Page:KAL801Finalreport.pdf/137

From Wikisource
Jump to navigation Jump to search
This page has been proofread, but needs to be validated.
Factual Information
123
Aircraft Accident Report

hazards of tactical decision errors that are errors of omission, especially when those errors are not challenged; and (3) includes practice in monitoring and challenging errors during taxi operations, specifically with respect to minimizing procedural errors involving inadequately performed checklists.

On April 26, 1994, the FAA stated that it was amending AC 120-51A, "Crew Resource Management," to emphasize the areas detailed in the recommendation. On July 6, 1994, the Safety Board noted that including the recommendation's material in an AC would be an acceptable alternative to regulatory change. However, on May 8, 1995, the Safety Board expressed disappointment that the revised AC 120-51B (issued on January 3, 1995) made no specific reference to practicing PNF procedures, such as monitoring and challenging the errors of the other pilots, during line-oriented simulation training. Likewise, the AC contained no specific references to line-oriented simulation training in the areas of monitoring and challenging tactical decision errors or inadequately performed taxi checklist procedures.

On September 8, 1995, the FAA issued a revision (Change 2) to AC 120-51B. On January 16, 1996, the Safety Board stated that the revised AC's reference to line operational simulation was responsive to all aspects of Safety Recommendation A-94-3. The provisions for PNF functions, monitoring and challenging of errors made by other crewmembers, tactical decision errors that are errors of omission, and errors made during taxi operations would achieve the Board's objectives as an alternative to the regulatory change that was originally proposed. Therefore, Safety Recommendation A-94-3 was classified "Closed——Acceptable Alternate Action."

Safety Recommendation A-94-4 asked the FAA to

Require that U.S. air carriers operating under 14 CFR Part 121 structure their initial operating experience programs to include (1) training for check airmen in enhancing the monitoring and challenging functions of captains and first officers; (2) sufficient experience for new first officers in performing the nonflying pilot role to establish a positive attitude toward monitoring and challenging errors made by the flying pilot; and (3) experience (during initial operating experience and annual line checks) for captains in giving and receiving challenges of errors.

On April 26, 1994, the FAA stated that its actions in response to Safety Recommendation A-94-3 addressed the issues referenced in this recommendation. On July 6, 1994, the Safety Board reiterated that one intent of Safety Recommendation A-94-4 was for air carriers to provide crewmembers undergoing initial operational experience (IOE) with experience specifically in the PNF role. The Safety Board believed that the FAA should, at the very least, provide guidance to air carriers on this issue in the form of an AC.

On February 28, 1995, the FAA informed the Safety Board that, on January 3, 1995, AC 120-51B, "Crew Resource Management," was issued to provide emphasis for the PNF to monitor and challenge errors and for the PF to give and receive challenges of errors. On April 24, 1995, the Safety Board expressed its disappointment that AC 120-51B