I know this is probably getting boring for many of you, but for those still
interested......
I have just done a review of global aviation incident reports over the past
two years, looking for other examples of pilots going against their training
and obeying ATC ahead of their on board collision warning systems when there
have been conflicting instructions.
It turns out there have been three such incidents involving passenger
carrying airliners (none of them actually resulting in a collision), one in
Japan, one in the United States and one over the Mediterranean. None of them
involved Russian pilots. In the Japanese case the subsequent miss was by
less than 20 metres.
What they have in common is this - they all happened when there was an ATC
failure of some kind and the collision avoidance ATC instruction came AFTER
the on board warning system had been activated. That sent me back to the
ICAO documentation. I now see that this documentation - on a 25th
reading!!! - assumes that if the on board system is activated, then an
incorrect or misinterpreted ATC instruction must have come before it.
Therefore all the rules about reacting to on board warnings are based on the
(tacit) assumption that they will always be correcting a pre-existing
incorrect or incorrectly obeyed ATC instruction.
But in these cases the pilots reported that they obeyed ATC because it came
last - so they assumed that it was their on board systems that must have
given them the incorrect instruction, or else ATC's instructions reflected a
change in the situation since the on board warning.
If that is what the Russian did over Germany, then it is possible that he
was NOT behaving in a culturally situated way, but in a universal sense
making way. In order to confirm this we must now look to see if there are
any examples of pilots getting the ATC instruction second, but still obeying
their on board warning systems. If such examples exist then the question
becomes - why do some react one way and some the other?
All of this also raises the possibility that we can be too quick to
attribute observed actions to the effects of cultural mediation, when maybe
tool or rule mediation was more important
Phillip Capper,
Centre for Research on Work, Education and Business Ltd. (WEB Research),
Level 13
114 The Terrace
(PO Box 2855)
WELLINGTON
New Zealand
Ph: +64 4 499 8140
Fx: +64 4 499 8395
Mb: +64 021 519 741
This archive was generated by hypermail 2b29 : Thu Aug 01 2002 - 01:00:11 PDT