By Jan U. Hagen (auth.)
In such a lot corporations, mistakes - even though universal and unavoidable - are hardly pointed out bottom-up. utilizing this instance of the excessive hazard aviation this publication examine how energetic errors administration can paintings and bring about luck. utilizing educational study and 10 genuine aviation injuries instances, this booklet will offer compelling and informative reading.
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Extra info for Confronting Mistakes: Lessons from the Aviation Industry when Dealing with Error
It is the job of the pilot not currently flying the plane to read out the information from the quick reference handbook. ” This form of address is very unusual in Turkish. It is more likely that Gergin said “Efendim” (sir), indicating his respect for and trust in his captain. 32 C O N F R O N T I N G M I STAKE S indicators. This would have revealed that one of the indicators was showing a different value, and was therefore defective. Even if all three airspeed indicators were to have failed completely, there is a specific emergency procedure that would have enabled the crew to continue flying the plane based on precisely defined settings for engine power and pitch angle.
In all the examples we have looked at, the tendencies to submit to authority, worry about possible reactions, or fear what will happen if the authority figure gets annoyed ultimately had fatal consequences. All that the copilots had to do was ask, give a warning, issue a correction, or – as we saw in the last case – insist on compliance with a specific regulation. This would have reminded van Zanten that he was not allowed to take off without explicit permission from the tower. It is possible that criticism would PAR T I ▶ PRE CRE W RE S O U RCE M A NA G E M E N T 45 not even have annoyed the captains in our case studies.
Although he knew that, Erdem said, “Okay, it’s no matter. Pull 47 Volume 3 of the Birgenair quick reference handbook contains clear instructions for pilots flying with unreliable airspeed indicators. In particular, it lists recommended angles of attack and engine powers for a range of flight attitudes (climb, cruise, descent, and approach), depending on the gross weight. This should enable the flight to continue even without the primary airspeed indicator. ” Pulling and reinstalling the circuit breaker deactivated the loud warning alarm.