Lessons Learned

Technical Related Lessons

The risk associated with a flight crew's preoccupation with an emergency can exceed the risk posed by the emergency itself. (Threat Category: Crew Resource Management)

  • During the course of the investigation, it became apparent that the flight crew did not keep track of the fuel onboard and the fuel flow rates. The crew had the fuel quantity information available to them to accurately determine their remaining flying time. However, this information was either overlooked or not effectively conveyed to the captain.

Common Theme Related Lessons

Crew Resource Management (CRM) training can enhance the ability to prevent and/or manage flight crew errors, and in maintaining continuity in flight crew performance of duties. (Threat Category: Human Error)

  • During the investigation, it was found that only at one point did the flight engineer comment about the possibility of being low on fuel. However, no other information or details were provided to the captain who, even as the engines began to fail, believed they still had sufficient fuel on board to land the airplane.

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