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Command gradient

It is the cockpit interaction resulting from a severe seniority gradient which produces this.

In the 3rd World it is fairly normal to have a LHS who is aggressive (often ex mil, which in the mil jet sphere is a testosterone laden environment) and often is handed an ATPL just by doing the jet TR (Turkey is known for giving an ATPL to ex F4 pilots just via the TR course (check out the Turkish 737 pancake at Amsterdam) and there are much worse countries which operate passenger jets), and you have a submissive RHS occupant.

It used to be like this in the 1st World too. Check out the Trident crash at EGLL in the 1970s, for a seminal example of a bully “captain”. The airlines gradually got rid of those types. Many came from the WW2 ex Spitfire/Hurricane crowd and were good in a high stress single pilot environment, which is not suitable for the “teamwork” process in passenger jets. As to why the latter is the case is another debate but not wholly unrelated to airline pilots relying on procedures because they don’t fully understand the aircraft systems complexity.

In GA, it is common for a student to make lots of mistakes if an FI is around.

So, a long answer to a one-liner question which didn’t sound like it wanted an answer

Administrator
Shoreham EGKA, United Kingdom

the gear retraction which was performed on finals

Reading the report and noting the lack of cockpit communication, I understood that FO assumed they would orbit and retracted the gear without notifying captain while the captain continued his insane try to land. In shower of warnings he missed to connect relevant information with aircraft actual configuration.

LDZA LDVA, Croatia

Emir wrote:

I understood that FO assumed they would orbit and retracted the gear

You might be right @Emir… though OTOH why retract the gear to do an orbit to kill speed and altitude? Well, we’ll never know what they were thinking or rather not.

Dan
ain't the Destination, but the Journey
LSZF, Switzerland

though OTOH why retract the gear to do an orbit to kill speed and altitude?

I don’t know… confusing orbiting for go-around… who knows… Anyhow, it’s very sad occurrence and disturbing CVR transcript showing total disregard and disrespect of procedures.

LDZA LDVA, Croatia

Could it be that the captain was completely focused on salvaging the approach because doing a 360 to lose altitude would automatically trigger an investigation?

Private field, Mallorca, Spain

The first thing I would look at, as with many other accidents where procedures or communication appear to go amiss, is crew fatigue. This is one of the first holes in the cheese for so many CAT accidents.

France

gallois wrote:

The first thing I would look at, as with many other accidents where procedures or communication appear to go amiss, is crew fatigue. This is one of the first holes in the cheese for so many CAT accidents.

Quite likely. The accident report says this:

2.4.1.5 Effects of Hydration and Somatic Stressors on Flight Crew

(a) Tests results of study for effects of hydration on flight crew flight performance and spatial cognition were significantly poor for pilots who had low fluid intakes and experienced dehydration in comparison to the hydrated pilots (Refer section – 1.16.12.6 "Study on Effects of Hydration on Flight Crew”). Similarly result of research for hypoglycemia (decrease in blood glucose) pointed to the risk of increased somatic stressors because of hypoglycemia (Refer section – 1.16.12.7 “The Impact of Somatic Stressors on Flight Crew”)

(b) Muslims abstain from food or drink each day from sunrise until sunset during the Holy Month of Ramadan. Islamic Fasting as a time restricting eating habit may invert the normal human day-night routine, sleep patterns (circadian rhythms) and general health (reduction in day time hydration, blood glucose, etc). Flying with Fasting may affect flight performance of a flight crew in terms of reduction of spatial cognition and increases the risk of somatic stressors (hypoglycemia).

(c) Accident took place during the Holy Month of Ramadan (Month of Fasting for Muslims). Both the flight crew were having regular Sehri (morning meal eaten by Muslims before the sun has come up during Ramadan) and Iftar (Evening meal eaten by Muslims after the sun has gone down during Ramadan). On the day of accident, both the flight crew had Sehri prior to the event flight. Moreover, in the initial part of flight, the flight crew were offered snacks by the cabin crew which was politely refused by them. Both flight crew were probably Fasting at the time of undertaking event flight and they continued with their Fast during the flight.

(d) Flying with Fasting may affect flight performance of a flight crew in terms of reduction of spatial cognition and increases the risk of somatic stressors (hypoglycemia). The judgement of both flight crew was probably impaired due to effects of fasting while flying. However, its consequence on flight performance of the flight crew could not be determined

This is downplayed in the conclusions – the lack of regulations concerning fasting is given as a contributing cause although the possible effects on the crew of fasting is not mentioned as either a primary or contributing cause.

In any case, the Qur’an explicitly exempts “travellers” from fasting during Ramadan and I would have expected subsequent interpretations of the Qur’an to extend that exemption to situations where fasting would (indirectly) cause danger.

ESKC (Uppsala/Sundbro), Sweden

Gosh this sort of thing must be an absolute minefield to do an accident investigation in. Even in the 1st World we have well known examples of govt influence on an investigation, but this elevates the political (and political correctness) requirements to a whole new level.

Writing that report must have been like visiting your ex wife for dinner when she is cooking mushrooms (and I am not referring to psychedelic ones).

Administrator
Shoreham EGKA, United Kingdom

Airborne_Again wrote:

In any case, the Qur’an explicitly exempts “travellers” from fasting during Ramadan and I would have expected subsequent interpretations of the Qur’an to extend that exemption to situations where fasting would (indirectly) cause danger.

Indeed – there are lots of exemptions, but most Muslims I know try hard to not use them, since they have to “make up” the fasting day later on – which is obviously harder if you are the only one fasting.

Fly more.
LSGY, Switzerland

I have had the ‘pleasure’ to work in Muslim countries during Ramadan and it’s a nightmare. Everyone is sleep deprived, many people are like zombies during the day. Totally idiotic not to exempt aircrew from the fasting (well, officially they may be…), but hey. Just avoid these places during that month.

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