Discussion
Good morning,
Having just watched the latest Blancolirio update relating to the Vietnam Airlines 787 late take off / tail strike. He too is speculating that perhaps one of the pilots stood on the brakes at the last minuet.
https://m.youtube.com/watch?v=PMa4wmyV7Cs&pp=u...
This got me thinking, and it s an entirely different subject, aimed mainly at the pilots on here. And this does not imply that it is yet known if there was CRM issue in this case.
To what extent, during a commercial pilots career are mistakes etc acceptable? As in, what is considered enough to end a career?
I know this is not an easy question to answer, and is very much subjective due to the size of the mistake, impact, and I guess the employer. I just wondered how it is evaluated (by whom) and how long kept on record - so to speak.
Having just watched the latest Blancolirio update relating to the Vietnam Airlines 787 late take off / tail strike. He too is speculating that perhaps one of the pilots stood on the brakes at the last minuet.
https://m.youtube.com/watch?v=PMa4wmyV7Cs&pp=u...
This got me thinking, and it s an entirely different subject, aimed mainly at the pilots on here. And this does not imply that it is yet known if there was CRM issue in this case.
To what extent, during a commercial pilots career are mistakes etc acceptable? As in, what is considered enough to end a career?
I know this is not an easy question to answer, and is very much subjective due to the size of the mistake, impact, and I guess the employer. I just wondered how it is evaluated (by whom) and how long kept on record - so to speak.
Edited by Jim H on Sunday 23 August 12:14
From what I have seen it appears as though EASA and the Europeans have a more “let’s all learn from that” approach. The Swiss do love issuing a fine, though.
Other authorities, FAA being one of them, seem keen on pursuing and punishing the individual. Certain countries and airports can ban pilots after a number of violations.
A colleague of mine had a fairly serious incident that was blamed on pilot error and, while it involved lots of chats with the authorities, he kept his job and position. We all got further specific training in the sim. In the US or Asia I don’t think that would’ve been the case.
Other authorities, FAA being one of them, seem keen on pursuing and punishing the individual. Certain countries and airports can ban pilots after a number of violations.
A colleague of mine had a fairly serious incident that was blamed on pilot error and, while it involved lots of chats with the authorities, he kept his job and position. We all got further specific training in the sim. In the US or Asia I don’t think that would’ve been the case.
Hi Jim,
You have already identified the key, subjective. It is very much how long is the string.
Generally, if it's something down to shear negligence and deemed serious enough by regulators and management, then I'd expect the boot.
However, as already identified, Culture, factors (lots), circumstances, there are so many, will dictate.
To give an Idea, In my company two examples.
One was pretty serious, but there were mitigating circumstances and with a fair attitude and retraining, the crew concerned kept their jobs.
Second was a new captain who had extensive experience else where, who when released on the line decided his rule book superseded the companies. He didn't last very long with us. Yet he had no great direct incident that presented immediate danger.
We are all human, ergo we will make mistakes, computers will crash and mechanicals will break. What happens after that, well.....
You have already identified the key, subjective. It is very much how long is the string.
Generally, if it's something down to shear negligence and deemed serious enough by regulators and management, then I'd expect the boot.
However, as already identified, Culture, factors (lots), circumstances, there are so many, will dictate.
To give an Idea, In my company two examples.
One was pretty serious, but there were mitigating circumstances and with a fair attitude and retraining, the crew concerned kept their jobs.
Second was a new captain who had extensive experience else where, who when released on the line decided his rule book superseded the companies. He didn't last very long with us. Yet he had no great direct incident that presented immediate danger.
We are all human, ergo we will make mistakes, computers will crash and mechanicals will break. What happens after that, well.....
I don't know about commercial pilots, but in WW2 a Spitfire pilot who was lost and without radio landed at a base where my father was stationed. The pilot stopped near the tower and got out to seek help. Unfortunately, he left the engine running and a Merlin, even at idle, produces a few h.p. With no chocks to hold it back it trundled into a hangar and caused a fair bit of damage. The pilot was grounded for life.
(I appreciate that this is hearsay)
(I appreciate that this is hearsay)
Aviation people draw a big distinction between 'pilot error' on the one hand and carelessness/recklessness on the other. Diagnosing an issue as pilot error can be a precursor to saying 'perhaps having the undercarriage lever and the flap lever side by side and looking the same might not be a good idea'.
Austin Prefect said:
Aviation people draw a big distinction between 'pilot error' on the one hand and carelessness/recklessness on the other. Diagnosing an issue as pilot error can be a precursor to saying 'perhaps having the undercarriage lever and the flap lever side by side and looking the same might not be a good idea'.
For instance, the VARIG 737 that ditched in the rainforest because it flew in the direction, got lost and ran out of fuel.The pilots had their licenses revoked and served prison times for manslaughter of the passengers who died.
The proximal cause of the error was that the airline's flight plans changed format (while the Captain was on leave) so that headings were suffixed by a zero to represent fractions of a degree (for more modern aircraft with RNAV systems, which the incident aircraft didn't have) but without a decimal point - their planned heading of 27 degrees was printed 0270, which led the Captain to set his instruments to 270 degrees.
That is a 'pilot error' or 'human factors' failing. In a study by the IFALPA a significant majority of pilots shown the same flight plan made the same error of interpretation.
But the mistake was compounded by such a basic and ongoing failures of airmanship, professionalism and effective thinking that the revocation of licenses and criminal sentences were handed down. There was no thought that their destination [i]didn't] lie due west of their starting point (it was more than 90 degrees off). The first officer didn't independently check and set his instruments (he just copied the Captain's settings) and the pilots didn't meaningfully discuss the flight plan and the instrument settings. They didn't think it was odd that they were flying towards the setting sun when they should have been flying north. They didn't think it was odd that they first couldn't reach the ATC at their destination, and then could only do so by establishing a radio relay with another VARIG aircraft.
And so on.
By contrast, the crew of the Gimli Glider - who did, at the sharp point of the incident, use the wrong conversion formula and got their pounds and kilos mixed up and so departed with far less fuel than they thought they had and required - retained their licenses and maintained their careers (after initially being suspended/demoted during the investigation, IIRC). The 'swiss cheese model' of that incident - the many other errors made/factors introduced by other individuals and systemic issues - plus their superb handling of the emergency once it developed - meant a very different outcome.
2xChevrons said:
The proximal cause of the error was that the airline's flight plans changed format (while the Captain was on leave) so that headings were suffixed by a zero to represent fractions of a degree (for more modern aircraft with RNAV systems, which the incident aircraft didn't have) but without a decimal point - their planned heading of 27 degrees was printed 0270, which led the Captain to set his instruments to 270 degrees.
That is a 'pilot error' or 'human factors' failing.
I'd call that a failing on the part of the person who took the decimal point out.That is a 'pilot error' or 'human factors' failing.
Simpo Two said:
2xChevrons said:
The proximal cause of the error was that the airline's flight plans changed format (while the Captain was on leave) so that headings were suffixed by a zero to represent fractions of a degree (for more modern aircraft with RNAV systems, which the incident aircraft didn't have) but without a decimal point - their planned heading of 27 degrees was printed 0270, which led the Captain to set his instruments to 270 degrees.
That is a 'pilot error' or 'human factors' failing.
I'd call that a failing on the part of the person who took the decimal point out.That is a 'pilot error' or 'human factors' failing.
Simpo Two said:
I'd call that a failing on the part of the person who took the decimal point out.
That's my point. The Gimli Glider crew were failed in a similar fashion by their 'office' ops and maintenance colleagues - their 767 was in service with non-operational fuel gauges due to a shortfall in maintenance/service capacity at Air Canada and there was a breakdown in communications and procedures as to what exactly the fault with the aircraft was and under what conditions and contingencies it was being dispatched (legally the aircraft shouldn't have been flying in the state it was handed over to the incident crew...but it was in that state by accident and could have been put back into a legal state very easily). Ground crews hadn't been officially trained to convert fuel volume into weight, nor that the 767 worked in metric rather than Imperial. And there was ambiguity in Air Canada manuals about who, in the absence of a flight engineer, had the responsibility for checking and converting fuel quantities - the flight crew or the ground crew.
They were 'set up to fail' just as the VARIG crew were and the 'sharp end' of both incidents was one human error that is very understandable in the circumstances and wouldn't have happened without the trail of contributing factors and errors leading up to it.
But while the Gimli crew handled their situation with superlative professionalism and excellent airmanship, the VARIG crew not only displayed appalling non-adherence to procedures and CRM principles but complete bone-headedness and bad decision making throughout.
A human error made as a result of systemic issues and with the results handled competently and without significant (or any) injuries or casualities is one thing. If the results of the error are compounded by amateurish incompetence and lead to loss of life, then that's a very different matter when it comes to deciding penalties.
2xChevrons said:
They were 'set up to fail' just as the VARIG crew were and the 'sharp end' of both incidents was one human error that is very understandable in the circumstances and wouldn't have happened without the trail of contributing factors and errors leading up to it.
Yes, and if I was the judge I'd have exonerated the pilot/s. See 270, steer 270.If anyone goes to jail it should the software guy.
Simpo Two said:
Yes, and if I was the judge I'd have exonerated the pilot/s. See 270, steer 270.
If anyone goes to jail it should the software guy.
It's not the initial error that they were tried and punished for. It was their joint inability to realise and respond to the error, and the long sequence of nonsensical and incompetent decisions that they did make, right down to a forced landing which was entirely counter to training and best practice (they stayed high until the engines ran out of fuel then glided to a forced landing rather than making a shallower, lower-rate landing under power and control), made several major errors in handling and systems management in the lead-up to the landing and more. The official investigation concluded that the low injury rate in the crash landing was despite their actions, not because of them. If anyone goes to jail it should the software guy.
The incomparable Admiral Cloudberg sums up the incident thus:
Admiral Cloudberg said:
Trying to determine what lessons to draw from this utterly bizarre tale may be an exercise in futility. It certainly goes without saying that every pilot ought to know where their destination is located and how to interpret a compass heading. Zille has gone to great lengths to show how easy it was to confuse “0270” for 270 degrees, and certainly no one denies that the printout was highly misleading, but neither he nor anyone else can explain why this interpretation wasn’t immediately discarded as nonsensical. How can you fly west from Marabá to Belém? Any pilot responsible for that route should know that you can’t. Had no lives been lost, the story would have been rather amusing, but instead twelve people died because of an ignorance so fundamental that it defies rational explanation. This conundrum remains the greatest unanswered question about flight 254, and it will probably never be answered, except by resigning ourselves to the conclusion that Garcez and Zille were both so spatially impaired that they entered a ridiculous course, and, trapped by their own unresponsiveness to critical self-examination, blithely followed it to their common doom.
It's absolutely a good thing that the days of pilots being harried during investigations or when pilot error was deemed an adequate conclusion to an investigation (never mind the surrounding factors) are largely gone. In the old days a pilot who accidentally shut off fuel to an engine when meaning to lower the flaps when handling a pedestal full of identically-shaped and -sized levers in a dark cockpit at night would have taken the blame for not being a flawless godlike aviator and that would have been that. It's good that aviation, and many other safety-critical industries, take more holistic and less punitive stances.For instance, I think it was absolutely justified that the captain of the British Midland flight that crashed (with 47 causalities) at Kegworth won his retrospective case for unfair dismissal. He made many errors which compounded into the Big Error of shutting down the good engine and leaving only the one that was slowly disintegrating. But those errors were due to inadequate training and design flaws with the aircraft. The engine failure that kick started the incident was due to shortfalls in manufacturing and certification.
But there has to be a limit, and something like VARIG 254 just shows rank incompetency and unprofessionalism, which was exposed by the situation caused by the human error.
The Gimli Glider crew rose to their situation like true pros. The VARIG guys simply did not.
Good evening, sincerely.
Many thanks for all replies. I forgot to mention in my first post - yes we are all human. And therefore fallible.
I work in a heavily regulated industry where mistakes and human factors are analysed - constantly.
It’s been interesting reading, thank you all very much.
Many thanks for all replies. I forgot to mention in my first post - yes we are all human. And therefore fallible.
I work in a heavily regulated industry where mistakes and human factors are analysed - constantly.
It’s been interesting reading, thank you all very much.
One of the worst examples of being let down by their employer was the BA 777 crash at LHR.
The crew were paraded in front of the press only the day after the accident, where the Captain made a short speech praising the crew and passengers, and also mentioned that the First Officer was the pilot flying the aircraft at the time of the incident.
As a result, the papers latched on to this (completely normal procedure) and made it out that the Captain had 'frozen at the controls' and the First Officer took over and saved all the lives.
Worse still, when the Captain returned to flying, cabin crew were being told in their annual training about this (taken from the newspapers) and in some cases, were refusing to fly with the Captain. He then went to the company and asked them to put it out there internally, about how the First Officer was the pilot flying, and that it's a completely normal way of operating, but they refused to do it.
Goes to show, what a thin line pilots walk - one day you're being paraded as a hero, next day, vilified in the press and by your own colleagues for something that isn't even remotely true.
The crew were paraded in front of the press only the day after the accident, where the Captain made a short speech praising the crew and passengers, and also mentioned that the First Officer was the pilot flying the aircraft at the time of the incident.
As a result, the papers latched on to this (completely normal procedure) and made it out that the Captain had 'frozen at the controls' and the First Officer took over and saved all the lives.
Worse still, when the Captain returned to flying, cabin crew were being told in their annual training about this (taken from the newspapers) and in some cases, were refusing to fly with the Captain. He then went to the company and asked them to put it out there internally, about how the First Officer was the pilot flying, and that it's a completely normal way of operating, but they refused to do it.
Goes to show, what a thin line pilots walk - one day you're being paraded as a hero, next day, vilified in the press and by your own colleagues for something that isn't even remotely true.
Hi Jim
As you appear to interested in the subject, I thought I would share a little more about a pilot’s life.
All pilots undergo regular simulator assessments, most UK airlines do two days every six months, some do four days once a year.
We also complete a line check every year, which is a normal revenue flight observed by a training captain. This ensures pilots are operating to the company’s standard operating procedures, and covers how the pilots operate as a team.
Also every year, we have classroom refresher courses usually over two days. This includes a couple of written exams, covering dangerous cargo, technical knowledge etc.
Every year we also have a medical, as one gets older the requirements change eg ECGs frequency.
On UK registered aircraft, I also suspect many other countries too, there is a “quick access recorder”. This records many of the aircraft parameters, eg speed, altitude, rate of descent, g forces, you get the picture. This information is downloaded to the company’s flight safety department everyday. It can then be used to monitor a pilot’s performance, however it is more used to detect trends. For instance rotation rates on take off, which if many flights are rotating too fast you may have training problem with new pilots, any this could be incorporated into the next years simulator assessments.
So to answer your original question, the airline training department have a very good idea of the quality of its pilots. All airlines will therefore have a number of first officers who will not be promoted to captain. Accidents and incidents are always a number of factors all lining up together, if the pilots involved are known to be good they will not disciplined or sacked.
I really enjoy a YouTube channel called Mentour Pilot, it is hosted by an ex Ryanair training captain. The videos tend to show how a chain of events leads to an accident and how the industry learns and develops changes, I think you may enjoy it.
As you appear to interested in the subject, I thought I would share a little more about a pilot’s life.
All pilots undergo regular simulator assessments, most UK airlines do two days every six months, some do four days once a year.
We also complete a line check every year, which is a normal revenue flight observed by a training captain. This ensures pilots are operating to the company’s standard operating procedures, and covers how the pilots operate as a team.
Also every year, we have classroom refresher courses usually over two days. This includes a couple of written exams, covering dangerous cargo, technical knowledge etc.
Every year we also have a medical, as one gets older the requirements change eg ECGs frequency.
On UK registered aircraft, I also suspect many other countries too, there is a “quick access recorder”. This records many of the aircraft parameters, eg speed, altitude, rate of descent, g forces, you get the picture. This information is downloaded to the company’s flight safety department everyday. It can then be used to monitor a pilot’s performance, however it is more used to detect trends. For instance rotation rates on take off, which if many flights are rotating too fast you may have training problem with new pilots, any this could be incorporated into the next years simulator assessments.
So to answer your original question, the airline training department have a very good idea of the quality of its pilots. All airlines will therefore have a number of first officers who will not be promoted to captain. Accidents and incidents are always a number of factors all lining up together, if the pilots involved are known to be good they will not disciplined or sacked.
I really enjoy a YouTube channel called Mentour Pilot, it is hosted by an ex Ryanair training captain. The videos tend to show how a chain of events leads to an accident and how the industry learns and develops changes, I think you may enjoy it.
There was also the case of a BA 747 pilot struggling to get into Heathrow in poor visibility with engineer and co pilot ill with food poisoning and a dodgy autopilot. He decided to go around a moment too late and perhaps a bit too gently, missing a hotel by less than 50 feet.
He was prosecuted for endangering an aircraft and endangering people on the ground. The jury after much thought told the judge they had a verdict on the endangering people in the air charge only. The judge , with some exasperation told them to hurry up and decide the other charge, presumably on the basis they had to be the same verdict. But the jury apparently decided to split the difference and found him guilty of endangering people on the ground but not guilty of endangering people on the ground.
He was prosecuted for endangering an aircraft and endangering people on the ground. The jury after much thought told the judge they had a verdict on the endangering people in the air charge only. The judge , with some exasperation told them to hurry up and decide the other charge, presumably on the basis they had to be the same verdict. But the jury apparently decided to split the difference and found him guilty of endangering people on the ground but not guilty of endangering people on the ground.
Many thanks Claret. I am very interested in the subject of all aviation.
A very informative post, and well received, I’m sometimes rather reluctant to put posts up like this. I’m never so sure if pilots would really want to share the workings of the industry on an open forum. More than likely, not wanting to talk about the day job - in down time.
Mentor Pilot, I think I’ve watched all his videos - Im a subscriber, and since he’s gone full time on YouTube Improved obviously. It must have been hard piloting and doing YT (having the time).
I’m the same with Blancolirio (subscriber). I’m not so sure about Captain Steve? I just find his delivery style a bit frustrating. However if it’s anything about aircraft and aviation - I’ll watch it.
A very informative post, and well received, I’m sometimes rather reluctant to put posts up like this. I’m never so sure if pilots would really want to share the workings of the industry on an open forum. More than likely, not wanting to talk about the day job - in down time.
Mentor Pilot, I think I’ve watched all his videos - Im a subscriber, and since he’s gone full time on YouTube Improved obviously. It must have been hard piloting and doing YT (having the time).
I’m the same with Blancolirio (subscriber). I’m not so sure about Captain Steve? I just find his delivery style a bit frustrating. However if it’s anything about aircraft and aviation - I’ll watch it.
Austin Prefect said:
There was also the case of a BA 747 pilot struggling to get into Heathrow in poor visibility with engineer and co pilot ill with food poisoning and a dodgy autopilot. He decided to go around a moment too late and perhaps a bit too gently, missing a hotel by less than 50 feet.
He was prosecuted for endangering an aircraft and endangering people on the ground. The jury after much thought told the judge they had a verdict on the endangering people in the air charge only. The judge , with some exasperation told them to hurry up and decide the other charge, presumably on the basis they had to be the same verdict. But the jury apparently decided to split the difference and found him guilty of endangering people on the ground but not guilty of endangering people on the ground.
The real issue in that case (IIRC) was that the pilot was doing his approach along the A4, not 27R!He was prosecuted for endangering an aircraft and endangering people on the ground. The jury after much thought told the judge they had a verdict on the endangering people in the air charge only. The judge , with some exasperation told them to hurry up and decide the other charge, presumably on the basis they had to be the same verdict. But the jury apparently decided to split the difference and found him guilty of endangering people on the ground but not guilty of endangering people on the ground.
https://aviation-safety.net/wikibase/147119
CanAm said:
I don't know about commercial pilots, but in WW2 a Spitfire pilot who was lost and without radio landed at a base where my father was stationed. The pilot stopped near the tower and got out to seek help. Unfortunately, he left the engine running and a Merlin, even at idle, produces a few h.p. With no chocks to hold it back it trundled into a hangar and caused a fair bit of damage. The pilot was grounded for life.
(I appreciate that this is hearsay)
Any pilot leaving a merlin idling on the ground needs sent to coventry anyway, they overheat for fun unless they're in the air.(I appreciate that this is hearsay)
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