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There was ample time to prepare for the approach diversion, go-around and associated
procedures.
There was ample opportunity for the pilots to review and manage potential threats linked to
weather, the nature of the approach, the environment through which they were flying and even their
own limitations.
Simple prevention strategies and lines of defense discussed below were followed to maintain good
situational awareness, make good decisions and follow standard operating procedures (SOPs).
Weather;
Approach type;
configuration.
Explicitly define task sharing so it is clear who is to monitor all critical flight parameters.
Do not fall victim to press-on-itis by yielding to ATC or time pressures to rush the approach.
Buy time needed to create common situational awareness among crewmembers and stabilize
any stressful situation.
Key Points
This incident was well managed. The crew had lots of time to think and used this time productively. Even
though the captain almost decided not to divert or to delay a diversion, the collective approach helped to
implement the group decision as soon as necessary:
The crew first had to ponder whether the oil quantity loss was a real problem or just an indication
problem.
The crew then reviewed ETOPS diversion alternatives taking into account weather, airport
characteristics and airplane condition.
The crew then collectively set up decision criteria as to when to divert, based on any additional
problem such as oil pressure or temperature dropping.
When the critical additional problem became apparent, the pilots were entirely ready to implement
the next step that is, where and how to divert without pressure or haste.
Situational Awareness
Press-on-itis
Decision-Making
Decision-Making Training
Visuals:
Situational Awareness
Stress Management
Checklists:
Decide - Checklist
Flight Safety Foundation Approach and Landing Accident Reduction (ALAR) Toolkit
U.K. Civil Aviation Authority. CAP513, Extended Range Twin Operations, third edition, October
2002.
Note: Due to regulation changes and the publication of JAA GAI20, CAP 513 will remain at Issue 3 and is to
be used as guidance material only for older aircraft types. For all ETOPS operational and airworthiness
requirements reference should be made to Joint Aviation Authorities Document GAI20 ACJ 20X6.
ETOPS