Originally Posted by
HIFLYR
BTW Doc don't let the guys who have to be right beat you up too bad, some guys just have to get the last word in. I never read where you were out of line, besides this is just a discussion.
Thanks - I've gotten quite good at just ignoring those posters. Makes things more pleasant. Thankfully it is a small childish minority that just simply add no value, but they are indeed the usual suspects and repeat offenders.
Originally Posted by
HIFLYR
Yes most accidents are rooted in a failure of following SOP, being vigilant regarding Threat Error Management and CRM. So yes going low on the approach did cause the accident and so did the above things I listed and it's same in all the crashes the guy listed. One could argue if in the glades accident if the light bulb never went out they would be alive today.
They are completely opposite layers in the swiss cheese model though, which is what I was arguing.
The inciting factor might obviously be the light bulb, but the crash happened because nobody was paying attention to the autopilot disconnect and they lost altitude and flew into the swamp. Same thing with Aeroflot 593. We have to pay the most attention to the last layer (MDA, altitude) because there are too many top layers (light bulbs, kids in cockpit, weather, malfunctions, distractions) to eliminate them all.
I'd bet this crew (and many crews) did poor hybrid approaches before, using the V/S dial, but nothing happened because they arrested the descent above MDA or broke out in plenty of time.
This crash may have had a bunch of issues, but it crashed because the crew went below mins. Last layer MUST be inviolate. Same principles apply with my surgical cases (and my IMC approaches too!)
Originally Posted by
HIFLYR
This business is all about learning from others mistakes and realizing yes you too could find yourself rushing and loosing SA. Hopefully you will recognize the red flags and either slow down, GA, automate or de-automate to a appropriate level or go hold if in the air and set the brake if on the ground.
The truly scary guys are the ones who think they are always right and think they will not make a mistake.
True. I do this personally all the time, and as a single pilot without cross-checks it is all the more critical. I also do it professionally. I like your attitude and your posts. We see some of the "other" attitudes here (appeal to authority, invulnerability, macho) on full display.
