topic for discussion.
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It's not complacency. It's a failure to adopt procedures and policies to adequately managed highly automated airplanes in the environment in which we fly. Most company cultures still seem to based on steam airplanes in a different time.

We've updated the capabilities of the airplanes and airspace but not how we approach flying them. If you uplink your flight plan, punch it all in at the gate and not get a single change that is as easy as flying gets. If you have an automated jet (even old junk like a 747400) you have to tell it where it is. If you have nothing programmed, you really can't do anything with it.

So, if no changes is the easiest, some of the busiest is reprogramming for changes at the end if a flight. It is super easy to fat finger a violation and not notice until it is too late. We take great pains at the gate to ensure everything is correct. We take great care enroute to ensre changes are accurate. In the terminal area, you can be very task saturated switching runways. It is totally manageable, but most guys on here joke about automation. Proper management is a critical part of running these type of airplanes. Your management and CRM skills need to be the equivalent of your flying skills flying old busted 210s and Barons on circling adf approaches to mins.
 
Polar742 said:
Your management and CRM skills need to be the equivalent of your flying skills flying old busted 210s and Barons on circling adf approaches to mins.
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Now why do I feel like that was directed at me, specifically? I thought we were just having a nice discussion about how to make the national airspace system safer.

In any case, taking it that you're jumping off from my post and suggesting that the road to increased safety lies through programming the computer correctly and responding to any idiot lights in the way that produces a banana for the yoke operator, what do you reckon was the programming-failure on the A300 in New York? Or Colgan? Or, I mean, Asiana, right?
 
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Seggy said:
Yes it does matter who is in charge, the company culture, and the CRM/TEM Training.

What happens if the First Officer (who is flying the airplane) as the crew is trying to find an airport at night. The Captain thinks it is 'over there', while the First Officer thinks it is 'no over there'. The Captain then says 'MY AIRPLANE', takes control, and starts heading to his 'over there'. Was the First Officer who was the PF making an error? Or was the Captain who was the PM making an error?

Or better yet. An airplane is landing at LGA. The Captain, who has hardly been to LGA is the PM, doesn't like the way things are looking and says 'my airplane' at 500 feet AGL. What does the First Officer do? What happens if the First Officer is saying 'go around' but the Captain says 'nah, I got this'. Once again, does the role of the PF really matter? Or is it more important to focus on the company culture and proper CRM which teaches the crew to handle these types of situations?
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any 121 people here not have the crm that if either PM or PF says Go Around/Abort ya'll are going around no questions asked/no discussion? any 121 out there with the culture of the 51/49% authority that if the FO says the words you might get the "captain override"?
 
Sol Rosenburg said:
any 121 people here not have the crm that if either PM or PF says Go Around/Abort ya'll are going around no questions asked/no discussion? any 121 out there with the culture of the 51/49% authority that if the FO says the words you might get the "captain override"?
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It's not what is written it even what is practiced. It's what is perceived, rightly or wrongly, by the folks on the line.

Take a moment and think about "probationary" period.
 
Certainly not the culture, but it has happened in my company. Hard windshear warning at around 500ft, PM (FO) calling GO AROUND all the way to touchdown. Skipper said on taxi in something like "see, I told you we'd make it in".

We also have a hard gate at 500ft, and continuing an unstabilised approach past that gate would involve some serious trouble. A go around at the 500ft gate for being unstable requires an ASR (as do all go arounds below 1000' aal) but no comeback whatsoever. We also ban visuals unless briefed and set up beforehand after some issues with some guys (Captains mainly) seeing the runway, disconnecting, and leaving the PM behind.
 
Sol Rosenburg said:
any 121 people here not have the crm that if either PM or PF says Go Around/Abort ya'll are going around no questions asked/no discussion? any 121 out there with the culture of the 51/49% authority that if the FO says the words you might get the "captain override"?
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Yes. It was like that at Colgan prior to our accident.

I am sure there is still some of that lingering at places with a bad culture.
 
Seggy said:
I am sure there is still some of that lingering at places with a bad culture.
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No different from 135, in my experience. I was fortunate enough that it never came up, but I've heard some stories. That said, I always briefed and flown that "if there is a doubt, there is no doubt", and the vast majority of people I've flown with operated the same way. Ohhhhhhhh, no! We went around when we didn't have to! Pfft, if you can't afford the gas for us to go around, you should walk.
 
Seggy said:
@MikeD, I think you are looking a little to deep into this. @Polar742 hits the nail on the head here.

The single pilot example doesn't help out at all here. The bottom line is they weren't single pilot, they made a mistake as a crew, and the goal is how do you prevent another crew from making that mistake again.
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Correct. However lets not miss that a crew or a team is made up of individuals. Understanding how those individuals were or weren't affected by factors that may have only been affecting them at the time (as everyone is different), is key to understanding how/why their individual contributions to the overall cockpit CRM did or did not occur. Each individual brings something to the team and is affected by different things in different ways at different times. Understanding this in the particular incidents that have occurred, will help tie together what the crew did wrong as a team, or why they did what they thought was right.

And too, this is only discussing the crew aspect. The culture problems, I fully agree are an issue. They are their own body to dissect.
 
Dugie8 said:
"Programming" doesn't just mean putting digital 1s and 0s into the box.
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Obviously. It seems equally obvious to me that there are situations which will arise which no amount of "programming" (however you define it) will give a clear, obvious "do A and B results" solution. If there weren't, well, we'd all be out of jobs, wouldn't we?
 
I apologize in advance if this has already been stated. I usually try to read all of the posts before providing my opinion and insight but I'm short on time.

As was stated by several in the beginning of the thread, I don't think we need to change regulation on visual approaches. Why? Because it's already there, though rather hidden in the FARs if you ask me.

§91.129
subpart (e) for large or turbine aircraft.

I'll use my paraphrase because I think it gets the point across more than the legalese of the FARs.

It states if you have an approach with vertical guidance, even on a visual approach, you must remain on or above glide path between the FAF and DA. So to me this is stating you really need to have the approach in there and using it. Otherwise how can you guarantee you are above the glide path? You could do the math using DME I suppose, or the PAPI/ VASI but that could lead you wrong for confirming the airport.

In this case, if they had done the math from the GPS or whatever else, they would have realized something was off. If they had briefed the ILS and didn't even tune it in they would have realized they were staring at a VASI when they wanted a PAPI. And finally, if they had actually used the approach as I interpret the FAR, none of this would've happened.

But hey, I'm on the ground, not moving at 250KTS, and I've had a lot of time to think about this, even look up FARs. Mistakes do happen. They will continue to happen. There's gotta be at least one more with the rule of three. I'm glad this one was uneventful and I hope any to come are the same.

EDIT: I do notice they only have an RNAV on 14 so that does nix the precision glidepath. I'm sure the plane is equipped with some sort of RNAV, but if not It would definitely make it harder to brief an approach for backup.
 
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MikeD said:
Correct. However lets not miss that a crew or a team is made up of individuals. Understanding how those individuals were or weren't affected by factors that may have only been affecting them at the time (as everyone is different), is key to understanding how/why their individual contributions to the overall cockpit CRM did or did not occur. Each individual brings something to the team and is affected by different things in different ways at different times. Understanding this in the particular incidents that have occurred, will help tie together what the crew did wrong as a team, or why they did what they thought was right.

And too, this is only discussing the crew aspect. The culture problems, I fully agree are an issue. They are their own body to dissect.
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The 'however' is largely a moot point with places with a good culture you want to work for.

Interestingly enough, most 'good' airlines to get on today screen their applicants with a psychological screening test to see if the individual applicants fall into a 'grouping' of personality traits that shows they can play nice in the sandbox. That 'grouping' is further verified by the performance based interview that the applicant will go through. Then there will be a CRM scenario with the interview that triple checks the psychological screening test and the performance based interview to once again shows the applicant falls into that 'grouping'.

After all of that the applicant will be followed their probationary year to see if the interview checks were correct to finally verify they fall into that 'grouping'. Do outliers exist? Absolutely. But the focus is put on the individual before they can even get into the cockpit. That focus is there to make sure they play well in the CRM environment.

Two guys I know at Colgan who didn't play well in the sandbox were denied by some of these 'good' airlines recently. One didn't make it past the psychological screening, the other one didn't pass the interview/crm exercise. I don't think that is a coincidence.
 
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I have flown with a 9E CA who, when I debriefed "we probably should have gone around" told me he would not have if I had called the go around.
 
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