Human Error and Training

I certainly can see why airlines with good safety records have vigorous training programs, and in many if not in most cases of mishaps, if not in all cases, human error should be found as the cause of the mishap. Let’s examine the AF Toronto mishap. Human Error: crew continued approach and landing during adverse wind field encounter. Crew did not brief a runway that had failed to have been grooved by the national airport authority contractor, presuming dry runway – like stopping performance.
I would bet dollars to donuts that the Toronto AF flight crew training program DID NOT include a segment of approach briefing covering whether or not the runway was grooved, porous friction coated or not grooved. [by the way this information is on the 10-9A page]. And yet wet runway stopping and control performance degradation is a commonly known hazard. Yet look at the investigation and you will see virtually all the blame heaped upon the flight crew, with little or no mention of this severe training deficiency. Also if the crew was trained and certified upon dispatch by AF and French CAA, why did they continue their approach to land into an adverse wind field generated by convective weather occurring in the approach corridor? Were they acting in accordance to the procedures for which they had been trained and qualified? Yet no where in the investigation do you see any questions raised about AF convective weather avoidance procedure training and why is that?

For a safety investigation to have any merit, it must identify what went wrong and what steps can be taken that will prevent the mishap from recurring. Why do so many airlines have their pilots “practice to proficiency” the windshear go around procedure, auto and manual?
Why do so many airlines require their flight crew, by procedure to brief whether or not the landing runway is grooved or not? How could any airline operating be oblivious to the notes on 10-9A about grooving? How could any airline not make this information an element of the approach runway briefing?

How could the Canadian national airport authority contractor make a decision to not groove their main instrument runway in their biggest city, or any runway in the country for that matter, and ICAO and not one other global safety authority object? How is it that ATSB could complete their investigation and not cover these subject areas? Is it possible that the humans on the ATSB made an error? Of what use is their report? What steps did they recommend to prevent the re-occurrence of this same mishap?

Is it possible, just possible, that what the ATSB really did was conduct a legal and administrative investigation where they found fault and laid blame for the damage and injury, but never really found the cause and recommended the actions to prevent a re-occurrence?

Lastly, the purpose of training is to put a crew together, working as a team, using standard operating procedures, designed to give crew members a pretty comprehensive set of well practiced actions to deal with whatever is expected to be encountered. The argument that no one can not make no mistakes is irrelevant. When you look at any and all of the major airline mishaps, the crew made massive errors, the crew did not trap the error and correct each other (two heads are better than one theory of CRM.)

I am not arguing the academic argument of purity from error. Rather I am arguing the very practical argument that a crew well trained in well written procedures will be able to handle just about anything that it encounters.

In the mishap reports that I have read, not only did one crew member make an error, but moreover other crew members did little or nothing to trap and correct the procedures in use. Take the Amsterdam Turkish B737-800 mishap where the crew allowed the aircraft to stop in the air and fall out of the sky. What kind of procedures were those? Where was the training to proficiency program for that airline?

Leave a Reply