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Analysis of the incident - a missed approach

Analysis of the incident - a missed approach


Incident 2. The crew carried out all the procedures necessary for landing. Before landing from the ground, a command was given to go off to a second round. The commander of the ship commanded the flight mechanic: RUD-100. Remove the chassis. " The flight mechanic, looking at the instruments indicating the position of the throttle, moved the levers to the "100" position and, without taking his eyes off the instruments, transferred the Chassis switch to the Removed position. Immediately after switching the chassis switch, the flight mechanic could not check the position of the chassis by the light signaling - it only works a few seconds after the toggle switch is activated. Later, when the light signaling of the position of the chassis should have already worked, the flight mechanic did not address it, since he was completely occupied with observing (by instruments) the work of the engines.

The need for continuous monitoring of the operation of the engines was due to the fact that at the maximum mode, their failure is most likely, and at a low flight altitude, instantaneous processing of the failed engine is required. The flight mechanic did not report on the execution of the command. So, the plane left on the second circle with the retracted landing gear. It should be noted that, under the instruction, the crew must clean the chassis when leaving for the second round. In fact, this is done for various reasons, not always. Therefore, on the second lap the commander of the ship, bearing in mind that the flight mechanic did not report on the release of the chassis, and drawing from this the conclusion that the mechanic of the chassis did not clean, did not give the command to release the chassis, but only asked just in case: "Is the chassis released?" . He himself personally, despite the relevant requirements of the instruction, did not check the position of the chassis, as he was entirely engaged in piloting: landing is the most stressful stage in flight. Bortmehanik responded confidently to the question of the commander: "The chassis is released," being firmly convinced that when he left for the second round, he did not clean the chassis this time. As a result, the plane landed on the fuselage.

As in the incident, signaling of chassis and display of flight and landing alarm worked properly, audible alarm has been turned off, and the commander also rechecked job mechanic. And just the fact of landing on the fuselage caused a first assumption of failure of the landing gear mechanism, and then realized the error of the ball.

Thus, due to non-issuance of the chassis, as in the incident 1, not forgetting or negligence and false confidence. But unlike the incident 1 mechanic is not sure that he released the chassis, and that it is not cleaned at the missed approach, ie if in the first case, mechanic considers not doing the procedure performed, in the second case, he believes the procedure done really outstanding. The phenomenon of confidence in default actually performed the procedure is called the phenomenon of non-compliance. He was the cause of the error.

The incident, using the concept of psevdodeystvie can be explained as follows.

Since in the situation to take off or missed approach procedure ORE-100 and cleaning of the chassis are connected in time and follow one another, and the motor part of these procedures is quite simple, they actually considered as one flight engineer procedure. Considering this, and taking into account that in this incident was a mechanic obsessed with monitoring the operation of the engine, it can be argued that in this case the procedure for landing gear did not form a separate independent intention - it was understood as part of a complex act.

Appeared unrepresented and experience to achieve that fell on the following reasons, the actual position of the chassis is not determined by the position of the toggle switch '' chassis' and the color lights on the flight and landing annunciator. Color lights

Is considered an indicator of the true position of the chassis. The significance of their color is indicated by the fact that the flight mechanic often reports on the execution of the team for cleaning or releasing the chassis, indicating not only the execution of the crew (the "chassis" was released), but also the color of the lights ("the chassis has let out - the green lights" ). Since in the described incident the flight mechanic did not apply to the flight-landing signaling device during the missed approach, it means that the control of the chassis cleaning procedure did not take place and, consequently, there could not be any experience achieved. Thus, the experience of the procedure for harvesting the chassis was defective, incomplete.

But on the subjective plane, the formal structure of the activity performed by the flight mechanic is not broken. There is a state of intent in relation to the procedure '' RUD-100 '', followed by the state of relevance, and beyond it - the state of attainment. True, two different acts correspond to the state of relevance, but due to the fact that one of them is represented by an independent experience of intention and attainment, there is a connection, the combination of two actions into one. A pseudo-action is formed, which is experienced as an operation of the Rud-100, but the chassis harvesting procedure is not represented in the experience. The absence of the experience of the procedure is realized as its non-fulfillment. Therefore, the flight mechanic, when the commander of the ship draws his attention to the chassis, answers; The chassis is released, as I'm sure that I did not remove the chassis when I left for the second round.


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