Normalization of Deviance

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ScudRunner-d95
Posts: 1349
Joined: Thu Feb 13, 2014 5:08 pm

[url=http://www.rapp.org/archives/2015/12/no ... -deviance/]http://www.rapp.org/archives/2015/12/no ... -deviance/[/url]

Good read about the accident that killed all on board in Bedford Mass last year in a G-IV

[quote]Just the Facts Let me summarize the ten most pertinent errors and omissions of this incident for you:
[list type=decimal]
[li]There are [i]five[/i] checklists which must be run prior to flying. The pilots ran none of them. CVR data and pilot interviews revealed that checklists simply were not used. This was not an anomaly, it was standard operating procedure for them.[/li]
[li]Obviously the gust lock was not removed prior to flying. This is a very big, very visible, bright red handle which sticks up vertically right between the throttles and the flap handle. As the Simon & Chabris [url= attention test[/url] demonstrates, it’s not necessarily hard to miss the gust lock handle protruding six inches above the rest of the center pedestal. But it’s also the precise reason we have checklists and procedures in the first place.[/li]
[li]Flight control checks were not performed on this flight, nor were they [i]ever[/i] performed. Hundreds of flights worth of data from the FDR and pilot interviews confirm it.[/li]
[li]The crew received a Rudder Limit message indicating that the rudder’s load limiter had activated. This is abnormal. The crew saw the alert. We know this because it was verbalized. Action taken? None.[/li]
[li]The Pilot Flying (PF) was unable to push the power levers far enough forward to achieve takeoff thrust. Worse, he actually verbalized that he wasn’t able to get full power, yet continued the takeoff anyway.[/li]
[li]The Pilot Not Flying (PNF) was supposed to monitor the engines and verbally call out when takeoff power was set. He failed to perform this task.[/li]
[li]Aerodynamics naturally move the elevator up (and therefore the control column aft) as the airplane accelerates. Gulfstream pilots are trained to look for this. It didn’t happen, and it wasn’t caught by either pilot.[/li]
[li]The Pilot Flying realized the gust lock was engaged, and said so verbally several times. At this point, the aircraft was traveling 128 knots had used 3,100 feet of runway; about 5,000 feet remained. In other words, they had [i]plenty[/i] of time to abort the takeoff. They chose to continue anyway.[/li]
[li]One of the pilots pulled the flight power shutoff handle to remove hydraulic pressure from the flight controls in an attempt to release the gust lock while accelerating down the runway. The FPSOV was not designed for this purpose, and you won’t find any G-IV manual advocating this procedure.  Because it doesn’t work.[/li]
[li]By the time they realized it wouldn’t work and began the abort attempt, it was too late. The aircraft was traveling at 162 knots (186 mph!) and only about 2,700 feet of pavement remained. The hydraulically-actuated ground spoilers — which greatly aid in stopping the aircraft by placing most of its weight back on the wheels to increase rolling resistance and braking efficiency — were no longer available because the crew had removed hydraulic power to the flight controls.[/li]
[/list][/quote]


Rookie Pilot
Posts: 404
Joined: Tue Sep 08, 2015 1:44 am

Hmmmmm. 


And if Scudrunners were my primary source of how to fly aircraft, I would think from reading here I should be able, SP, to jump in a GV and fly it without checklists or a formal training regime.  Or any aircaft for that matter -- isn't that the message often repeated?


Boy I am confused now ---


O0
ScudRunner-d95
Posts: 1349
Joined: Thu Feb 13, 2014 5:08 pm

It is funny how some complain about the over-site and call it interference by TC to private operators,  then you read about shit like this and think ya I am happy they are there. A friend of mine down in the US has been ripping around on a Falcon 50 with no type rating or any real training on it and that is perfectly legal.

As for the narrative of some on here, remember opinions are like assholes everyone has one.

Except this guy:  [url=http://www.nbcnews.com/health/body-odd/ ... f1C6437420]http://www.nbcnews.com/health/body-odd/ ... f1C6437420[/url]
O0
Colonel
Posts: 3450
Joined: Wed Apr 29, 2015 10:31 am

Checklists are like braces for your teeth,
or corrective underwear.

Some people need them, some people
don't.  Some people need a little, some
people need a lot. 

Aviation is a bit complicated, airplanes
are sometimes different, and what works
for one person doesn't always work for
another. 

This is something you learn as a flight
instructor - not everyone is created the
same, and some airplanes are more
challenging than others.

If someone claims to need a 100 page
checklist to fly a Piper Cub, well, who
am I to argue with them? 

On the other hand, I don't use a 100
page checklist in a Piper Cub, and I
guess that makes me a [b]BAD PERSON[/b]
with the requisite nonsense quotes from
TC's fuckhead Tribunal 15 years ago
thrown at me every day.

No aerobatics below 18,000 feet, remember  ::)


The good thing about checklists is that not
ONE PILOT using a checklist has EVER forgotten
to put the gear down.
woodzi

Since most of the time, my flights do not involve scrambling to intercept incoming Messerschmidts, I take the time, while I am still on the ground, to go over my (simple) pre-takeoff checklists. I agree that it is very important to understand what you are doing at each step and just blindly going through the list is not very useful.
Colonel
Posts: 3450
Joined: Wed Apr 29, 2015 10:31 am

A good example is open cockpit.  Checklists
in an open cockpit will blow away, never to
be seen again.

What do you do at that point?  Declare a
mayday and hope ATC will land your airplane
for you?  Jump out and parachute down? 

But how will you operate the parachute without
a checklist?  I can't think of a more important
time to do it right - hanging in a parachute -
and I have NEVER seen anyone use a checklist
in a parachute.

When I see someone will a 100 page checklist,
I see someone that is carrying a "How To Fly"
book with them.

If you need to carry a "How To Fly" book with
you to safely operate your aircraft during normal
ops, you should not have been sent solo, and
need remedial training in the normal operation
of your aircraft type.  There are many people
like that, and they often have four gold bars
on each shoulder.  They frequently fly jets,
and they always fly with another pilot, because
two weak pilots is always better than one good
pilot, TC tells us.

Just 42 years of aviation experience here, and
I think I am learning that it is impossible to
safely fly open cockpit, or parachute for that
matter.
woodzi

On the ground and not in motion, there is no excuse not to focus 100% on making sure the airplane is ready to go. Checklist is good. (I will agree that your open cockpit aircraft is probably simple enough that you should not need a written checklist, or you could just keep it in your shirt pocket.)

Off the ground, when the focus is on flying the plane, the checklist can be distracting - checklist is bad.

There are always distractions. Humans are far from perfect. Why not use every tool to minimize the possibility of tying to get an unfit aircraft off the ground?
Colonel
Posts: 3450
Joined: Wed Apr 29, 2015 10:31 am

[quote]Why not use every tool[/quote]

With my meagre aviation and engineering
experience, I have learned to use the
[i]appropriate[/i] tool.

If you want to hammer a nail in, do you
use a hammer, or do you wail at it with
a crescent wrench, as well as a hammer,
simply because it's in your toolbox?

I opine that pilots and airplanes are not
all made the same (egalitarian gasp) and
a 100 page checklist is simply not appropriate
for either a Piper Cub or an open cockpit
PT-22 Ryan or Stearman or Waco.

Once the thin edge of the wedge slips in,
and someone admits that gosh, maybe you
don't need a 100 page checklist for a Cub
or Stearman, maybe people might start to
think about [b][u]only putting important stuff on
checklists.[/u][/b]

The problem is that in reality, [b]ALL[/b] checklists
get polluted by all sorts of low-priority
items that drown out the high-priority items
and thus frequently do more harm than good.

Pilots do a really dreadful job of prioritizing -
trust me on this - and they don't need any
more "assistance" (i.e. a bad checklist) to
fly an airplane even worse than they already
do.

I say again, if someone needs a "How To Fly"
book to safely - normally - operate an airplane,
it's time for some more dual.

I spend a lot of time on a motorcycle in traffic. 
It's a complicated piece of machinery - far more
complicated than the jets I issue type ratings on -
and I would not ever dream of using a checklist
on a motorcycle, head down, riding into an intersection.

Remember that, the next time you hear about a
fatal mid-air collision at an uncontrolled airport
on a sunny weekend.  They died, the way Transport
wants them to, with a checklist in their hand. 

Transport doesn't like me, and I'm still alive after
many decades of really weird flying.  That's me in
the yellow S-2C.  Did a head-on takeoff with a 20
knot tailwind.


[img width=414 height=500][/img]


Here we are, opening the show with a three-plane
vic formation jumper dump - 1/2 roll to inverted.


[img width=500 height=375][/img]


Not a checklist in sight.  If there was, it would
have blown out after takeoff.  Somehow, we did
it without checklists.
Slick Goodlin
Posts: 721
Joined: Thu Jun 11, 2015 6:46 pm

[quote author=Colonel link=topic=1519.msg5350#msg5350 date=1450790378]
If someone claims to need a 100 page checklist to fly a Piper Cub, well, who am I to argue with them?
[/quote]
Later that day, the Colonel was seen arguing this very point...






I kid, of course.  A massive checklist in a Cub is just silly.  Beyond a bunch of things which are probably just as good to track on a calendar instead of doing every time, I can't think of anything other than carb heat for landing that you would have to think of.  But that's the point, isn't it?  Ensuring your plane is properly prepared for the next phase of flight, and at some point it's nice to have these things written down.  It's up to the operator to decide on where that changeover point is; based on complexity, total crew experience, anticipated recency, and whatever other things may play a part.
Colonel
Posts: 3450
Joined: Wed Apr 29, 2015 10:31 am

[url=https://en.wikipedia.org/wiki/Sarcasm#Understanding]https://en.wikipedia.org/wiki/Sarcasm#Understanding[/url]

[quote]Understanding the subtlety of this usage requires second-order interpretation of the speaker's or writer's intentions; different parts of the brain must work together to understand sarcasm. This sophisticated understanding can be lacking in some people with certain forms of brain damage, dementia and autism[/quote]
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