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Analysis of incident type landing with landing gear

Analysis of incident type landing with landing gear

Incident 1. At the moment when the commander of the ship gave the command to release the chassis, the instruments of the engine group showed a surge of parameters. Having received the command, but not having had time to fulfill it, the mechanic went to another procedure: control of engine performance parameters. But nothing serious happened, the instruments "calmed down." Having convinced himself of the proper operation of the engines, the flight mechanic did not return to the procedure for releasing the chassis and, without making a report to the commander of the ship about the chassis, proceeded to perform other of his regular functions; Control of aircraft systems and preparation for the next full-time command of the ship's commander - the release of flaps. After their release, the commander of the ship, without receiving a report, but knowing that the chassis should be released, asked the air mechanic: The chassis was released ?. To which the mechanics confidently replied: The chassis is released.

The warning board and the pilot-landing signaling device worked properly, the sound signaling was shortly before it was turned off in the process of reducing the speed of the flight. As a result, landing was carried out on the fuselage. The fact of landing on the aircraft engineer and other crew members initially provoked a malfunction of the chassis release mechanism. And only after a while they drew attention to the lights of the pilot-landing signaling device, corresponding to the retired position. "I was so confident in myself," the air mechanic later said, "that I could not even imagine that I had done something wrong."

So, do not release the chassis due to confidence in the mechanic that he released it, and not forgetfulness or negligence. Therefore, aviator, and I did not look at flight control and landing switch and alarm display to check itself. Why re-examine what is sure? Therefore, the designation of this error as a '' pass' is fixing only the external action plan (mechanic failed to make another standard procedures - has not released the chassis), in the domestic same plane no pass - mechanic did not do this procedure because sure it's already done.

The phenomenon of self-fulfillment is actually unfulfilled procedure is called the phenomenon of the execution, which was the cause of this error.

Here it is necessary to clearly distinguish between the causes of the error and the occurrence of the incident. If the error is corrected in time, the incident will not occur. Alarms and the requirements of instructions on the need for crew members to check and re-check chassis positions are aimed at preventing accidents It would seem that the three alarms - the audible siren, the flight-landing signaling device 'and the emergency panel' 'Release the chassis ”- guarantee a clear determination of the position of the chassis. But the fact is that the siren is turned off as interfering with work, and the light alarm system is created without taking into account the psychological factor - the possibility of the occurrence phenomenon, due to which the pilot simply does not look at her.

The instruction provides for the need for the crew to monitor the chassis position. But, as it turned out, the flight mechanic does not fulfill this requirement because he is confident in his actions. And what about the commander of the ship, who in accordance with the instruction should monitor the actions of other crew members? The good intention of the drafters is quite understandable: the commander is personally responsible for the flight, and therefore he must follow everything himself, and man is prone to make mistakes, so it will be better if he duplicates the actions of both the crew members and his own. Concern for security seems to be obvious.

However, consider the situation from a psychological point of view. Firstly, the act of verification is the second action, parallel to the main one - piloting, very important and very complex. In addition, psychologically alien to him, not logically included in it, but because it requires distraction. In other words, the pilot must simultaneously perform two different actions. As simple as they themselves are, however, it is very difficult to combine them psychologically. Secondly, control generates an interpersonal conflict between the ship's commander and the air mechanic. Of course, the crew members understand well that the instruction is an instruction and it must be strictly observed. However, the requirement to check the position of the chassis by the ship's commander from a purely human point of view is a manifestation of distrust towards the flight mechanic. If the commander trusts the subordinate, then he will not recheck it. Yes, and how not to trust, when together they made hundreds of flights.

Thus, in itself, a requirement of personal checks commander of the ship landing gear position contributes to the destruction of the task of piloting and conflict in interpersonal relationships between crew members. As it happens in many ways because both signaling and user manual are designed without taking into account the psychological regularities of the activities of members of the crew, and therefore are often not effective.

To reveal the true reasons for not releasing the chassis allowed only an analysis of the content of the flight mechanic's consciousness. The procedure for parsing what happened, which guarantees high reliability of its result, is rather complicated. It includes special psychological methods and is carried out by a qualified aviation psychologist. This complexity explains the fact that the phenomenon of performance has not been found for a long time, and the attention of researchers has turned to the factors accompanying the activity, but causally not related to the error: emotions, violation of the stereotype of actions, etc. This, in turn, predetermined the fact that preventive measures were not effective.

But why is there a false confidence? From a psychological point of view, using the concept of pseudo-action, these events can be explained as follows.

The flight mechanic has hundreds, maybe thousands of times, of the procedure for releasing the chassis, and the very movement to switch the tumbler never caused any difficulties and did not require special control. This means that the procedure is performed at the operation level. Extraordinary action (control of devices) is defective, defective in the activity of the air mechanic, as it is unexpected and not coordinated with the plan for ordinary activities. The air mechanic does not intend to implement it. But this action has a full-fledged phase of achievement: it is very important for the mechanic to fix that the engines are in order, everything is fine. Forced and unexpected switching of attention to the control of engines led to the fact that the action that the flight mechanic was preparing (was intended) to perform, was not carried out in a timely manner - the state of intention hung in the air. Thus, we can state the existence of conditions for the formation of pseudo-action: there is a state of intent in relation to one action (release of the chassis) and there is a state of relevance and achievement in relation to the other (control of the operation of the engines). The conjugation of these fragments leads to the formation of a formal integrity of the performed activity and, accordingly, to the absence of discontinuities in it, which creates a subjective sense of the correctness of the performed activity.

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