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ATSB Transport Safety Report Aviation Occurrence Investigation – Loss of…

- - - - Senior FO
        
        19,000 Total Flight Hours
        
        350 Flight hours in last 90 days
        
        3,500 Flight hours in B777
        
        3,500 Total Instrument Hours
        
        350 Instrument hours last 90 days
      - Observer 1 FO
        
        17,600 Total Flight Hours
        
        175 Flight hours in last 90 days
        
        2,500 Flight hours in B777
        
        2,500 Total Instrument Hours
        
        3 Instrument hours last 90 days
      - Captain
        
        21,072 Total Flight Hours
        
        166 Flight hours in last 90 days
        
        4,309 Flight hours in B777
        
        11,000 Total Instrument Hours
        
        100 Instrument hours last 90 days
      - Observer 2 FO
        
        14,200 Total Flight Hours
        
        148 Flight hours in last 90 days
        
        2,600 Flight hours in B777
        
        2,600 Total Instrument Hours
        
        Unknown Instrument hours last 90 days
- - - - Plane 1
        
        2:23:04pm (1423:04)
      - Plane 2
        
        2:22:29pm (1422:29)
    - - Plane 1
        
        2:24:33pm (1424:33)
      - Plane 2
    - - 2:24:36pm (1424:36)
    - - Plane 2
        
        2:21:41pm (1421:41)
      - Plane 1
        
        2:22:23pm (1422:23)
- - - - Plane 2 take off
        
        About 1,500 ft (2:23:04pm)
    - - Plane 1 take off
        
        1,417 ft (2:24:06pm)
        
        2,120 ft (2:24:33pm)
- - - - No confirmation necessary from co-pilot
        
        System made around pilots knowing to tell the appropriate parties
        
        Pilots known for being well trained
        
        System made expecting pilot to know all information
    - - Technology/ System doesn't instantly notify change
  - - - Has options for accidents that recover and avoid harm
        
        This accident avoided danger with the communication from air traffic control
      - Effective at breaking down an accident
    - - New model focusing on Deficiencies of Safety Culture
      - Gives insight into who poor decisions were made
      - Not enough focus on technological errors
    - - Can be used to find a deeper systematic failure
      - Shows how the pilots error could have been avoided
    - - Complex and very effective
      - Works effectively on accidents where all information is known
      - Could be more complexity then needed
    - - Simple but effective
      - Applied easily to this accident
      - Not very detailed
    - - Holistic model that doesn't blame the pilot
        
        Still does not ignore the human error but does not focus on it
      - Creates helpful recommendation to prevent similar accidents
      - Breaks down the accident effectively
  - - - Was under the belief he would be taking another path
        
        Foreign pilots given different path usually
        
        Was given the standard path of local pilots
    - - Pilot told none of his crew
        
        Believed his judgment was correct
        
        Possibly work environment based decision
        
        Relaxed environment about safety
        
        Overconfidence
        
        Pilot and crew was all experienced
  - - - It is known that foreign pilot usually take a different path
        
        Other path is simpler and easier
        
        Path was already taken
        
        Taken by the second plane (ATR 72)
    - - Unknown as why the crew didn't read it
      - Air Traffic Control workers trusted crew read it
        
        Crew has lots of experience