Interoperabilidad sociosanitaria

What happens when you have a viciously punitive system for pilots (and other employees) who make mistakes? What happens when you fine pilots money for operating outside of an arbitrarily tight set of parameters? What happens when you have a widely publicized department tasked with constantly monitoring and reviewing said parameters with a team of non-pilots who pride themselves on finding said mistakes and consider tallying the numbers and publishing them with the names of the guilty an act of safety? What happens when everyone has this sword of Damocles emphasized, constantly referred to and reminded of in their daily lives? What happens when this sword is unyieldingly referred to as a safety measure? We all know the answer:

On your marks… get set…

Go!

Uh-huh… uh-huh… I see… and??? Aw jeeze. OK, fine, let’s do this. So what were the weather conditions? Icing? No mention… so we don’t know. I guess we have to assume it was clear and a million (pfft, yeah right, China clear?) and the vibrations were the indication of a mechanical problem. Fine.

Page | 160 OK, great theory. They didn’t run a checklist… yet at least. How many of us, at the first indications of a problem, escalate to defcon 1 and run a checklist? No, of course not; we trouble shoot for a minute, see what’s going on and then do something about it. God forbid you run the wrong checklist after all.

But, it is interesting that they didn’t disengage the auto-throttle, and worrisome they did nothing when the indications returned outside of the limitation. I think most of us would have disengaged the auto-throttle almost without thinking. Isn’t it one of the lessons we learned from Alaska 261: you should disconnect the automation when you think you’ve got a problem? This crew thought they had a problem initially but they didn’t stick with it. Huh. I wonder why?

Hmm. Now things are getting a little interesting: they finally disconnected the auto- throttle, and then reconnected it. Did they run the checklist at this point? I’m inclined to say maybe because the checklist calls for the pilots to reduce thrust until the vibrations for that engine show green, and then advance as necessary. If the vibrations increase again, then reduce it to return to the green and leave it there. So, maybe… But it is a bit troubling that they reconnected the auto-throttle; it would seem that having the auto-throttles disengaged was a configuration they were not comfortable with (which harkens right back to Asiana at SFO).

Page | 161 OK, finally. They disconnected the automation and left it off. Good.

With all of this discussion about not running a checklist you have to wonder if the crew divulged this fact during their de-briefing. Perhaps, and if it was the case that they didn’t pull the QRH then yes, they should have run it.

But, there is a really important question not being asked here: does Tianjin Airlines have any theory as to why they didn’t run a checklist and why they were so quick to re-engaged the automation after having released it? No, and the answer has nothing to do with CRM or checklist use and everything to do with a hostile work environment, in my opinion. If you are afraid of dealing with a situation because of the possible repercussions for your actions, the impulse is to sweep the problem under the rug and not deal with it properly. It becomes a self-fulfilling prophesy.

Page | 162 OK, this was not entirely explained in the facts above. Regardless, the question here again is why. My theory, which may or may not hold water, is that when you have a brow-beaten group of individuals operating in an environment that requires a certain degree of extemporaneousness and freedom of thinking, there will be shortcomings. One tends to engage in CYA activities instead of engaging with the issues. This is a sign of weak leadership on deck which has been modeled on the examples of weak leadership throughout the organization; and having a big hammer (that falls unfairly and therefore arbitrarily) waiting at the end of this escape chute only compounds the situation.

“Familiarity” can really be equated to rote knowledge. The problem is that, while you can have all the rote familiarity possible with such documents, when you have a group of people not used to thinking on their own or taking the initiative to deal with situations happening in a live environment, familiarity fails quickly. It gives way to the far more pressing need of higher forms of mental activity like experience and correlation, application and synthesis. These higher levels of cognition are edited out of the Chinese experience, i.e. have been brow beaten out of them.

Page | 163 This whole analysis I’m engaging in is pretty vanilla when you boil it down; I mean, these are all issues we’ve dealt with scores of decades ago in the West. So, while we’re in the thick of wading the bullshit here, the next issue I’d like to bring to your attention is the gap, the vast divide between the power-holders in the Chinese Tianjin Airlines hierarchy and foreign pilots. We foreign pilots eat these kinds of situations for breakfast with a glass of OJ and side of hash browns. The Chinese, on the other hand, are incapable of dealing with them rationally. In exactly this way, as a foreign pilot operating in China you WILL NEVER be able to relate to their body of policy; and I’m not talking about the policy in the SOPM. I’m talking about the word-of-mouth policy that the airline runs on. As a decision maker, you WILL eventually run into a situation where you will be manhandled and punished for using your judgment. You cannot change this situation. Some foreign pilots have opted to just follow along, but that’s ultimately untenable and unsafe. At least one foreign pilot has been weaving his little web and encouraging the Chinese to keep doing what they’re doing… So, good luck with all of that.

In the interests of brow beating, let’s continue on with a related kind of beating: the kind that involves a dead horse. Shall we? Nega?

Again, the essence of what they are talking about here (if we can make sense of the crappy translation) is true in the case of malfunctions like STEERING RUNAWAY: you have no time to run a checklist, you have to react and save the day. On the other hand, as it seems this crew was initially doing, you need to troubleshoot when the situation calls for it. After you have deemed a situation is abnormal, then you run the checklist and apply the relevant items. Despite their reluctance to disengage the auto-thrust, the crew eventually acted appropriately. So why is this being made into a federal case?

The thing that would be going through my mind as a potential candidate is, “What situation will I end up in where I make a decision (there is no “we” on a Chinese flight deck), the defense of which I will have to mount and ultimately fail and then suffer humiliation and public criticism along with a monetary punishment that could potentially be upwards of $10,000.” To take this a step farther, “What situation have I been in recently as a western pilot flying for a western company that was a non-event; how would it be blown totally out of proportion in China and expose me to a number of unsatisfactory company procedures and arbitrary punishments?”

Page | 164 Now we see a complete reversal of the policy they have been hammering away at with these wild exceptions that confuse the rules. In the West, this stuff has all been settled a long time ago; in China it’s fresh and dangerous. Do not expose yourself to this, the money is not worth it.

But really, the subtext here is that IF the PIC is a company leader, instructor or good friend of a leader or instructor, yes these rules don’t apply to you and we’ll get you out of it with the help of good ol’ Mr. Delete Button. He sure is a good friend.

Here we go with the CRM again. Yes, the CRM concept is exceedingly important in airline operations and key to successful resolution of emergency situations (which this scenario was not); yet, it is not flight-crew CRM that is necessarily at fault here. This is a misapplication of the concept and shows how little they know what CRM is really about.

Page | 165 Again, yes safety is very important. What is completely being missed by the people who wrote this document is that safety cannot be brow-beaten into the pilot group or halo of support staff. This event is being treated as an extremely important incident by the company; they spent a lot of energy interviewing the participants, generating the document and disseminating it at large. Accepting that, it’s the stuff that’s missing or just patently wrong which causes the most concern.

And so, in conclusion:

Yes China, great spelling and a very good concept: safety is safe. Very very good.

Page | 166 Let’s see you not get some kind of foot fungus, I mean, this shower curtain is totally clean right?

So, the floor should be just fine…

The written went well; there are several questions not in the bank. Make sure you study the bank and the book. If you do not, you will not pass.

The sim is squirrely. Don't jump on the rudders or you will end up in a 'Dutch Roll' on your V-1 cut. The CAAC guys are douchebags; don't let them rattle you. Wear a button up and tie, nice shoes; one in our group got hammered for wearing sneakers to the sim. My ride began short of the runway with low viz and freezing conditions. You ought to mention de-icing; for sure taxi and takeoff in the icing configuration. There will be a start malfunction. Call for the checklist.

My first roll was an aborted takeoff from compressor stall; then a normal TO to FL200 where we did the rapid depressurization with an emergency descent. After level at 10k we lost ESS bus 1; ILS with 20kt crosswinds (everything is flown with 20kt or more). Then a V1 cut to a single engine ILS without an FD, handflown to minims and a missed approach. Single engine pattern to a VOR approach. I messed up and went missed; they didn't really care. Single engine visual. Then a 2 engine visual with max crosswinds. I should have done a flaps-22 landing. Done.

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