![]() ![]() Had the crew 'balled it up' on final approach due to vertigo or loss of SA in the clouds, I think it's likely that the mishap board would have found pilot error-due to poor selection of a landing site-as the final 'causal factor'(2) in the so-called Swiss cheese model that leads to a mishap. ![]() There are a number of clear-air diverts to the East (March/Ontario Maybe, NAF El Centro, probably best) that certainly would have been a better decision(1), given the nature of their emergency. Having flown in the area for several years, I know that the marine layer never (almost) extends east of the 'Peninsular Ranges' of San Diego / South OC. It's a miracle (and it speaks to the superb piloting abilities of the Captain/crew) that they were able to maintain a prescribed glideslope while in IMC. They were essentially controlling the aircraft pitch (and airspeed/altitude) solely with thrust and configuration changes. To armchair-quarterback a decades-old incident: I think it was definitely the wrong choice to continue to LAX knowing that field (and the entire coastal region) was IFR. The specifics of the fault making it extraordinarily hard to anticipate in advance, though I suspect that's now part of some design spec somewhere. Water intrusion into a bearing disabling control surfaces and leading to near complete loss of aircraft. The WashPo article proves that not everyone is appreciative.Īnd, finally: the after-incident root cause analysis shows just how critical the smallest elements in a tightly-constrained system can be. The flight attendant response at the end caps the story. Speaking of which, it's notable that this short flight had a regular cockpit roster of three - captain, copilot, and engineer. And McMahan was absolutely the hero of this story, with excellent assists from his cockpit crew. But in that grey zone between a well-behaving ship and one that won't stay in the sky no matter what, pilot skills matter. Good piloting is not always enough - sometimes an aircraft is simply too crippled to fly, see Alaska Air 261. Air France Flight 447 or the Tenerife incident (latter mentioned in McMahan's account) are other exemplars of poor response, situational awareness, or flagrant violations of procedure. Or Air Florida Flight 90, which crashed into the Patomac, following a series of poor pilot judgements regarding anti-icing practices ( ). Despite a successful landing, all perished. Two that stand out are Saudi Air Flight 163, with a fire on board. There are any number of sharp contrasts with exceedingly poor pilot/crew response. UA232 also comes to mind as an impossible situation saved by excellent piloting, situational awareness, and crew resource management. In another, later incident, NWA 85, October 9, 2002, also with partial loss of control, the crew elected to drop gear early in order to assess aircraft performance. The only possible fault I could find was in not testing gear-down performance before final. Electing for a water rather than land approach to LAX. The choice of landing sites (and the surprising lack of alternatives in California - things are really spread out - though Bakersfield might have been one to consider). Throttle control over pitch and roll (a case where a three-engine design proves particularly useful), and moving the passengers forward (a thought I'd had before it was mentioned in the video). The counterintuitive down-throttling during a pitch-up / stall situation. It's a tricky balance to strike.Īs the video account continued, I was struck by each of McMahan's responses, and how each was clearly prudent, effective, and/or demonstrated exceptionally high situational awareness. And the situation can evolve quite rapidly. If you're flying an aircraft with souls aboard (or even just yourself and cargo), a sufficient grasp to regain minimal control and effect a safe landing is usually enough. I'm thinking now that a minimal working diagnosis/root are helpful in crisis, but that rabbitholing into a precise diagnosis when the immediate situation is critical can be a dangerous distraction. Two elements of that I've been revisiting is the diagnosis / root-cause steps. One concept I've been working on is the notion of a hierarchy of failure (or conversely, a success-chain) in problem solving. Reading about nose-up on takeoff and the failures of trim-control attempts brought to mind the 737 MAX story of the past year. My first thouht on seeing the pilot's bio at the start of the video was "man, what a way to end that career". The Washington Post) also has an excelent article (. I first watched the video lists in a comment ( ), then read McMahan's own account (the PDF here). Studying various technical disasters is something of a hobby/professional interest, and in particular, the responses of the humans involved. Spoilers for those who've not yet read/viewed. ![]()
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |