CoolP, there is always a chain of events that lead up to the incident. If someone can break one of the links in the chain, then the incident may not happen. All the checks are in place, but they must be used. Case in point... one pilot is loading the FMC with a flight plan. It is established procedure that the other pilot check the information and that the second pilot execute the plan. This is to insure that there is a second set of eyes checking the input to the computer - very important. It is very easy to put in a course that is off by one degree. You are tired and it's dark and you miss the keys by one number... this could lead to something bad.

Another story. We used to do training in the real plane along with the simulator. Gas (Jet - A) was 13 cents a gallon, so it was sometimes easy to grab a plane and take 10 or 15 pilots and go to a quiet airport and shoot landings. (Pilots need 3 landings every 90 days to stay current in Part - 121- sometimes hard to do on long haul flights.)

So one bright morning, an instructor crew takes a 707 and a bunch of pilots from New York down to Atlantic City airport to do a bunch of landings. Several of the pilots also need a short check, also called a 6 month instrument check. They take off from JFK and head down to ACY - a short trip of maybe 15 minutes. Along the way they simulate an engine failure by pulling back an outboard engine. They commence to fly a 3 engine ILS under the hood to simulate an engine out approach in IMC. Remember, there is nothing wrong with this plane.

During the approach it is noticed that there is a slow leak in the hydraulic system that powers the rudder. The aircraft is down to 500 feet on the approach. Now because there IS a slight problem with fluid loss in the rudder system the instructor calls for the fluid loss checklist. (This is part of the chain of events.) The first thing on the fluid loss checklist is PUMPS OFF! The instructor tells the "student pilot" to go around. The pumps are turned, but the "student pilot" is not really in the loop since he thinks he is still flying a three engine approach. As the pilot pushes the throttles up for the go around the rudder pressure falls to zero. Rudder control is lost and the plane, which is now around 300 feet rolls over on its back and impacts the ground right in front of the tower. All are lost.

A sad story, true, but if someone had broken the chain of events it would not have happened. The instructor was too busy with his "simulation." There really was no big problem with the slow leak. Someone should have screamed JUST FLY THE PLANE! That's easy after the event, but during the flight it is sometimes hard to filter all the information and break one of the links in the chain.

It was very soon after this incident that all airlines stopped regular training in the real plane and switched to simulation. Hopefully, we learn from mistakes. We used to kid around saying... Do you know why PanAm is the most experienced airline??? Because they have the most experiences!  :o  Some times with black humor the point gets across.