Pilots Engaged in Small Talk Before Botched Jet Takeoff

[KLB]

Doug lobs a grenade!

You forgot the "So I'll be back in four minutes!"

 

[ctab5060X]

I'd take a Huge piece of paper and write what I needed to do on it. Clip it on the yoke clip so I'd always be bumping it. Never forgot.

I fold my copy of the release and use it to write stuff on.

I am one of those guys that will write down alomst everything... ATIS, clearance (even if both are in gotten via ACARS), weight and balance and performance information (pax count, cargo, ZFW, TOGW, XTOG, stab trim, % MAC, flex temperature). If the takeoff briefing is anything but "normal" for 9E, I write down the abnormalites so I don't forget (it can be a long time from the brief on the before start to actually configuring everything on the before takeoff). I will also write down complex taxi instructions, inflight re-routes, anything I feel that needs to be remembered or referenced later.

 

[E_Dawg]

But in the CVR, the crew notes the flap setting. Which is used most often? 20? And out of CRW, would there be that much difference is performance between 8 and 20? Now we seem to be getting into more than just 'sterile cockpit'.

FWIW, I think the sterile cockpit rule is good but used too often as some trump card. The lesson I see is the small item of a delay throws the crew off its normal pacing. And it is a good idea to run the checklist two or three times when a less than normal progression occurs.

Yes there is a large difference in performance between 8 and 20. And to clear it up there would be no takeoff config warning with EITHER flaps 8 or 20... but when the flaps are in transit (apparently) you would get the takeoff warning.
The -200 eats up significantly more runway at flaps 8 than 20 and CRW is one of 'those' airports where there's not much wiggle room.

 

[Cptnchia]

I like our taxi check. It has two things on it, FLAPS and FLT CONTROLS. Simple and easy. Set flaps prior to taxi. Check flaps setting comparing handle position with annunciated flap position and verbalize. Check flap setting again on Before Takeoff with comparing and verbalizing.

You have got to have to totally piss poor pilots to dork up following this procedure.

 

[E_Dawg]

I am really curious to know what the general policy is over at PSA regarding rejected takeoffs for incorrectly set items. Is it a discipline-triggering event?

Word was the feds were looking at RTOs pretty closely a few years back, and some airlines were more scrutinized than others.

 

[derg]

I like our taxi check. It has two things on it, FLAPS and FLT CONTROLS. Simple and easy. Set flaps prior to taxi. Check flaps setting comparing handle position with annunciated flap position and verbalize. Check flap setting again on Before Takeoff with comparing and verbalizing.

You have got to have to totally piss poor pilots to dork up following this procedure.

Me too.

But we're also the (un)lucky combination of two carriers that learned the hard way about configuration confirmation.

 

[Cptnchia]

But we're also the (un)lucky combination of two carriers that learned the hard way about configuration confirmation.

That is the truth! As far being (un)lucky, RUMOR has it SEA ER on May AE, with whispered talking about how GUM 73N is a nogo, but HNL ER is the back up plan??????

 

[derg]

Nooooo idea.

It's been "rumor central" around Southernjets so it must mean that they're looking for something out of Moak so he can "solve it".

 

[SlumTodd_Millionaire]

And old trusty method of remembering a non-standard flap setting is throwing a empty cup over the flap handle. Works great!

That seems to be a common trick from Deltoids. All of our retired DAL guys seem to do it. I'd never heard of it before, but it works.

Here is my question to those with more experience than me, at what point do you go well maybe they don't deserve just a training event and send them on their way? When does a blatant lack of judgement justify one losing their job? Ever?

In my opinion, that point comes when someone's actions indicate an intentional disregard for SOP, FARs, generally recognized safety procedures, etc. If someone cannot be "scared straight" or trained to correct whatever the deficiency is, then it's time for them to go. These cases are rare.

PIn this case the answer would be, "they'll be quiet during sterile cockpit and pay attention to their job". Really? You can not train that behavior. They were fully aware of the requirement to conduct sterile cockpit. They were likely very aware of the requirements to be properly configured for takeoff. They were capable of doing those things. The standard was clear. They lacked the motivation to do it right every single time. Training can't fix that unfortunately.

I completely disagree. Would training have fixed it in this captain a year ago? Probably not. But will it fix the problem now? I think it's almost a certainty. He's now experienced something that will change his entire outlook on sterile cockpit. I'm sure for the rest of his career, he'll be running through the abort procedure in his head prior to every takeoff. I would wager that this captain would be one of the safest at the airline, in fact.

It's very similar to what you see in the HIMS program. Pilots that have gone through HIMS and have returned to flying are usually the most professional pilots and the best employees. Why? Because they have gone through complete hell and turned things around, and they want to make sure that the rest of their career (and life) is smooth as silk.

I personally would have no problem getting on this crew's airplane in the future. Probably be one of the safest rides in the sky.

 

[mikecweb]

In my opinion, that point comes when someone's actions indicate an intentional disregard for SOP, FARs, generally recognized safety procedures, etc. If someone cannot be "scared straight" or trained to correct whatever the deficiency is, then it's time for them to go. These cases are rare.



I completely disagree. Would training have fixed it in this captain a year ago? Probably not. But will it fix the problem now? I think it's almost a certainty. He's now experienced something that will change his entire outlook on sterile cockpit. I'm sure for the rest of his career, he'll be running through the abort procedure in his head prior to every takeoff. I would wager that this captain would be one of the safest at the airline, in fact.

It's very similar to what you see in the HIMS program. Pilots that have gone through HIMS and have returned to flying are usually the most professional pilots and the best employees. Why? Because they have gone through complete hell and turned things around, and they want to make sure that the rest of their career (and life) is smooth as silk.

I personally would have no problem getting on this crew's airplane in the future. Probably be one of the safest rides in the sky.

You raise some interesting and valid points. What is this HIMS program you speak of, I've never heard of it.

 

[Polar742]

You raise some interesting and valid points. What is this HIMS program you speak of, I've never heard of it.

http://www.himsprogram.com/HIMS_about.html

It is an excellent program. I have flown with some people that have completed it, and they are exceptional and professional aviators. They are also very grateful to have the opportunity to be back in the cockpit.

 

[mikecweb]

http://www.himsprogram.com/HIMS_about.html

It is an excellent program. I have flown with some people that have completed it, and they are exceptional and professional aviators. They are also very grateful to have the opportunity to be back in the cockpit.

Ahhh I see. Well I hope I never have to go through the program but I can see how those that have completed it would be changed people and aviators.

 

[aloft]

True, but I also think stopping and taxiing clear BEFORE fixing the flap setting woulda been the best option. Then you avoid both A and B above. From the transcript, it looks like they tried to "fix" the issue on the roll.

From my read, that's exactly what happened.

 

[derg]

http://www.himsprogram.com/HIMS_about.html

It is an excellent program. I have flown with some people that have completed it, and they are exceptional and professional aviators. They are also very grateful to have the opportunity to be back in the cockpit.

I've got some friends that went through the program as well. Very helpful it seems!

 

[gtpilot]

I see stuff that could happen to anyone. ONE mistake happened. Someone called for FLAPS 20 and FLAPS 8 were set. No one caught that ONE mistake. If someone had, it would have been one of those quick fixes that could have turned this into an "almost".

What hazards were presented?

1) An interruption of normal flight "flows".

2) Fatigue.

3) Lack of transition from being "parked" back to "flying" mode.

4) Delay

In the not so distant past, I have intimate knowledge of a crew that made this same error in a very similar situation - two real differences -a lack of chatter on the taxi after the delay and the speeds were set for flaps 20 but the flaps remained at 8. Some points of interest from that experience - the CRJ200 will rotate and climb out just fine 10kts early (I'm guessing gust protection would be a problem). If your four day duty schedule is progressively changed, this could be your first flight and you could still be fatigued. Read ASAP reports - as dull as some of them can be, you might not learn about situations like this before they happen to you!

I completely disagree. Would training have fixed it in this captain a year ago? Probably not. But will it fix the problem now? I think it's almost a certainty. He's now experienced something that will change his entire outlook on sterile cockpit. I'm sure for the rest of his career, he'll be running through the abort procedure in his head prior to every takeoff. I would wager that this captain would be one of the safest at the airline, in fact.

Because of personal experience, I am extremely vigilant about flap settings now. While I have concerns about the captain's post accident reactions, I have no doubt he will be a more vigilant pilot as well!!

 

[jtrain609]

There would still be an induced error. You mean to put in flaps 18, you type in 9. You set 18. Still bad juju.

Config warning is a gross-error check...will it fly? Yes...eventually

Attention to detail by both pilots using procedures and managing workloads is a fine check.

Lots of levels of safety.

I'll say it again, not recognizing the hazards, and not recognizing that there were mitigating factors that lower your point of task oversaturation without realizing it.

Again, that's my opinion from reading the transcript.

I've gotta disagree with you, Martin, and I'll cite a few reasons why.

The extension of your line of thinking is that configuration checks are things that are so wrong and so obvious that you should always catch them, and if you don't then you've got other, bigger problems to deal with.

I disagree.

http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR88-05.pdf

It's this crash that created the takeoff config warning on the EMB-145. I know some folks, some folks that actually post on here, that have had that button save their bacon when they got distracted, thought they had completed some items, but in the end did not. They screwed up the checklist, then they screwed up looking at the EICAS, then they screwed up a few other things, but when they hit that button they realized, "Oh crap, we screwed up," slowed things down, and fixed the problems.

So can technology save you? No, not all the time. Can technology, and we're talking about VERY simple technology here, provide an extra layer of safety you have to get through in order to bend metal? Absolutely.

And that's all I'm saying, is that with another, very, very, very simple layer of safety, this incident is avoided.

EDIT: Same thing, same plane, different country.

http://en.wikipedia.org/wiki/Spanair_Flight_5022

 

[Baronman]

I like our taxi check. It has two things on it, FLAPS and FLT CONTROLS. Simple and easy. Set flaps prior to taxi. Check flaps setting comparing handle position with annunciated flap position and verbalize. Check flap setting again on Before Takeoff with comparing and verbalizing.

You have got to have to totally piss poor pilots to dork up following this procedure.

I think CAL's is even simpler. Their flaps and flight controls are checked before the a/c even moves. Seems like a good time.

 

[spbrian]

In my non-airline background look at this there was a large chain of errors that led to this event, but the one that I feel was the most blatant was when the Captain noticed on the roll above 80 knots but below V1 to move the flap selector to fix his mistake.

Shouldn't that count as a reason to abort, noticing an improper takeoff setting. Of course natural human nature would be to fix the problem but it should be to abort, fix it under controlled conditions and then try again.

 

[jtrain609]

In my non-airline background look at this there was a large chain of errors that led to this event, but the one that I feel was the most blatant was when the Captain noticed on the roll above 80 knots but below V1 to move the flap selector to fix his mistake.

Shouldn't that count as a reason to abort, noticing an improper takeoff setting. Of course natural human nature would be to fix the problem but it should be to abort, fix it under controlled conditions and then try again.

He could have done it for any number of reasons. Mindless mistake. Fatigue. Mindless mistake caused by fatigue. Thinking he could cover his mistake. Thinking he could *fix* his mistake. Etc. etc.

 

[spbrian]

He could have done it for any number of reasons. Mindless mistake. Fatigue. Mindless mistake caused by fatigue. Thinking he could cover his mistake. Thinking he could *fix* his mistake. Etc. etc.

While true, what reaction should be trained for this situation where you would notice it going through 80 knots? I but for the grace of stubbing my toe and crying out would hope to abort.