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The incident involving US Airways flight 1954 that only 4 days ago is an excellent example of good airmanship and professionalsm.
I'm sure most have read about this incident but here's a brief overview on what happened.
US Airways Flight 1954 took off from LaGuardia Airport in New York City and was headed to North Carolina. Less than 2 minutes after take off, first officer Jeffrey B. Skiles who was nominated to fly the first leg of the journey noticed a flock of birds apporaching the aircraft and almost immediately loss power of both engines of the A320. Subsequently Captain Chesley Sullenberger, took over controls while FO Skiles attempted to restart engines.
Captain Sullenberger then made his Mayday call and imformed ATC of the bird strike. Reports said that passengers in the cabin heard loud bangs and the smell of fuel filled the cabin. Controllers then gave the flight crew heading to return for emergency landing at LaGuardia. The captain informed ATC that it would be very risky as it was reported that they were merely at 3200ft AGL before beginning the descent for emergency landing.
Captain Sullenberger started looking for other options and spotted an airport which was actually Teterboro Airport in New Jearsey and that option was also too risky due to low altitude. The captain finally made a radio call to ATC informing them of his intentions to land in the Hudson River.
Captain Sullenberger made repeated announcements over the cabin PA system to remind all passengers and cabin crew to 'brace yourselves' and successfully landed the Airbus 320 in the Hudson river. Investigators were informed that the captain attempted to land close to nearby boats to facilitate rescue procedures. He also made use of the 'ditch switch' which closes all valves and openings on the aircraft. Following SOP, the captain ensured all women and children were evacuated first before men. He also made 2 runs through the cabin to ensure everyone was safely removed from the aircraft. All passengers survived
His decision to land in the river was due to his prior knowledge of the area and good pilot judgement and decision making skills.
The 'ditching' incident of US Airways Flight 1954 was praised as 'the technically challenging feats in commercial aviation'.
From this case, we see how the captain veto-ed ATC instructions and decided to go for what appeared to be a more dangerous decision. I feel that having good personal situational analysis can at times take priority over what others feel to be a safer or more viable decision.
The airmanship and professionalism displayed in this incident is truly examplary. Captain Sullenberger displayed exceptional flying abilityand still adhered strictly to SOP and his quick thinking also eased the rescuing process.
This incident is an excellent example of superior decision making skills. It is the actual decision making of the crew to put an A320 into water that made this incident survivable. During this event, the controllers gave the flight crew heading to return for emergency landing, this turn, is known as the ‘impossible turn’. The ‘impossible turn’ is turning back to the runway in the event of an engine failure on take off. Many unfortunate crashes, mostly fatal, have occurred when the pilot attempted to make a 180 degrees turn back to the runway for a downwind landing or just to touch down somewhere within the airport boundary. Without engines to produce thrust, gliding in a turn will result in greater loss of altitude. Steep bank angle will also increase the stall speed and increase the sink rate. When should you and when should you not consider executing this controversial manoeuvre? Here is a short video that explains this matter further.
I consulted a senior captain, and also a senior instructor rated on the B747, B777 and A330, just recently and asked him to explain the good airmanship practices which he has experiences as a pilot in the airlines.
The element which affects a flight the most is the weather, and as professionals we have to take in to consideration the comfort of our passengers, taking every effort to make their flight as safe and as comfortable as possible.
Preparation for the fligtbegins even before the pilot reaches the airport. En-route, be it in a taxi, bus or car, he must observe the developing weather patterns and begin to think about the appropriate actions to perform during the flight.
This form of airmanship also arises in the cockpit during taxt. According to him, it is not in the SOP to swithc on the weather radar and TCAS during taxi. However, it is good practice to do so to get a clear picture of developing weather cells and the position of other aircraft in the air (this also in addition to listening out)
He stressed that since mordern aircraft are now controlled by the auto pilot for the vast majority of the flight, it is very important that the pilot maintains radio vigilance. he should listen out for weather conditions which may not be reflected on the weather radar. One example is, Clear Air Turbulence. This phenomenon is not fatal, but can be particularly dangerous for passengers and cabin crew. Hot drinks may be spilt luggage may drop and people may lose their balance and fall, injuring themselves. Listening out to reports of such weather phenomenon could provide an advanced warning to the crew, who can then finish up their jobs and prepare the passengers for the bumpy ride.
The captain said that good airmanship come not only from doing things right when stuff happens, but also actively anticipating the condition and preventing it from even happening.
This incident happened in 2003 to a commercial Boeing 747 flying long haul, departing from an international airport for its international destination.
The departure from the international airport was uneventful and on schedule, albeit with an unserviceable auxiliary power unit (APU). The weather at destination was forecast cloudy with rain, but comfortably above the legal weather limit. Approximately 5 1/2 hours into the flight, during a routine system check, the No. 1 hydraulic system quantity was seen to be falling rapidly and already indicating low. The engine and demand pumps were immediately turned off while the flight crew evaluated the situation. The contents indication stabilised.
A check of the weather at destination seemed to be deteriorating. The cloud base was at 300’ ft, rain reducing visibility, temperature and dew point the same. The flight crew was losing fuel to the flight plan, already 1.5 tones down. The weather at the alternate, was good. Before making any decision the flight crew discussed at length the implications of loosing No. 1 hydraulic system, including making an approach without ‘Autoland capability’ into deteriorating weather, possibly on minimum fuel, together with the possibility of having to stop on the runway with no nose-wheel steering capability and temporarily closing down a major airport operation on the edge of low visibility status.
The flight crew established communication with the duty pilot back at the airline and acquainted him with their status and discussed the risk of damage to the gear doors, if alternate extension due to loss of hydraulic system should be required. With the little fluid still available, the flight crew would be able to steer off the runway at least onto the high speed exit from the active runway. It was decided that the flight crew would attempt to lower the gear normally by pressurising the system for the extension, then depressurising again and hopefully also having enough fluid remaining to pressurise once more on the runway to clear. If this did not work it would be alternate extension and a stop on the runway.
Duties were assigned so that the Pilot In Command (PIC) flew the airplane, the First Officer (FO) in the right hand seat, carried out normal Pilot Not Flying (PNF) radio and monitoring duties with the Quick Reference Handbook (QRH) as applicable, and crew member 3 (CM3) at the back contact all control areas in advance to warn them of their condition and requirements for lower than normal speeds earlier in the approach, extended pattern as necessary and of worst case scenarios.
Their destination airport accepted them onto another runway since the weather was below limits for the active runway, gear lowering was achieved normally, flaps were lowered on the secondary system, and after breaking out of cloud at 300’ ft a successful landing was made. With the No.1 hydraulic system quantity showing low the flight crew pressurised again to clear onto the high speed exit and cross the active runway where they stopped to be towed in, the aircraft was shut down with 10 tones of fuel, one ton of which was unavailable as it had not scavenged from the center tank. The end result was a safe and successful arrival at destination with minimum disruption to the destination airport’s operations, and the passengers were hardly aware of anything out of the ordinary.
All contributions from the crew’s attention to Crew Resource Management (CRM), flight following by maintenance, duty pilot input and all the assistance and preparedness from area Air Traffic Control (ATC), arrival, tower and ground controllers, ramp operations, airline operations and destination maintenance made this incident a successful one.
How the flight crew on this aircraft handled the situation is a very good example of exercising airmanship and CRM during abnormal situations. Getting all the information first, and then discussing the various options before making a decision. In any complex situation, it would be very unusual for one pilot to have all the answers, therefore it is important to discuss the situation with other crew, duty pilot and maintenance before any decision is made. Of course this changes if flight time is limited by fire, smoke or being short of fuel. Once a decision has been made, it is then important to inform everyone who is affected by the non standard operation. This flight crew appears to have covered all these complex considerations in the appropriate sequence and achieved a good result. A very good example for us as pilots to learn from!
Here is a discussion about the appropriate use of the Controller Pilot Data Link Communications (CPDLC) system, and Crew Resource Management (CRM) skills including Threat Management, Decision Making and Error Management, to improve safety of aircraft operation, hence achieving good airmanship. This discussion will use ‘Track and altitude deviations...without a clearance!!!' incident as an example.
Technological advances, such as Controller Pilot Data Link Communications (CPDLC), offer improved efficiency and accuracy in communications and Air Traffic Control (ATC) monitoring, however, there is always a downside to be considered. Often, a loss of situational awareness can be identified that led to failures in communication, workload management, decision making and error management. Furthermore, operating in an ATC environment where only long range communication systems are available, (i.e. HF, SATCOM, DATA LINK, etc.) poses the additional threat of a possible time delay when sending and receiving messages versus normal Very High Frequency (VHF) voice communications.
How is Situational Awareness degraded when using CPDLC? Data links provide two- way communication between a ground station and the subject aircraft. Using previous High Frequency (HF) standard position reports, flight crew would have better situational awareness of other aircraft in their immediate vicinity which assist in building some sort of picture of the operating environment. With CPDLC it seems as if there is no one else out there. However, there will always be traffic around you! Although Traffic Collision Avoidance System (TCAS) offers some degree of awareness, it does have its own limitations. It is very easy for pilots to feel like they have the sky to themselves and are safely guarded by TCAS, which will degrade pilots’ situational awareness.
CPDLC is a communication system AND a monitoring system that is able to track your position and altitude with greater accuracy than some area radars. However, deviation from cleared flight path requires the same attention for compliance with Air Traffic Control (ATC) clearance procedures in any type of airspace and using any type of navigational aid.
Let us use the ‘Track and altitude deviations...without a clearance!!!' incident as an example. The flight crews’ lack of situational awareness prevented them from taking any avoidance measures to avoid the weather build- ups ahead until the aircraft was within 40nm from the build- ups. Given the time delay in receiving clearances using only long range communication systems, e.g. CPDLC, it is crucial for the flight crew to maintain their situational awareness during all phases of flight operations and initiate the appropriate communications with ATC as early as possible.
The lack of situational awareness of the crew can pose serious threats during flight operations. When referring to Threat Management in CRM and its application, this part requires flight crew to estimate the risk of the threat and then take timely measures, hence Decision Making to avoid the threat. In this incident, we can observe a lapse in decision making. Part of the ‘Decision Making Model’ is “A” for “analyse the options”. This requires the flight crew to find as many options as possible that could resolve the situation and to use all available resources to find these options. However, the flight crew in this incident had not fully analysed the situation, or seek all possible options. A good option, that was not used in this case, was to consult the Quick Reference Handbook (QRH).
In the area of Error Management, the ‘Error Management Model’ uses the process of Avoid, Trap and Recover. By using the Error Management Model, a better approach to handling the situation encountered by the flight crew (in this incident) can be identified. ‘Avoiding’ an error is done by using threat analysis skills which, if the flight crew had analysed earlier, the weather build- up ahead to be a threat, a proper action would have been initiated which would have kept the flight well clear of the weather threat in the first place. ‘Trapping’ error, in this case refers to the readily accessible procedures (QRH) provided to the flight crew for reference during situations when other alternatives have failed, i.e. consult QRH. The ‘Recovery’ from an error that has been made is the last critical step. This involves returning the aircraft to a safe state. In this incident, the aircraft was returned to a safe state. However, the steps taken to recover the aircraft were not correct. The flight crew arrived at the ‘Recover’ step without being aware of the fact that they had bypassed the first two steps.
Flight Operation is itself, a very complex environment and requires coordination between flight crew and ATC, and between flight crew and the system which they operate, to achieve both efficiency and safety
‘Track and altitude deviations…without a clearance!!!' incident can also be found here.
This incident occurred in the year 2007 involving a commercial Airbus A340 during takeoff.
The weather on the day when the incident happened was good for flight operations. Wind was light from west, broken cloud in the high sky, good visibility and the temperature was twenty-seven degrees centigrade. This A340 was also dispatched with good condition. Everything proceeded as normal. At the time, the Pilot In Command (PIC) was the Pilot Flying (PF). When the flight crew received takeoff clearance, PIC lined up the airplane and set the thrust levers for takeoff. All displays were indicating normally until the “eighty” knots standard callout was made by the Pilot Monitoring (PM). Meanwhile, PIC checked his airspeed indication, and to his shock it was showing only speed trend without active airspeed indication. Immediately, the PIC aborted takeoff. The takeoff was aborted around one hundred knots.
Various underlying threats can be recognised in this incident. Firstly, the Electronic Centralised Aircraft Monitor (ECAS) had failed to detect a fault with the airspeed indicator. Second threat is the fact that the airspeed indicator is giving false readout indications which might not be easy for flight crew to pick up during high workload situations. Thirdly, by choosing to abort takeoff, the flight crew had taken a chance that possible runway overrun may happen. Fourthly, when choosing to abort takeoff, the brakes will be very not, and in some conditions may not be able to handle the load of the aircraft.
When the aircraft was back safely at the ramp, and after troubleshooting, maintenance found that the PIC side’s pitot tube was blocked by a small bug. The blocked pitot tube caused the airspeed indicator functioning failed and confirmed that this malfunction is unable to be detected by aircraft monitoring devices. During the takeoff roll, the ram pressure from the blocked pitot tube remains zero and the airspeed instrument remains pegged at its lower stop. If the flight crew had not abort the takeoff, the pitot pressure will remain plugged at field-elevation pressure as the airplane climbs, but the static pressure will begin to drop. Due to the dropping of the static pressure, its resulting sensed dynamic pressure will cause the airspeed indicator to come alive seconds after liftoff.
Regardless of the actual climb speed of the airplane, the faulty airspeed indication will continue to increase as altitude increases. The Maximum Operating Speed (Vmo) can appear to be exceeded. Additionally, an over speed warning can be triggered. The best action to take in this kind scenario, and to prevent it from worsening is to aborted the takeoff, as what the flight crew had choose to do.
The purpose of doing a check at eighty knots, i.e. the standard callouts during takeoff is to verify the proper functioning of the engines, flight instruments and possible crew incapacitation. If an abnormality is not recognised by monitoring systems, it must rely on flight crews’ basic instrument scanning skills to identify any faulty indication during takeoff. In this incident the flight crew had successfully implemented Standard Operating Procedures (SOPs) thoroughly, they prevented the aircraft from entering further undesirable states. The flight crew in this incident demonstrated highly professional performance during high workloads, compliance with SOPs, and the good application of instrument scanning skills.
Any non-normal occurrence during a takeoff represents a threat. The risks from these threats range from Catastrophic to Negligible and occur in the range of Occasionally to Remotely. Flight crews have minimal control over the frequency of an occurrence but do have control over the outcome. Often in the past, flight crews who have failed to correctly identify an ‘Airspeed Disagree’ situation have taken the problem into the air with sometimes catastrophic results.
So what causes some of these events to end badly while others have negligible effects? The answer is to be prepared. Before any takeoff all flight crew members, not just the PIC must have a clear understanding of the things that can go wrong. Do not only consider the usual failures such as engine failure or fire. Weather, runway surface conditions as well as a large variety of system failures will have an effect on the correctness of the decision to go or not to go. Not only must the flight crew make the correct callouts but they must know why the callouts are there in the first place. Armed with this applied knowledge, flight crews then need to use accurate crew to crew communication skills. When all these variables are well controlled, good decisions can be made. This incident is a good example in demonstrating how a good decision is made, even under high workload situations.
I was a Pilot in command of a light twin engine aircaft approaching Whangarei. As I left Auckland controlled airspace, they adviced me there was a departing scheduled airliner out of the airport, and instructed me to change to local traffic frequency to communicate with them.
I made my radio calls, and continued on my course to Springfield, which was a way point for the start of the approach. The departure procedure for that airfeild also require the departing aircraft to set heading over Springfield.
It was an ok day, with scatted cloud around 2000 feet, I was in and out of the cloud, and unfamiliar with the area, so I elected to continue tracking to SF and hoping to get visual separation from the departing aircraft. They elected the departure and tracked visually to the habour, before turning back to SF to intercept their track. I did not sight the departing aircraft, but able to conduct visual approach via SF, and then landed without drama.
However, 1 week later, my company received an incident report regarding that day, where the departing airliner had "resolution advisary" on their traffic avoidence system, according to that report, we were in close proximity of around 4 miles.
The lesson learnt here is that if I was better prepared with visual maps of the area, I could of elected visual approach earlier on, clear of SF area, so the departing airliner could have unrestricted tracking and altitude. But of me staying on track on a reasonable good weather day, caused the airline and I to loose separation, and for them to recieve traffic warnings and take abrupt actions to avoid a collusion. Better communication is required from my part, rather than just telling them what I was doing, as per AIP, I should of discussed my options and their couse of actions together, so to make my arrival and his departure more efficently and safe.
As the 3rd pilot in the cockpit on a trans-Pacific flight landing into an Asian airport, the following observations were made.
The F/O was given the sector as PF and we were making preparations for landing at the destination. Weather reported at the destination was heavy T/storm and rain. During the briefing, both pilots discussed the use of auto-pilot until they are clearly visual with the runway. They also discussed the possibilty of windshear occuring and the recovery procedures that were required. The Captain decided to allow the F/O to continue being the PF until such time he deems fit to take over control should the PF be unable to cope. We were established on the ILS early and auto-pilot was still engaged. At approximately 400ft, the onboard Predictive Windshear warning activated with an aural warning, "Windshear ahead, windshear ahead". This means that the system detected a windshear condition ahead. Instead of taking over control to execute the go-around, as what I expected most Captains to do, the Captain told the F/O, "Go-around". So the PF executed the go-around the way he was trained to do while the Captain continued to monitor the procedure. Once the procedure was completed, the aircraft was radar vectored for another approach. ATC reported that the visibilty now is at 1500m in heavy rain. This time, the Captain told the F/O that he has to take over control as the conditions have reduced to below the Company's F/O flying limits. The Captain flew the approach and landed safely.
At the end of the flight, the Captain asked the F/O if had he taken over control and did the go-around procedure himself, would the F/O be ready to switch duties and become the PNF almost immediately. He answered Yes but will take a few moments to change the mindset. The Captain explained that during a go-around procedure, it is imperetive that both crew are in the loop and are ready to carry out the appropriate actions required by the procedure. Should any crew member suffer the loss of situational awareness during that critical time frame, the situation can get very dangerous very quickly. Had he taken over control and the F/O was not ready to assume PNF duties, the Captain would have basically lost a crew member in a critical phase of flight. Loss of situational awareness during a switch of flying duties at a critical phase of flight is a real danger. This got me thinking to the times when I myself had been in such a situation when the Captain abruptly took over control to execute a go-around. While I was able to 'keep up' with the aircraft during the procedures, I was actually being reactive instead of proactive and my SA was only at the basic level of perception and reacting to it.
The F/O and myself both discussed what happened and now fully understand the human factors and appreciate the actions of the Captain during the procedure.
As pilots, we face, on a daily basis the normal pressures of the commercial side, balanced with the safety aspect of our operations. Sometimes, some creative thinking is required to balance the two. The following flight was relayed to me by a colleague of mine as a discussion on how we could manage our resources better as pilots.
He was called up on standby from our home base to passenger into a station because the crewmember at the station had taken ill. Because of the frequency of the company’s schedule, he positioned in late in the evening for the flight that was due to be operated the next morning. Due to flight time limitations, the flight would have had to be delayed for him to meet the minimum rest period required by AOC. On his flight into the station, as passenger, he felt continuous moderate clear air turbulence (due to the jet stream in the area) on the last two hours of the flight into the station. In got so bad, that at one stage, service was suspended to ensure the safety of the cabin staff. When it was finally safe for the cabin staff to continue, it was a mad rush to complete the service. In his conversation with the pilots who flew in, he gathered that the “ride” was much smoother at the lower levels, FL 280 and below.
On arrival into the station, he took the initiative to contact the ground staff. He determined the length of delay that would be required to satisfy the AOC limits. This delay came up to 20 minutes. He then coordinated with the ground staff and the first officer who was already at the station. His plan was to send his first officer to the aircraft on schedule to help manage the initial stages of the flight, such as refuelling, walk around and technical status of the aircraft. He would then follow 20 minutes later from the hotel. It work out beautifully. He was still able to get the aircraft off on schedule without compromising safety and still conduct a safe pre-flight and briefing.
With the turbulence that he felt on the previous day and the conversation that he had with the pilots flying in still fresh in his mind, he queried the local pilots (at the briefing room)and ATC on the levels that would be acceptable. He then requested a new flight plan that was planned at a lower level to “duck” under the jet stream and hopefully the clear air turbulence. The original level planned was FL 340. He opted for FL 280 to take advantage of the lesser headwind. In the end, he ended up saving 20 minutes, one ton of fuel and had a relatively smoother flight.
We had this discussion together with our younger colleagues in the hopes of relating to them the benefits of communication, coordination and forward planning. It’s very easy to succumb to the mindset of “going with the flow” and accepting the generated flight plan without question. My colleague could have very easily have stuck to his original flight plan and call time. This would however, mean a delay and the possibility of safety being compromised with the effects of clear air turbulence. He on the other hand, choose to use the experience and situational awareness gained on the flight into the station to cater for safety on the flight back. He opted to engage all parties in the station, ground staff, first officer and cabin staff for a more efficient method of dispatch.
In this regard, I found his experience, use of communication and high situational awareness a very productive learning experience. One of the more important lesson learned, beside the effective use of communication, coordination and awareness of the environment (situational awareness), is that the situation must be managed. We mustn’t let the situation manage us.
I was the First Officer rostered on an afternoon shift which involved two return trips over the same leg from a regional New Zealand destination (my home base) to Wellington and back. Our first leg to Wellington was uneventful and upon landing in Wellington we had a planned aircraft change to collect a different company aircraft and return to our point of origin. Upon entering our new aircraft and reading over the aircrafts defect list (referred to as "the book"), we learnt the aircraft had an issue that rendered the Flap system unserviceable. This meant the normal performance figures we would usually use (that assume the use of Flap) were incorrect. We were then forced to delay the flight while we calculated our new figures which included new speeds and new restricted Takeoff and landing weight limitations.
We departed late and enroute learnt the Weather at the destination was now marginal for our operation. A change the company made just prior to me joining was the inclusion of a threat briefing before takeoff and again prior to commencing descent. Often we do not perceive there to be many real threats but today we were able to identify several. Without Flap, our approach and landing would have to be at a higher speed than normal and the actual landing itself involves a slightly different technique to prevent a tail strike. We also had the threat caused by the marginal weather and the very real possibility of a diversion being needed and our finite fuel state. I was the Flying Pilot during the approach and still fairly new to the company (another threat) although the Captain was one of our most experienced pilots (hopefully threat mitigation). We briefed that on the approach I would continue flying by reference to our instruments and in the very narrow window of time in which we had to see the runway, if the Captain could see the runway and I could not, he would take over and complete the landing. Having identified all our threats and hopefully put in place as many strategies as possible to reduce them we continued and managed to make a safe and uneventful landing.
Our next sector back to Wellington was again uneventful and having made up some time, we managed to turn around and depart at something resembling on time for our last sector back home. Enroute we received news that the VOR at our destination was now not working and we would be required to conduct a GPS approach. The threats present earlier were still all relevant and adding to the list was now the fact we had to fly an approach that, although we were familiar with, we do not do as often as some others so consequently had less residual mental capacity to spare. Fatigue was also starting to set in as this was our fourth sector and we were fast closing in on nearly 4.5 hours flying time in challenging conditions. We ended up burning 10 minutes of fuel when we had to hold and wait for the weather to improve at our destination to a limit where we were allowed to commence the approach.
Finally the weather gets to a point where we can try the approach. This was the Captain's leg so I was the Pilot monitoring which required me to make radio calls and call pertinent height and tracking information on the approach. As we commenced the final portion of the approach (still in cloud) our GPS system failed. This was our sole source of navigational information so now we are effectively pointing at a hole in space, not knowing where we are or we are going. Instinctively and immediately the Captain called for a missed approach and attempted to gain height as quickly as possible. We both had the benefit of local knowledge and knew that even if unsure of our position, if we could gain a couple of thousand feet of altitude, terrain would not be an issue and we could then assess our situation. Whilst this was going on, as the Pilot monitoring, I was following company recommended procedure to try and re-establish GPS navigational information. With that achieved and at a safe height, we discussed our options and decided that a diversion to our alternate aerodrome would be prudent and that we would not use the GPS for the approach in case it failed again.
We were however not yet done! As we were about to commence the approach at our alternate, we were informed it was no longer suitable! This required a further diversion to another nearby field which was still open. This was entirely unexpected and required us to both dive into our books and find the new relevant approach plates. Under control again, the Captain comments that, "I don't like this, the Swiss Cheese holes are lining up." I could only agree. Finally however, we managed an uneventful landing, at an aerodrome we never expected to be at, after 5 hours flying over a very long day.
From the shift I took away several things. With everything going on, the Captain still kept up with and made sure the cross cockpit communication continued. He had 25 years in the company to my 3 months but emphasised I was to speak up if I saw anything or felt he had missed anything and to not assume he would get it right because of all his experience. We decided to carry extra fuel out of Wellington to give us plenty of options and time to make decisions which paid off greatly. The company decision to introduce the threat briefing to make sure crew are aware of risks present and discuss the implications of those risks. Thinking about things though, especially after the Captains reference to Swiss Cheese, some of the company actions may have actually introduced more threats to the operation. Although the aircraft will fly safely without flap, many companies would not consider having a flight depart with no flap and passengers onboard a prudent decision. My company considered it to be an acceptable option rather than cancelling the flight. On it's own it is not a significant threat but combined with other factors, it could provide enough of a distraction to allow something else to 'slip through the net.' Through this example (although we had many other things going on) I can see how decisions made by management could potentially flow through an organisation and introduce threats at an operational level that might one day lead to a failure in the last line of defence and that final Swiss Cheese hole lining up. I witnessed on this shift how important knowing about and managing threats can be and it was an invaluable lesson.