Rwy20 wrote:
It’s also completely useless to try to single out things in the pilot unless you want to make the point that some pilots should rather give up flying so that accidents are prevented because there are only the skygods left in the air.
I agree. What pilots do is conditioned by training, habits and experience in general.
If a pilot gets used to doing something over and over again, either because he has developed a bad habit that has proved to work out well x times, or because he has been specifically trained to perform certain actions without thinking (for example shutting down and feathering an engine that looses power in cruise), he will reproduce these actions when shit hits the fan single pilot in IMC. If he has been trained to perform certain actions to attempt restoring power before shutting down the engine, he will most likely perform these actions and maybe have a better outcome.
Improvisation may work, but then it may also bite you. I read a lot about people who make up their own approach procedures, replace DME distance by GPS distance etc and publically claim it is perfectly safe. One day we may read about an accident where such a deviation from published procedures was a factor.
So (recurrent) training, sticking to procedures, checklists and then if nothing else works some creativity. Mentally preparing yourself for unusual situations by reading accident reports may also help.
Making conjectures about what you would do in the same situation and criticising the pilot from you cosy armchair in front of a fireplace is easy. But if aviation safety has improved to the point where it is the safest means of transportation in the world, it is because everyone is playing with open cards without fear of being judged when an incident or accident happens so we all can learn from it, improve equipment, improve training, improve procedures etc.
Professional pilots are regularly trained on a variety of emergencies and the appropriate responses – for a reason. We are not. But we should.
What strikes me here is that you always seem to try to judge the pilots involved in accidents or incidents, rather than just try to understand what went wrong and how we can learn from it. It looks to me as if you try to justify to yourself why this could never happen to you because all those pilots in accidents were “stupid” or had at least some personality deficiency.
You are wrong. I am SURE that any of this could happen to me, like to any of us if we are not careful, and I consider myself only a mediocre IFR pilot, who is trying to get better. I have 0 (zero) “skygod attitude”. I also have not judged the accident pilot. I have no idea why you write that.
When I write that somebody made a mistake I do not mean that he is “stupid”. That is only your interpretation.
Flyer59 wrote:
I have no idea why you write that.
Then I misinterpreted your statements, please accept my apologies.
Don’t worry ;-), maybe I expressed myself in the wrong way. …
I spent a while thinking “why on earth does a pilot with a 530W not load the overlay?” And then I remembered that until a couple of years ago, I would not have loaded the overlay on most approaches, because it was only coded for Cat C and D. So instead I used OBS mode on the navaid for the outbound leg of a teardrop, so I could fly the Cat A radial. For most the approaches I would have flown, the DME and GPS distances would not be significantly different, but I can imagine getting caught out.
Perhaps the very fact he knew the airport well, lead to some complacency, and this cost him his life?
He mixed up DND and the airport, and as David P says, descended to a “landing” at DND instead of the airport.
The chart does look busy, but as stated, the Jepps are well laid out, and again, I wonder if he knew the approach well enough not to brief from the chart, thereby missing the opportunity to remind himself that the NDB was NOT collocated. Or maybe he did brief, but confirmation bias took over.
I’d also imagine that someone used to flying jets and stuff like the 737 would have to work very hard not to get a little complacent, as things happen slower, so if I can do it in a jet, I don’t need to worry too much about doing it in a slow MEP
Sure, not using the 530 to its full capabilities did not help but again, perhaps this was routine enough not to be seen as an issue.
The above is obviously speculation, but it does fit with known human performance error occurrences. No criticism is aimed at the pilot, because the sobering truth (and the main takeaway lesson) is this could happen to any of us. We only need to make this type of error once, because we enjoy a wonderful hobby, but do so in an extremely unforgiving environment.
What is good to see here, is no one is seeing this as a simple case of a bad pilot , that way lies no learning.
Afsag wrote:
What is good to see here, is no one is seeing this as a simple case of a bad pilot…
Probably because most of us (me at least) have done similar things (and luckily got away with it) without considering ourselves to be bad pilots.
what_next wrote:
Probably because most of us (me at least) have done similar things
Or bias. An airline captain is after all considered to be well above average. Yet he acted nonchalant, didn’t use the equipment correct or didn’t know how to use it correct, or didn’t bother, which is the very mark of a bad pilot. Maybe a good captain, but bad GA pilot?
Very sad, and well worth reading and using for CRM purposes.
The PIC seemed to have a pretty typical, for these times, CPL career with lay offs due to bankruptcies, winter furloughs and presumably some informal free lance work in a non AOC environment (although this is presumed, but if the Baron and King Air were on an AOC they may have mentioned this).
His airline SOP, presumably, would have flown the approach with A/P on, and he would have loaded the approach on the FMS, and the FMS would have switched NAV source automatically when the pilot flying pressed the APP command. His motor memory and situational awareness skills would need to have been refreshed for operating a vintage twin, with possible other, unrecorded maintenance issues (inoperative A/P, intermittent DME on the Mesozoic KNS80, for example, picked up in the report), but with manual interface between the Garmin and the HSI. He also, self evidently, wasn’t as current or familiar with this aircraft, which hadn’t been flown for months.
Basic IR habits such as selecting, identifying and displaying correctly NAV sources, (our dear friend S-I-D) may have been lost due to the FMS on his airliner automatically loading and identifying sources.
Basic IR habits such as selecting, identifying and displaying correctly NAV sources, (our dear friend S-I-D) may have been lost due to the FMS on his airliner automatically loading and identifying sources.
Maybe. But as I wrote above “Localiser alive – localiser captured – glideslope alive …” is second nature to everybody who ever flew in an environment with SOPs. Why he commenced his final descent without a glideslope indication or at least a DME reading (ideally both) is beyond my understanding.
