GA1382

CHIRP highly commends the reporter for this candid report, which was also communicated to the reporter’s line manager. Could we all honestly say that we would have done the same? After all, they got away with it and no harm done. But, by altruistically sharing the experience, there’s an opportunity for everyone to learn and consider the human factor implications of this ‘near miss’.

It serves to remind us all how a combination of tasks and cockpit activities carried out in close succession can quickly lead to distraction and loss of focus of attention away from the flight instruments at a critical point. The reporter self-identified the key lesson as being communication and teamwork in the cockpit. The decision to configure the aircraft just when VNAV capture was expected meant that the crew became distracted from monitoring the flightpath. Avoiding selection of services at critical points for an approach is advisable to prevent such occurrences, albeit that’s sometimes easier said than done, as there may have been a valid reason that caused the flaps and gear to have been selected at that point.

Don’t forget that as well as enabling the experience to be shared through this FEEDBACK, all reports to CHIRP also contribute towards our disidentified safety database and our efforts to analyse and understand the bigger safety picture.