NTSB Case Study & Panel Discussion - Identifying the Safety Focus through the Causal Factors
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- Опубліковано 2 чер 2024
- Truckee, California Challenger 605 Accident
In 2021 a Challenger crashed in Truckee, California while circling to land that resulted in 6 fatalities. This accident, which was the result of an unstabilized approach, self-induced pressure, poor crew resource management, and a lack of leadership, has captured the business jet industry’s attention.
In this session, NTSB Board Member Michael Graham will host a panel to discuss key safety topics and factors that contributed to the accident.
www.ntsb.gov/news/press-relea...
00:00 Beginning
00:15 Introductory Remarks by Member Graham
02:00 Questions We're Looking to Answer
03:15 Program Overview
04:01 Overview of Truckee Challenger Accident Investigation
25:03 Panelist Introductions
28:02 Circling Approaches
33:22 Crew Resource Management (CRM)
44:25 Shared Mental Model
52:10 Leadership/Followership
01:02:42 Decision Making
01:09:10 Contract Pilots
01:12:43 Technology to Prevent Similar Crashes
01:15:26 Audience Q&A
01:29:38 Closing Remarks by Member Graham
POINT ONE 28:02 Each of these two training vendors (FSI and CAE) specifically cite the PROBLEM as "regulatory limitations" for both training and checkrides. The training vendors are profit driven and only want to train the minimum necessary sim time to get the client his piece of paper. Until now, there has only been two airports in USA that offered a full visual circle to land that was FAA approved. They were KMEM and KJFK. Therefore, all clients only practice for what is going to be on the checkride,, they pay the bill and leave with the piece of paper fully FAA certified, but the training and checkride that they got is NO WHERE CLOSE to what they are going to see in real world operations. Operators would be money and lives ahead to request and pay for extra circle to land training at non approved airports for a real-world check of procedures (all the "other things in this video that were faulty in the CL-605 crew.) Just because the FAA hasn't approved a particular IFR circle to land approach due to lack of visual realism limitations, doesn't mean that you can't train it!
POINT TWO 1:12:42 Graham: "Is there any technology out there that might have prevented this?" You paid to bring all these people in to one stage at the same time, you produced a video that went on for 90 minutes. You talked about everything with regard to organizational issues and CRM, but you never mentioned the cause of the accident! This crew had zero speed awareness requirement knowledge at any time. The minimum maneuver speed (maneuvering is a requirement of the IFR circling approach) was NEVER bugged, briefed, or flown! They had zero training vendor supplied training material or guidance concerning level of automation, flap/slat selection, minimum speed to bug and fly, who is going to be inside, and who is going to be outside!
Both of these guys likely practiced one ILS 27 at KMEM with Circle to 18R and examiner said, "good job, let's go eat."
There is no wonder that this crew crashed, they had a FSI or CAE produced FAA piece of paper in their pockets that "enabled" them to attempt the fated IFR circle to land while very poorly equipped to actually accomplish it, even though they paid their invoice. Each of these training vendors allow the client to fly like they want to and configure when they want to use a "Vref plus X" catch all that is specifically "not" standardized and does "not" offer a 30% stall protection buffer.
POINT THREE The full result of this conference ends up on a UA-cam channel that gets 581 views in the first two days. You guys spent a lot of money, but you missed the whole point of the accident. But it's OK - no one will ever see it.
The Probable Cause of this accident was Industry lack of Awareness of their lack of Speed Awareness.
These people are tone deaf. They just don’t get it. @ProbableCause-DanGryder
Ya nailed it, Dan. I don't think I heard the word "airspeed" ever.
Thanks for posting!
Sheesh. Get a room.
Come on Browne. You know this isn’t even a good try.
Great professionalism in this NTSB video.
How are you saving lives when nobody sees this?
Nobody saw that you commented about how nobody saw. Like what was this even for?!?!
@@ProbableCause-DanGryder
They must feel like they have to justify their salaries and that this dog & pony show did that.
Unfortunately, this production merely satisfies the suspicion of critical thinkers that these people are simply bureaucrat grifters.