Normalization of Deviance
Posted: Tue Dec 22, 2015 3:22 am
[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]
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]