Ask The Pilot

When a hull-loss accident occurs, and is subject to a report (and sometimes I think, a preliminary report is released), how do the conclusions of those reports get a) disseminated and b) acted on, within an airline which has aircraft of the same type.

i'm wondering if its a 'corporate' engagement, dealt with from 'Chief Pilot' area, or above and then directed below, or if all relevant levels of the airline are engaged in the airline's response - comments from pilots etc (beyond the mandatory stuff). I imagine that it varies widely between airlines - how do Aussie airlines deal with it? Is there any regulatory oversight here that mandates how it will be dealt with internally beyond the mandatory stuff.
 
This sounds familiar:

Pilots have ‘forgotten’ how to fly because of hi-tech aircraft

Probably paywalled, so:

Planes are crashing because pilots have either forgotten how to fly or never learnt in the first place, an aviation regulator has claimed.

Over-reliance on automation has eroded basic skills and created a dangerous dependency on computer systems, the US Federal Aviation Administration has said.

“When automation ceases to work properly, pilots who do not have sufficient experience of manual control and proper training may be hesitant or not have enough skills to take control of the aircraft,” the FAA said in a report to the International Civil Aviation Organisation.

Between 2009 and 2016, manual errors caused or contributed to 92 per cent of all aircraft accidents in the world that arose from the management of aircraft flight paths, the FAA said. This referred to accidents that did not stem from a sudden, catastrophic event such as structural failure or terrorism.

Airlines are recruiting pilots to meet higher demand for flights, particularly from China and India. Experts are concerned that pilots are encouraged to switch on the autopilot after take-off and take back control just before landing. The FAA presented its paper to the ICAO conference in Montreal.

The FAA and Boeing are under fire after the malfunction of an automated stabiliser on the Boeing 737 Max jet after crashes in Indonesia and Ethiopia led to the grounding of all 737s. The company, backed by pilots mainly in the US and the West, argues that the crew lacked basic airmanship that would have averted the disasters in which 346 people died.
 
When a hull-loss accident occurs, and is subject to a report (and sometimes I think, a preliminary report is released), how do the conclusions of those reports get a) disseminated and b) acted on, within an airline which has aircraft of the same type.

i'm wondering if its a 'corporate' engagement, dealt with from 'Chief Pilot' area, or above and then directed below, or if all relevant levels of the airline are engaged in the airline's response - comments from pilots etc (beyond the mandatory stuff). I imagine that it varies widely between airlines - how do Aussie airlines deal with it? Is there any regulatory oversight here that mandates how it will be dealt with internally beyond the mandatory stuff.

Good question, both the 777 and 737 have had “crew are reminded” emails from the CP usually within a day or two of the initial report. If there’s some really pertinent points to be made this will be highlighted to the crew.

For example, when Asiana hit, there was already a limitation on the 777 in the flight manual, not to use FLCH below 1000ft because of the lack of protection. The email went something along the lines of “crew are reminded to refer to FCOM VOL 1 CH 1 LIMITATIONS - Use of FLCH below 1000ft”.

In the 737, I haven’t been on it long enough apart from the recent Max disasters, but its been “crew are reminded to review the runaway stabiliser memory items”. So far that’s it.
 
When a hull-loss accident occurs, and is subject to a report (and sometimes I think, a preliminary report is released), how do the conclusions of those reports get a) disseminated and b) acted on, within an airline which has aircraft of the same type.

i'm wondering if its a 'corporate' engagement, dealt with from 'Chief Pilot' area, or above and then directed below, or if all relevant levels of the airline are engaged in the airline's response - comments from pilots etc (beyond the mandatory stuff). I imagine that it varies widely between airlines - how do Aussie airlines deal with it? Is there any regulatory oversight here that mandates how it will be dealt with internally beyond the mandatory stuff.

Accidents don’t have to be hull loss events to be of interest to the safety authorities. There’s often much to learn from events that ended fairly benignly.

The amount of feedback after reports varies dramatically. Often lessons aren’t necessarily locked to one specific type of aircraft. Both Airbus and Boeing have sufficient similarity in their coughpits that lessons that came from (say) a 777 could be equally applicable to a 747. The flight level change management that was an issue in the SFO 777 crash applies to most Boeings.

Some years ago, one airline had a quite detailed report that was available to all of the pilots, that covered not just major events, but everything that caused a report to be filed. This was stopped by upper management, presumably because the media might be given copies. So, any learning that was happening, became less important than perceived PR value.

After QF1, which was arguably an outright management failure, the ATSB required that reports be given to all of the pilots.

Whilst my QF30 event was being investigated, I was sent copies of the report as a work in progress. When it was near the end, I was sent the draft final report, and asked for any comments. The recommendations from that report, were, in many cases enacted before the final had even come out, with the one that was most evident to the pilots being a change to the way some of the sim exercises were done.
 
Thanks AI and JB. One thing I was getting at was, if there is a serious accident somewhere in the world, of an aircraft type within another airline's fleet (say, an Australian airline), is there any discussion initiated within the pilot group - the union? - (and maybe other crew) by management or the pilots/union etc themselves along the lines of "how do these findings apply to us? How can we implement the findings to get the best outcome within our operational parameters?" Or is it just black-letter directives or changes in the manual/training from the top, and from the investigation report?

By the sound of it, just the latter.
 
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Links like this are often part of “single pilot” or “pilotless” articles. The basic premise being that if pilots cause 92% of the accidents, then by getting rid of pilots, we won’t have that 92% any more. The problem is that we don’t hear about the innumerable times, every day, that pilots stop the automation from doing something silly. Saves aren’t in the media, and mostly aren’t even reported. Imagine...an autopilot what will not, under any circumstances, with no exceptions, ever disconnect. Yeah, and I’m going to win lotto next week too. My QF30 lost the autopilots as almost the very first part of the event. QF72 also. The very first A380 flight of QF10 did too, and it was simply flown manually for the rest of the flight.

But, there is a lot of truth to the basic premise. I’ve said here, many times, that I don’t like the cadet schemes, that put minimal hour pilots into the right hand seat of airliners. That is not a place that they will learn how to fly. Manage perhaps, but not fly.

Children of the magenta was a brilliant talk, given a lot of years ago now. It’s even more true now than it was then. But the solution is not lower experience (MPL) pilots, or more rules. Back when I was an SO, whilst we were not allowed to land the 747, we were able to manually fly them down to a couple of thousand feet, by which time they were fully configured, and in the ‘slot’. This meant that when FO training did come up, you didn’t have to relearn a scan...the skill was still there. Rules now don’t even allow SO’s in an operating seat on descent below 20,000’...so they are actively denied one source of practice and experience.

MCAS is a great example of the manufacturers “trust us” position. And airlines themselves will accept anything that they perceive as allowing them a cheaper pilot. Safety has nothing to do with it, if they think that the odds are in their favour (i.e. short term management will have moved on before the chickens come home). The industry has collectively been involved in a boiling frog experiment with regard to pilot quality and training. The SFO 777 was in daylight, on a nice day. Here we have a captain who could not fly. AF447 was just the same.
 
After QF1, which was arguably an outright management failure, the ATSB required that reports be given to all of the pilots.

The QF1 report is a very long but interesting read. One of the things that struck me was the assumption that pilots had frequent exposure to the kind of adverse weather conditions that were present that evening and therefore in the sim the exposure to those conditions was kept to a minimum. After pilots were polled (just on the 747?) about how often they actually experienced those conditions, most said it was quite rare.
 
The QF1 report is a very long but interesting read. One of the things that struck me was the assumption that pilots had frequent exposure to the kind of adverse weather conditions that were present that evening and therefore in the sim the exposure to those conditions was kept to a minimum. After pilots were polled (just on the 747?) about how often they actually experienced those conditions, most said it was quite rare.
I don’t know what defines rare. I was on the 767 at the time, and operated to Hong Kong, Bangkok, and various other ports in Asia in similar conditions fairly regularly. But the 767 did many more cycles than the 747, so I guess there was more opportunity to keep in practice. Really poor conditions aren’t that common, simply because we do our best to avoid them. Holding isn’t always initiated by ATC.

The weather was much less of an issue than was the mindless application of an ill conceived company procedure. It was the cause of much angst at the time, with more than one of the “old and bold” predicting it would end in tears. They were simply fobbed off by the management and training heavies of the day, as being “resistant to change”. That’s another MBA term that’s as worthless as “world’s best practice”.
 
One thing I was getting at was, if there is a serious accident somewhere in the world, of an aircraft type within another airline's fleet (say, an Australian airline), is there any discussion initiated within the pilot group - the union? - (and maybe other crew) by management or the pilots/union etc themselves along the lines of "how do these findings apply to us? How can we implement the findings to get the best outcome within our operational parameters?" Or is it just black-letter directives or changes in the manual/training from the top, and from the investigation report?

By the sound of it, just the latter.
The only real discussion these days (other than pilots in the bar) is initiated by the training department.
 
I don’t know what defines rare. I was on the 767 at the time, and operated to Hong Kong, Bangkok, and various other ports in Asia in similar conditions fairly regularly. But the 767 did many more cycles than the 747, so I guess there was more opportunity to keep in practice. Really poor conditions aren’t that common, simply because we do our best to avoid them. Holding isn’t always initiated by ATC.

The weather was much less of an issue than was the mindless application of an ill conceived company procedure. It was the cause of much angst at the time, with more than one of the “old and bold” predicting it would end in tears. They were simply fobbed off by the management and training heavies of the day, as being “resistant to change”. That’s another MBA term that’s as worthless as “world’s best practice”.

jb what was the ill conceived company procedure!
 
jb what was the ill conceived company procedure!
They decided to make flap 25 and idle reverse the standard configuration for landing.

The use of full reverse has both engine wear and fuel use considerations The numbers are quite small, but add up across a fleet.

Flap 25 was a funny one. As I understand it, the driver was an issue with flap track cracking, that was accelerated by the use of flap 30. But, around the same time, the carbon brakes were being introduced to replace the steel discs, and it was believed that they lasted better with higher energy inputs, which sounded like rubbish at the time, and I think was proven to be.

Anyway, the use of F25 gave a higher approach speed, and a slightly less speed stable aircraft. Idle reverse, per se, did little harm, as normally there is virtually zero reverse thrust anyway. As you can see, all of this tended to increase brake loads and temperatures. No consideration had been given to the effect of reverse thrust on standing water, and subsequent brake performance.

In itself, none of this is harmful, as long as it's left as a company preference, with the Captains choosing what they want at the time. That's how it is now, and although they have the occasional whinge about people like me (I guess that should be past tense), there is no pressure to change. But, that's not how it was prior to QF1. A substantial percentage of the FOs had never even flown the aircraft with full flap and reverse. It was not being considered as one of many tools within a tool chest. Training were actively marking down pilots who resisted. Basically the management and training pilots, who are generally pretty good, but who get a small fraction of the flying that line pilots do, had stopped listening to anyone outside of the "office". They were living in an echo chamber.
 
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That's how it is now, and although they have the occasional whinge about people like me

I thought dissent was supposed to be encouraged in the profession?

Some tidbits from the report to backup your comments.
 

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More FYI than a question. QF2 SIN-SYD (11 October Departure) landed into Sydney this morning flown by Captain Richard Woodward. During the taxi back to the terminal the FO congratulated the Captain on his retirement from a 47 year flying career across both the RAAF (14 years) and Qantas (33 years). From my vantage point in 48C the landing on 16R was a good one.

A number of other disciplines would recognise 47 years of experience and turn it into some form of advisory / consulting role to ensure the IP isn't lost. Does this happen with flying?
 
I wrote to MP's and ministers, canned responses. Every time I go to the USA I fume over the one sided arrangement.
More FYI than a question. QF2 SIN-SYD (11 October Departure) landed into Sydney this morning flown by Captain Richard Woodward. During the taxi back to the terminal the FO congratulated the Captain on his retirement from a 47 year flying career across both the RAAF (14 years) and Qantas (33 years). From my vantage point in 48C the landing on 16R was a good one.

A number of other disciplines would recognise 47 years of experience and turn it into some form of advisory / consulting role to ensure the IP isn't lost. Does this happen with flying?
Ah, I knew that Woody was close. He was a flying instructor at 2FTS when I was on pilots' course, having previously flown helicopters. From there, he took a different tack, and was sent to the UK to do the Empire Test Pilots course. He kept in touch with that fraternity for the rest of his career, and was exceptionally knowledgeable. QF in its wisdom, hired a number of test pilots, and never used any of them in the roles for which they were trained.

As we retire, we all take 45 years or so of experience with us. And as captains, we are perpetually training our replacements. The FO who gave that talk for Woody would have the better part of 20 years experience himself. His next move will be to a command. Woody himself will be replaced by a captain from one of the other wide bodies. To be honest companies don't need the old farts hanging around.

Of course there is one role Woody could fill. Perhaps we could get rid of that attention seeker Byron Bailey, and replace him with someone with some real knowledge.
 
VFR Into IMC

over there years there has been a number of fatalities relating to pilots flying light aircraft while VFR into IMC.
This one is a Cessna inflight breakup in a NT wet season coughulonimbus:
Why do pilots fly VFR into IMC?
It’s very much the same as someone driving the last part of a journey home when very tired. Put simply it in a ‘get homeitus’
Fatigue leads to poor decision making which leads to people pushing past their limits and getting themselves caught out and into situations beyond their abilities.
Thunderstorms are a unique situation as can be seen from the example you quote.
It is not just IMC flight that is the issue here. Even if IFR qualified the severe turbulence, up & down drafts and ice, individually or combined, can really spoil your day.
 
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