Thursday, April 15, 2010

Under pressure

I've refrained from posting on the April 10, 2010, crash of a Tupolev Tu-154 outside Smolensk, Russia, killing all aboard including Polish President Lech Kaczynski and his wife mainly because I've been busy with other stuff. Some thoughts:

1. The Russian investigation is continuing. The all-important data recorders have been formally turned over to Polish authorities.

2. Early word from, apparently, the cockpit voice recorder suggests there was no pressure from the passengers to get into the destination airport.

3. Air traffic control apparently warned the flightcrew about the weather.

4. The crash occurred on the flightcrew's fourth attempt to land. The Tu-154, a Soviet version of Boeing's venerable 727, contacted trees short of the runway and broke up.

This is a classic case of "getthereitis," a situation wherein there is pressure, real or imagined, to complete the flight to the preferred destination. While no one from the back of the plane may have told the cockpit to get into Smolensk, you can bet the crew felt some pressure to do so.

The airport at Smolensk reportedly does not have a precision instrument approach (ILS). Instead, the crew was flying an unspecified non-precision procedure, probably an NDB, given the location. Non-precision approaches are reliable when properly flown, but they're not designed nor intended to enable a landing when the airport is totally obscured by weather.

Lessons? None with which the aviation industry is not already familiar:

1. Don't succumb to pressure -- real or imagined -- to do something against your best judgment while in an airplane.

2. The time-honored practice of taking a look -- attempting an approach when the reported weather is below its minimum altitude, visibility or both -- is only a good choice if/when you have the discipline to fly the procedure and then evaluate the conditions you encountered and make an intelligent decision.

3. WRT to 2., no one knows at this time -- maybe the CVR/FDR readouts will shed light -- whether the crew saw enough of the airport environment to make additional attempts.

4. My rule of thumb: Taking a look is fine, as long as an honest evaluation of the results is made. If I screwed up the first approach and know what I did wrong and am positive I can fix it on the second attempt, I'll make a second attempt. If not, I'll go somewhere else. If I screw up the second attempt, I'll go somewhere else. Never are more than two bites at the apple appropriate.

There's simply no excuse for a professional flight crew -- which we have to assume this was, since it was flying seemingly the entire top echelon of the Polish government -- to make four attempts to land at this location.

A final thought: Never place all the important people on the same airplane at the same time.



Anonymous Krasnall said...

Bad training and bad operational procedures. As simple as that.

Two years ago we had another military accident:

Looks like nothing has changed. So many people died...

2:39 PM  
Blogger Juanpilot said...

Lack of any voice communication on the CVR does not mean the pilot did not feel pressure. The Presidents previous action towards another pilot were ample to pressure for this crew. That is why one of the cornerstones of any safety system; is a culture of safety from everyone involved. "Head of State" transportation also requires dedicated crews and aircraft.

7:28 AM  

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