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Hiding Your Mistakes? Flight Crew Incident  
User currently offlineTechRep From , joined Dec 1969, posts, RR:
Posted (11 years 10 months 1 week 3 days 8 hours ago) and read 3118 times:

I have found that hiding your mistakes can sometimes get people killed. I was taught if you make a mistake, pony up and come clean. As a mechanic this is common, "Hey boss I broke that stud off on the Fuel control unit". Instead of trying to hid it and causing a possible leak/fire condition. Mechanics find this easier IMO than pilots. Pilots seem more prone to hide mistakes IMO, the potential loss of considerable income and stricter penalties levied upon pilots by company seems to negate coming clean. For your review I will post an NTSB article that sums this up perfectly. (MODS this public material and CAN be copied from NTSB web site).

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20011030x02159&key=1

NTSB Identification: NYC02LA013

Scheduled 14 CFRPart 121 operation of Air Carrier Mesa Airlines (D.B.A. US Airways Express)
Accident occurred Tuesday, October 16, 2001 at Roanoke, VA
Aircraft:Embraer EMB-145LR, registration: N825MJ
Injuries: 33 Uninjured.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

On October 16, 2001, at 2114 eastern daylight time, an Embraer 145LR, N825MJ, operated by Mesa Airlines as US Airways Express flight 5733, was substantially damaged while landing at Roanoke Regional/Woodrum Field Airport, Roanoke, Virginia. The 2 certificated pilots, 1 flight attendant, and 30 passengers were not injured. Night visual meteorological conditions prevailed for the scheduled passenger flight. The flight was operated on an instrument flight rules (IFR) flight plan under 14 CFR 121.

According to Mesa Airlines personnel, the flight originated at Pittsburgh, Pennsylvania. No problems were reported with the en route or approach phases, and the flight had been vectored for a visual approach to runway 33.

According to the captain:

"???While on short final approach to landing at Roanoke (...[reported winds] of 280 at 25 [knots] gust to 40 [knots]), there was an abrupt drop in indicated airspeed. Upon simultaneous notification of the stick shaker, I applied power accordingly and landed without apparent incident.

As the landing was more firm than usual, the first officer and I mutually agreed to visually inspect the aircraft upon arrival at the gate. The visual post flight inspection noted nothing unusual, nor any damage to the aircraft.

As the occurrence noted no damage to aircraft, passengers, or crew, no further action was taken."

According to the first officer:

"???We arrived into the Roanoke area approximately 9:45 PM, and began a visual approach to runway 33. The captain briefed that a go-around was not an option due to hills on the other side of the runway. Takeoffs were not authorized on 33 during night and IFR operations. Although we had a quartering crosswind at 15 mph gusting to 21 mph, I do not think there was any wind shear. The approach was normal until approximately 300 feet AGL, when I called that we were one dot high on the PAPI and Ref +5. The captain appeared to pull the thrust levers to idle and placed both hands back on the yoke. At 200-300 feet I called Ref -5, Ref -10, then the stick shaker activated for one second and we began to sink rapidly. I saw the airspeed reach 110 KIAS, the captain pushed the thrust levers up, but the engines did not spool up in time, and the stall stick shaker went off [again]. At this point, approximately 100 feet AGL, the aircraft seemed to stall and within seconds hit the end of the runway. The main gear hit the runway very hard, then the nose gear followed quickly. I do not recall the pitch attitude. The events happened very quickly, and by the time I thought about going around it was too late.

Immediately upon deplaning I inspected the entire aircraft with a flashlight, paying particular attention to the landing gear. I did not notice any damage to the aircraft, and if I had, I would have reported it immediately. The captain verified that there was no damage and said that it was not necessary to have maintenance inspect the aircraft. I felt uneasy but complied."

The flight attendant stated:

"I strapped in, heard all the necessary commands from the computer in the cockpit: '300', '200', '100'...then right after I heard the computer say the 100...I heard this alarming shaking noise and rapid beeping alarm...The aircraft immediately slammed to the ground???."

According to a check captain for Mesa Airlines:

"At approximately midnight on October 16, 2001, I received a phone call from Captain... telling me she thought I was taking her plane the next morning...she told me about her arrival into ROA in strong gusty winds. She described it as a rough ride with a possible stick shaker and a hard landing at the end. I asked her if there was any damage to the aircraft. She said the FO and her had inspected the landing gear and tires during post flight and found no damage. I told her that if she was in doubt, she needed to report it as a hard landing...Upon arrival at the airport the next morning, I discovered that the Charlotte crew had the [accident] airplane and not myself. Wanting to pass on the information to...[that captain], I summarized the story from the night before...."

The accident airplane was subsequently flown to Charlotte, North Carolina, where a crew swap took place. The new flight crew discovered the damage during the pre-flight inspection.

the airplane was removed from revenue service and further inspected. A ferry permit was then issued, and the airplane was flown to a heavy maintenance facility for further examination. There, it was determined that the airplane had broken and cracked frames and stringers, popped rivets, and the skin had been worn through in the lower aft pressure vessel. Scraped skin was also visible on the lower aft fuselage, in an area about 10 feet long by 3 feet wide.

There were no notations in the airplane's log sheets regarding a hard landing at either Roanoke or Charlotte. However, the accepting crew at Charlotte entered a maintenance discrepancy of a tail strike due to overrotation.


The cockpit voice recorder and flight data recorder were retained for further investigation. According to the flight data recorder, the maximum g load at the time of touchdown at Roanoke was +2.75 fir 0.25 seconds.

The 2054 and 2154 weather observations at Roanoke reported winds from 300 degrees at 17 knots with gusts to 22 knots, and winds from 280 degrees at 16 knots, with gusts to 23 knots, respectively.

The captain's total flight experience was about 2,500 hours. She had accumulated 200 hours in the EMB-145, all within the preceding 90 days. She had upgraded from the Beech 1900, where she had been a first officer.

The first officer's total flight experience was 1,850 hours with 750 hours in the EMB-145. She had accumulated 90 hours in the preceding 90 days. She had upgraded from the Beech 1900, where she had been a first officer.

What will happen to this Captain in your opinion? Do you think I am incorrect in saying crew members try to hid mistakes?

TechRep





36 replies: All unread, showing first 25:
 
User currently offlineFlightSimFreak From United States of America, joined Oct 2000, 720 posts, RR: 0
Reply 1, posted (11 years 10 months 1 week 3 days 4 hours ago) and read 3025 times:

That's what you get with those new-fangled un-manned cockpits! (did you see that the Captain and F/O were both female? I'm guessing the flight attendant was too!)

User currently offlineNormalSpeed From , joined Dec 1969, posts, RR:
Reply 2, posted (11 years 10 months 1 week 3 days 4 hours ago) and read 3019 times:

I don't know. It's debateable whether the captain's statement "without apparent incident" is honest or deliberately vauge. I'm glad it's not my call.

'Speed


User currently offlineOPNLguy From , joined Dec 1969, posts, RR:
Reply 3, posted (11 years 10 months 1 week 3 days 4 hours ago) and read 3016 times:

Another example... (I'm sure this is somewhere on the NTSB's site, but I'm just doing this from memory)

Air carrier 727 crew shot an approach to minimums on 17R at Harlingen (HRL), missed approach, and diverted to San Antonio (SAT), and terminated the aircraft for the night. Another crew came out to the aircraft the next morning to ferry the 727 back to DFW, and they found damage to the tail section, including various punctures. Seems they'd descended below DH on the approach into HRL the night before, and actually made contact with the ALS structure(s), and maybe even the ground. (Can't recall if they found mud on that walkaround, or not). Aircraft was MX-ferried back to DFW, unpressurized, and was out for a few days. Crew had certificate actions taken, and I think I recall that they lost them for 1 year.

In general, I think all humans in aviation are fully capable of making mistakes, be they pilots, mechanics, or, yes, even dispatchers...  Big grin No human is immune from the possibility of doing so.

I also agree with your statement that if a mistake is made, it is indeed best to pony up to it, and take the consequences. Why that doesn't happen more regularly in real-life is a mystery that someday will get solved, but for now, it's still a mystery some of the time.

Mostly though, I think it's due to an attitude of self-deception and reality-evasion. Again, any human is susceptible, but it can often be seen in some crews' reluctance to write-up stuff after an incident like the one you mentioned. Perhaps the mentality is, "what should I do that for? Nothing really bad happened" when it also serves to avoid the possible reality that any post-flight inspections (walk-arounds, contract MX, etc) might discover something that proves their inevitable fallibility as humans.

Not saying that they're bad pilots, just pilots (and by association, us dispatchers and MX types) that are humans.

After the Air Florida accident back in 1982 (I there at the time) two fellows wrote an article on self-deception and reality-evasive behaviors that was dead-on, I think, and a basic element in many of these kinds of situations. An interesting aspect of the article was that it was written by 2 biologists, and not aviation-oriented folks with their own possible agendas. It's something that all humans are capable of, aviation industry or not.

I'll see if I can find a copy on-line somewhere and post it. If not, I've got some re-typing....


User currently offlineFredT From United Kingdom, joined Feb 2002, 2185 posts, RR: 26
Reply 4, posted (11 years 10 months 1 week 3 days 3 hours ago) and read 3001 times:

Good post, TechRep, thanks for bringing it up. It is an interesting issue.

One factor which I would like to know more about before passing any kind of judgement is the incident culture within Mesa Airlines. What would have happened if the captain told the story as it was right away? Saying, "Yes, I f*cked up since ... and here is what should be done by me and by others to prevent it from happening again, to me or others."

As humans, we all mess up from time to time. That's why we need to have SOPs, technical systems, training, other people and other barriers making sure that when we do, the consequences aren't catastrophic.

What barriers are in place? How were they circumvented in this case?

"Go-around not an option...", now that's something I don't like hearing.

And yes, flight crews do try to hide their mistakes at times, and probably most other professional categories who think they can get away with it. Education in risk management, quality management and anonymous reporting can do a lot, I think.

Cheers,
Fred



I thought I was doing good trying to avoid those airport hotels... and look at me now.
User currently offlineNormalSpeed From , joined Dec 1969, posts, RR:
Reply 5, posted (11 years 10 months 1 week 3 days 3 hours ago) and read 2997 times:

Yes, great post, TechRep.

OPNLguy, I'd love to read that article.

'Speed


User currently offlineOPNLguy From , joined Dec 1969, posts, RR:
Reply 6, posted (11 years 10 months 1 week 2 days 20 hours ago) and read 2945 times:

I'll start typing... Give me a couple of days..

Tech rep...can you email me?


User currently offline737doctor From United States of America, joined Mar 2001, 1332 posts, RR: 40
Reply 7, posted (11 years 10 months 1 week 2 days 19 hours ago) and read 2946 times:

The way I see it (the mechanic's perspective), if you screw something up, you better admit it and make it right while the plane is still out of service; that is the time to fix things. Like we say in Heavy MX, when it comes to sheetmetal work, you can't screw anything up so bad that it can't be fixed (even though a simple repair might turn into an extensive one).

Can't speak for pilots though. The vast majority of pilots I've dealt with were very professional and I have no reason to question their integrity. However when I worked on DC-8's, I do remember a few times finding the paint missing off of the tail skid with no mention of a tail strike from the pilots. I think maybe it boils down to pride.



Patrick Bateman is my hero.
User currently offlineFlyingbronco05 From United States of America, joined May 2002, 3840 posts, RR: 2
Reply 8, posted (11 years 10 months 1 week 2 days 19 hours ago) and read 2932 times:

I have made a few mistakes in a 172 as well as in the king air. However, they have all been minor and no one has been killed. The good part about mistakes is that you learn from them. The bad part is you can only make so many mistakes BEFORE someone does get hurt/killed.


Never Trust Your Fuel Gauge
User currently offlineAirplay From , joined Dec 1969, posts, RR:
Reply 9, posted (11 years 10 months 1 week 2 days 18 hours ago) and read 2926 times:

We have an local example that happened a few days ago. A Navajo pilot who was allegedly very low on fuel attempted a landing but he was very high and he and ATC agreed that he would go around. The ceiling was 400 feet AGL. They vectored him over the city for to circle for another runway. Both engines quit, and he came down on a busy city intersection.

There was no communication to ATC he was low on fuel. Everyone lived, but the aircraft was demolished, a few vehicles were damaged on the ground, the airplane was destroyed and one passenger has already lost a leg and may lose the other.

If he had made it on the initial approach, nobody would have been the wiser and the pilot's safety record would still be spotless. Unfortunately for the passengers in this case, this guy decided to take everyone's lives into his own hands.

This time at least, he couldn't "hide" his mistake.


User currently offlineTT737FO From United States of America, joined Jun 2001, 472 posts, RR: 9
Reply 10, posted (11 years 10 months 1 week 2 days 18 hours ago) and read 2921 times:

The walk-arounds must have been very cursory! It took three seperate crews to finally ID the damage done.

For any potential professional pilots out there, this case reads like A TEXTBOOK! I can see this scenario being used as an interview question/CRM case study.

Here are some points:

1. Pride can kill. Gotta swallow it sometimes, regardless of your job being on the line.

2. Capt was obviously flying the aircraft. FO's statement went into depth to cover her own ass. FO was lax in letting the Capt retard the thrust levers to idle--knowing the aircraft was in a pretty frisky crosswind environment (coupled with terrain) that made windshear very likely.

3. FO did not speak up and insist that maintenance take a look.

4. Flight attendant made statement but left out of the decision loop--did not make any post-flight remarks as to "maybe you should check this out".

5. When a plane goes into a high sink rate at 100AGL, something is sure to wind up broke.

Finally, hard landings have ended promising careers but at the same time they have also had no effect at other companies too. Based on the fact that Mesa is a knee jerk operator, I'm sure someone paid for this incident with their wings.


User currently offlineFredT From United Kingdom, joined Feb 2002, 2185 posts, RR: 26
Reply 11, posted (11 years 10 months 1 week 2 days 18 hours ago) and read 2906 times:

"Mesa is a knee jerk operator"

Well, if that's the case, there we have the main culprit... the kind of company culture that can get people killed.  Sad

Cheers,
Fred



I thought I was doing good trying to avoid those airport hotels... and look at me now.
User currently offlineNormalSpeed From , joined Dec 1969, posts, RR:
Reply 12, posted (11 years 10 months 1 week 2 days 16 hours ago) and read 2891 times:

Well, if that's the case, there we have the main culprit... the kind of company culture that can get people killed.

Aha! I had wondered if there was anything cultural about it. But what specifically about the culture contributed to the accident?

'Speed


User currently offlineSllevin From United States of America, joined Jan 2002, 3376 posts, RR: 6
Reply 13, posted (11 years 10 months 1 week 2 days 16 hours ago) and read 2888 times:

I think it also points out "thinking too much." While the FO and the Captain agreed to walk around and carefully check the landing gear, they got so fixated on "any damage must start from the landing gear" concept that they missed 10 feet of scraped panels on the tail of the aircraft!

When it doubt, check everything, and check it in daylight or a lit hangar.

Steve


User currently offlineBio15 From Colombia, joined Mar 2001, 1089 posts, RR: 7
Reply 14, posted (11 years 10 months 1 week 2 days 16 hours ago) and read 2885 times:

Did they really miss a 10 foot scrape?
Dunno, Sllevin....


User currently offlineSllevin From United States of America, joined Jan 2002, 3376 posts, RR: 6
Reply 15, posted (11 years 10 months 1 week 2 days 14 hours ago) and read 2864 times:

Bio15: Sadly, I've seen more than one inspection miss the forest for the trees... There was a Cherokee 235 that someone had bought, and they bought it knowing it had a cracked engine mount, so the first thing they did was pull the engine off, and send the mount off for welding.

Mount comes back, they reassemble the front end, and go for a flight -- and it had nasty nosewheel shimmy on landing. So off comes the engine again, and checking all this and that, and up goes the plane again. This time I was onboard and yes, it was shimmy like a washing machine -- I had serious concerns about nosegear failure.

So much head scratching is going on, and I suggest "hey, let's take the front wheel off and check it on a stand." So we take it off, and low and behold, this tires is BADLY out of round. As in visibly out of round. A new tire gets put on and voila! -- no more shimmy.

So the story wasn't too bad, since only extra labor was lost, and there wasn't an incident that did major damage or injury, but still, you would have thought 5 guys working on a simple aircraft would have done better, especially since there wasn't any ego on the line...

Steve


User currently offlineSailorOrion From Germany, joined Feb 2001, 2058 posts, RR: 6
Reply 16, posted (11 years 10 months 1 week 2 days 13 hours ago) and read 2851 times:

hm....I'm not a pilot, but how many mistakes have been done here? (Maybe this forum's pilots can help me out)

1) "Go around is not an option": This isn't a space shuttle, go around is always an option. Check the maps!

2) "..pull the thrust levers to idle": Maybe I'm wrong, but thats something you REALLY shouldnt do upon landing, especially not under these conditions.

3) "I felt uneasy but complied": WHY?

4) Both pilots had less than 1000 hours in that aircraft. Together. Is this a good idea?

SailorOrion


User currently offlineMetwrench From United States of America, joined Aug 2001, 750 posts, RR: 2
Reply 17, posted (11 years 10 months 1 week 2 days 12 hours ago) and read 2841 times:

Okay, I'm the guy at the end of the food chain. I really do want to know if something happened to the A/C. Here's how you do it.

Unless the main gear has been pounded through wing, this is how you write it up. (you must report this incident!)

Pilot Report:

"Due to unexpected atmospheric conditions, A/C experienced a firm arrival at ANC. Flight Crew requests an evaluation of the landing gear and associated components."

There! The Flight Crew is covered. The Maintenance Dept. knows what to do without a lot of FAA "fanfare".

Try to avoid using the words "hard landing"!!! That's like walking into a bank and yelling "THIS IS A STICK UP!!"


User currently offlineMetwrench From United States of America, joined Aug 2001, 750 posts, RR: 2
Reply 18, posted (11 years 10 months 1 week 2 days 12 hours ago) and read 2835 times:

I would like to echo FredT's comment about the "Go Around" not being an option.

Aviation's backbone is "SAFETY"! What was that "Bonehead" thinking?????


User currently offlineL-188 From United States of America, joined Jul 1999, 29706 posts, RR: 59
Reply 19, posted (11 years 10 months 1 week 2 days 11 hours ago) and read 2820 times:

Got to wonder about that pilot.

As far as go around's not being an option, Sometimes that is true.... but ometime it is smarter to head home.





I wonder why I say that.



OBAMA-WORST PRESIDENT EVER....Even SKOORB would be better.
User currently offlineDarius From Netherlands, joined Jul 2001, 141 posts, RR: 0
Reply 20, posted (11 years 10 months 1 week 2 days 2 hours ago) and read 2743 times:

This is a very interesting subject! The fact that pilots don't always report their mistakes (whatever mistakes these are) gives the industry a hard time doing adequate research for possible causes for accidents. Let me give an example to elaborate this.
Let's say chances of an aircraft getting involved in an accident are 10-6 (0,000001) (the numbers I use are obviously only for the example, not real statistics). This means that there aren't many accidents investigators can get any data from, data that can be used to prevent potentially hazardous situations of occuring.
But most accidents in aviation have multiple causes, that all need to be there in the chain of causes leading to an accident. Let's say for simplicity 3 causes are needed for an accident to happen. The chances of these causes to happen are 10-2, since the total risk is calculated as the chance of all 3 causes occuring, 10-2*10-2*10-2=10-6.
Now we have incidents happening during 1 out of hundred flights, so these incidents happen rather frequently, each and every day! And exactly these incidents contain valuable data for anyone involved in getting the aviation industry safer.
This is why reporting of incidents by pilots (to stick with the thread, but obviously this goes for anyone involved in the industry) is so crucial. Not only for unreported damage, but also so that can be learned from mistakes to prevent it from happening next time!

And to add a personal opinion, I think every company where risk for injury is involved in their operations needs a culture where every employee is very conscious of the importance of reporting everything that is not normal procedure or leads to any doubt.


User currently offlineMetwrench From United States of America, joined Aug 2001, 750 posts, RR: 2
Reply 21, posted (11 years 10 months 1 week 1 day 19 hours ago) and read 2678 times:

L-188, The coffee cup on the glare shield on the approach into KCR is a nice touch. I can't possibly remember how many CB's, switches, and instruments I've replaced due to liquids being spilled on them.

User currently offlineL-188 From United States of America, joined Jul 1999, 29706 posts, RR: 59
Reply 22, posted (11 years 10 months 1 week 1 day 18 hours ago) and read 2671 times:

I wasn't flying it  Big thumbs up


OBAMA-WORST PRESIDENT EVER....Even SKOORB would be better.
User currently offlineL-188 From United States of America, joined Jul 1999, 29706 posts, RR: 59
Reply 23, posted (11 years 10 months 1 week 1 day 18 hours ago) and read 2666 times:

Come to think about it, I don't drink coffee either.


OBAMA-WORST PRESIDENT EVER....Even SKOORB would be better.
User currently offlineMetwrench From United States of America, joined Aug 2001, 750 posts, RR: 2
Reply 24, posted (11 years 10 months 1 week 1 day 18 hours ago) and read 2658 times:

Okay, it's a "spitoon" for your Skoal. Even more disgusting!

25 TT737FO : Just be glad the coffee cup is secure and not in the pilot's right hand trying to fly the approach.
26 Metwrench : Check again, the cup is not in a captive holder or a gimbal mounted holder. It is standing loose on top of the glare shield which sits on top of a gre
27 FredT : Normalspeed spake thusly, to badly mangle shakespearean english: Aha! I had wondered if there was anything cultural about it. But what specifically ab
28 Erasmus : Hi everybody, First of all I don't think that pilots will try to cover up their mistakes more often then any other category of employees, like for ins
29 Metwrench : Being "forthright" really is the best policy. That's something I learned by the time I was 5 years old! My daughter did the same thing at that age. Sh
30 Darius : Erasmus, That is a great initiative from your company. Do you feel this has helped the pilots to report incidents without fearing reprisal? Do you fee
31 Erasmus : Yes darius, Every few weeks we get a leaflet with the "incidents" or safety related occurences that happened in the company. I do indeed think there's
32 NormalSpeed : FredT wrote: If it is a 'knee-jerk operator' who will have the pilot's wings on a plate for messing up an approach, pilot's won't report accidents, an
33 Vc10 : Airline management culture usually is the cause for crew wanting to hide their mistakes. The airline I worked in for many had the policy of anybody ca
34 TT737FO : Here are some "cultural" items pertaining to Mesa: 1. Mesa is probably THE most prolific commuter in America. It stretches from coast-to-coast and inc
35 NormalSpeed : I'm really glad that this has been brought up. I'm finding this thread very interesting. Tell me, does any of your companies use the NASA forms? 'Spee
36 Metwrench : It's really nifty that all these operators have these wonderful programs, but not once have I seen how Operations is supposed to communicate with Main
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