ethiopian airlines aircraft down near Beirut
Join Date: Jan 1997
Location: UK
Posts: 7,737
Likes: 0
Received 0 Likes
on
0 Posts
Interesting date on the prelim but here it is at last:
http://www.lebcaa.com/pdfs/Investiga...s%20Report.pdf
The section most discussed by actual pilots would be:
http://www.lebcaa.com/pdfs/Investiga...s%20Report.pdf
The section most discussed by actual pilots would be:
The flight was initially cleared by ATC on a Lateb 1 D departure from Runway 21. Just before take-off ATC changed the clearance to an "immediate right turn direct Chekka".
The flight took-off at 00:37:08 and just after take-off ATC (Tower) instructed ET 409 to turn right on a heading of 315 degrees and change to Control (ATC) 119.3. ET 409 acknowledged the clearance and heading 315 degrees was selected on the MCP.
ET 409 continued right turn, ATC instructed ET 409 to turn left heading 270 degrees. ET acknowledged and 270 was selected on the MCP. Maximum heading reached prior to left turn was 003 degrees.
ET-409 continued left turn to heading 270 degrees after acknowledgment and continued to a southerly track then on a sharp left turn until it disappeared from the radar screen and crashed into the Mediterranean Sea about 4 minutes after take-off.
The aircraft impacted the water surface at 00:41:30 around 6 NM South West of BRHIA and all occupants were fatally injured. SAR operations were initiated at 00:47:41.
The DFDR and CVR were retrieved from the sea bed and read, as per the Lebanese Government decision, at the BEA facility at Le Bourget, France. The recorders data revealed that ET 409 encountered two stick shakers respectively at time 00:40:01 for a period of 29 seconds and at 00:40:56 for a period of 26 seconds. 10 "Bank Angle" warnings were registered between 00:38:41 and 00:40:54; an over-speed clacker was also registered from time 00:41:25 till the end. The maximum registered AOA was 32 degrees at 00:40:14, maximum registered bank angle was 118 degrees Left at 00:41:14, the maximum registered speed was 407.5 knots at 00:41:28, the maximum registered G load was 4.412 at 00:41:28 and the maximum registered nose down pitch value was 63.1 degrees at 00:41:16.
The DFDR recording stopped at 00:41:28 with the aircraft at 1291 feet. The last radar screen recording was at 00:41:28 with the aircraft at 1300 feet. The last CVR recording was a loud noise just prior to 00:41:30.
The flight took-off at 00:37:08 and just after take-off ATC (Tower) instructed ET 409 to turn right on a heading of 315 degrees and change to Control (ATC) 119.3. ET 409 acknowledged the clearance and heading 315 degrees was selected on the MCP.
ET 409 continued right turn, ATC instructed ET 409 to turn left heading 270 degrees. ET acknowledged and 270 was selected on the MCP. Maximum heading reached prior to left turn was 003 degrees.
ET-409 continued left turn to heading 270 degrees after acknowledgment and continued to a southerly track then on a sharp left turn until it disappeared from the radar screen and crashed into the Mediterranean Sea about 4 minutes after take-off.
The aircraft impacted the water surface at 00:41:30 around 6 NM South West of BRHIA and all occupants were fatally injured. SAR operations were initiated at 00:47:41.
The DFDR and CVR were retrieved from the sea bed and read, as per the Lebanese Government decision, at the BEA facility at Le Bourget, France. The recorders data revealed that ET 409 encountered two stick shakers respectively at time 00:40:01 for a period of 29 seconds and at 00:40:56 for a period of 26 seconds. 10 "Bank Angle" warnings were registered between 00:38:41 and 00:40:54; an over-speed clacker was also registered from time 00:41:25 till the end. The maximum registered AOA was 32 degrees at 00:40:14, maximum registered bank angle was 118 degrees Left at 00:41:14, the maximum registered speed was 407.5 knots at 00:41:28, the maximum registered G load was 4.412 at 00:41:28 and the maximum registered nose down pitch value was 63.1 degrees at 00:41:16.
The DFDR recording stopped at 00:41:28 with the aircraft at 1291 feet. The last radar screen recording was at 00:41:28 with the aircraft at 1300 feet. The last CVR recording was a loud noise just prior to 00:41:30.
Join Date: Nov 2000
Location: I wish I knew
Posts: 624
Likes: 0
Received 0 Likes
on
0 Posts
Interesting initial findings, of note: The Captain was recently released after type conversion and most of his experience was on T/Ps. Only 188 hrs Jet. The 10 Bank Angle warnings indicating manual flight. Changing ATC instructions possibly confused the crew, it may be they selected 270 on the MCP, which could have given the RIGHT turn from HDG 315, when ATC wanted a Left turn, hence the AP disconnection and manual flight. Stalling after overbanking to the LEFT seems the most probable cause. The Trim tab is off for investigation as per AD, unlikely to be a big factor.
The Pussy cat approach to Unusual Attitude Training in the Simulator.
The DFDR and CVR were retrieved from the sea bed and read, as per the Lebanese Government decision, at the BEA facility at Le Bourget, France. The recorders data revealed that ET 409 encountered two stick shakers respectively at time 00:40:01 for a period of 29 seconds and at 00:40:56 for a period of 26 seconds. 10 "Bank Angle" warnings were registered between 00:38:41 and 00:40:54; an over-speed clacker was also registered from time 00:41:25 till the end. The maximum registered AOA was 32 degrees at 00:40:14, maximum registered bank angle was 118 degrees Left at 00:41:14, the maximum registered speed was 407.5 knots at 00:41:28, the maximum registered G load was 4.412 at 00:41:28 and the maximum registered nose down pitch value was 63.1 degrees at 00:41:16.
While unusual attitude G forces cannot be accurately replicated in 737 simulators, the flight instruments are capable of showing extreme attitudes. From reading accident reports involving unusual attitudes the majority were in IMC or dark night suggesting that pilot interpretation of the flight instrument readings were faulty. This is nothing more than a matter of regular simulator practice - not just once every cyclic three years.
One technique often used during practice unusual attitude training in the simulator is to direct the pilot to look down and close his eyes until the instructor says 'Handing over control." This is an ancient throw back to private pilot teaching under the hood to prevent the pilot glancing outside to see which way is up.
In real life, there is no way both pilots in a 737 would have their eyes closed and head down if an unusual attitude occurs. They would be fully aware of what is happening on the instruments as it all happened. But how to recover from that situation is another story altogether.
This is where unusual attitude training in the simulator must involve extreme attitudes not just a pussy cat approach. Note the extreme attitudes reached in the Beirut Ethiopean Airways situation. Obviously a competent pilot would have made the appropriate recovery control movements well before the aircraft reached an unrecoverable attitude and altitude. All the more reason for the investigation to look closely at how unusual attitudes are taught in the simulator and the qualification standard of the instructor to teach these manoeuvres. . Ticking the boxes means nothing. For example,
50 degrees angle of bank and 25 degrees nose up is defined as an unusual attitude. That may satisfy the check pilot as sufficient to tick the box and allow him to get back to more important things like the automatics
But in doing so, he may have sold the crew short. And one night, a Beirut style disaster happens. During the manouvering of the Ethiopean 737 there were two bouts of stick shakers and ten bank angle announcements. Seems that stalls were imminent at least and whatever recovery action taken (if any) was wrong or ineffective or both.
It was timely therefore to read the following letter to the editor of Aviation Week & Space Technology published 21 March 2011 and titled "Stymied by Stalls
"I am a retired U.S. Air Force pilot and a NASA astronaut with about 5000 hours in jet fighters and trainers, and I was a jet instructor pilot for more than three years.
With all this background, I never knew anyone who lost control of an aircraft and flew into the ground due to a stall. For one thing, stall recovery and unusual attitude recovery were essential parts of pilot training.
Even more important to ask what the pilot was doing while the aircraft got into a stall. Stalls occur when the angle of attack exceeds the critical value, and that normally occurs when the airspeed becomes too low or vertical acceleration (G-load) too high. These conditions do not occur instantaneously, and there is almost sufficient time for an alert pilot to recover with little loss of altitude.
Have we become so frugal with training time that we no longer teach pilots stall and unusual attitude recovery? Or have pilots become so complacent that they allow the automatic pilot to fly the aircraft without human monitoring?
For too long, unusual attitude training in the simulator has been tacked on as an afterthought towards the end of a session and not addressed seriously. Unusual attitude recovery from serious attitudes - not pussy cat ones - require good manipulative handling skills. It is a fact that automation has degraded these very skills needed for survival on a dark and stormy night. Throw in the propensity to have low hour recently graduated cadet pilots in the second in command seat and you have a recipe for potential disaster.
Last edited by Centaurus; 28th Mar 2011 at 10:18.
Join Date: Mar 2011
Location: Beirut, Lebanon
Age: 63
Posts: 4
Likes: 0
Received 0 Likes
on
0 Posts
Dont discount the weather
Hi All,
I live in Beirut and remember that night quite well.
I just want to add that weather conditions on that night were quite nasty by Lebanese standards and may have played a more significant part in the events than the Progress Report lets on.
Given the presence of thunderstorm cells in the area, wind shear could have could have caught the crew off guard.
Furthermore, there was thunder and lightning activity so severe that it offered one of the most spectacular fire works display I have ever witnessed. This could have further contributed to distracting the crew.
I live in Beirut and remember that night quite well.
I just want to add that weather conditions on that night were quite nasty by Lebanese standards and may have played a more significant part in the events than the Progress Report lets on.
Given the presence of thunderstorm cells in the area, wind shear could have could have caught the crew off guard.
Furthermore, there was thunder and lightning activity so severe that it offered one of the most spectacular fire works display I have ever witnessed. This could have further contributed to distracting the crew.
Newly converted captain and inexperienced first officer lose control of 737 just after takeoff in the middle of the night in stormy conditions. It really does seem very similar to the Kenya Airways crash. The report says the captain had 10,000 hours but few on the NG. It does not go into detail about his flying experience. But from his type ratings it looks like he flew the 757/767 as a co-pilot for several years before becoming a F50 captain. Hopefully the next report will shed some light on why they lost control. But the direction suggested by the posters above is looking increasingly likely.
Join Date: Apr 2002
Location: FUBAR
Posts: 3,348
Likes: 0
Received 0 Likes
on
0 Posts
Difficult to imagine how they managed to go through that sequence of extreme attitudes without anyone manging to effect a recovery.
Possible causes that spring to mind ? confusion about whether A/P engaged, as in the Kenyan & quite possibly Flash Airlines accidents / runaway stab and an incorrect attempt to offset it by elevator control which would of course be overwhelmed / A/P tripping into CWS following severe turbulence as a result of penetration of a CB and nobody noticing. . well, I am stabbing in the dark here, and still it is difficult to imagine these extreme attitudes continuing unchecked, but then so were the Kenyan/Flash accidents.
Possible causes that spring to mind ? confusion about whether A/P engaged, as in the Kenyan & quite possibly Flash Airlines accidents / runaway stab and an incorrect attempt to offset it by elevator control which would of course be overwhelmed / A/P tripping into CWS following severe turbulence as a result of penetration of a CB and nobody noticing. . well, I am stabbing in the dark here, and still it is difficult to imagine these extreme attitudes continuing unchecked, but then so were the Kenyan/Flash accidents.
Join Date: Jun 2006
Location: Australia
Posts: 1,186
Likes: 0
Received 0 Likes
on
0 Posts
well, I am stabbing in the dark here, and still it is difficult to imagine these extreme attitudes continuing unchecked, but then so were the Kenyan/Flash accidents.
Difficult to imagine these extreme attitudes continuing unchecked?
I am not surprised. During a simulator session in the Boeing 737-200 where the captain and F/O were undergoing a type rating, the captain's ADI was "frozen" during a normal 25 degree angle of bank turn to the left. Initially, he was unaware of this as the comparitor light had not yet come on. The scene was a black night. The captain was then asked by "ATC" to stop the turn on a certain heading and as he started to roll out his ADI indicated the aircraft was still turning. The aim of the exercise was to demonstrate scan rate skill in that the captain should have immediately switched to the standby ADI to compare which of the three ADI's was most probably faulty.
Instead he continued to turn the control wheel in an attempt to level the aircraft not realising his ADI was actually frozen in a left turn. He kept pressure on the control wheel for several seconds causing the aircraft to roll beyond 90 degrees angle of bank to the right and the nose started to drop beyond 30 degrees below the horizon. The first officer meanwhile gazed seemingly stunned at his own display which correctly showed the true attitude. But he said nothing because he didn't know what to do or say. He had a total of 300 hours and this was his first jet aircraft.
The captain was by now thoroughly confused and looked at the standby ADI which was correctly indicating the aircraft rolling inverted. He then called out "Standby ADI failure" and immediately pulled the standby ADI caging button which did its job and levelled the ADI. All the while the first officer watched completely out of his depth. The result was now obvious so the instructor froze the simulator to discuss events.
The captain was highly experienced with over 10,000 hours on F28 and turbo-prop types.
Join Date: Jun 2000
Location: last time I looked I was still here.
Posts: 4,507
Likes: 0
Received 0 Likes
on
0 Posts
I wonder if the FDR/CVR can tell us if the A/P was engaged and dis-engaged, was ever selected, or were they flying manually deliberately? What is their SOP in this regard? There are some operators that are manual until Flaps UP. daft, but true, especially on such a stormy night. Not the most freshest, most likely too.
Digressing slightly. How many of us are encouraged to scan SBY instruments. Remember Berganair as well. Today the NG has full LHS PFD on SBY electrics. Is this a customer options or standard? Anyway, when I did my command on B757, which did not have this luxury, I needed to demonstrate a SBY ILS. The same size dials as was the case on BAC 1-11. Good for the scan, power/ATT knowledge and precise trimming. One day in them sim the SBY RMI failed as well: sim fault but instructor let it run to see what happened. It was fun to fly the SBY ILS & ISA with old fashioned compass readouts by F/O. Good for crew coordination. Sweaty palms, but it worked. It also reminded us that the SBY's were there. I wonder about today's training. On MAP the 'needles' are out of view beyond 45 degrees. Do guys look just at the magenta line or do they look at the SBY RMI? On non-GPS a/c how do you know when you are within 5 degrees for descent on approach, or approaching the NDB inbd course for approach? Some of the old skills are still relevant; but never taught never learnt.
Digressing slightly. How many of us are encouraged to scan SBY instruments. Remember Berganair as well. Today the NG has full LHS PFD on SBY electrics. Is this a customer options or standard? Anyway, when I did my command on B757, which did not have this luxury, I needed to demonstrate a SBY ILS. The same size dials as was the case on BAC 1-11. Good for the scan, power/ATT knowledge and precise trimming. One day in them sim the SBY RMI failed as well: sim fault but instructor let it run to see what happened. It was fun to fly the SBY ILS & ISA with old fashioned compass readouts by F/O. Good for crew coordination. Sweaty palms, but it worked. It also reminded us that the SBY's were there. I wonder about today's training. On MAP the 'needles' are out of view beyond 45 degrees. Do guys look just at the magenta line or do they look at the SBY RMI? On non-GPS a/c how do you know when you are within 5 degrees for descent on approach, or approaching the NDB inbd course for approach? Some of the old skills are still relevant; but never taught never learnt.
Join Date: Feb 2010
Location: a shack on a hill
Posts: 128
Likes: 0
Received 0 Likes
on
0 Posts
scan SBY instruments
A threat to aviation!
Join Date: Nov 2000
Location: I wish I knew
Posts: 624
Likes: 0
Received 0 Likes
on
0 Posts
This Captain was not highly experienced...His total flying experience is 10,233 hours including 3,718 hours as PIC of which 2,488 hours are on different light and spray aircraft, 1,042 hours on Fokker 50 and 188 hours on B 737-700/800.
The radar trace show the a/c turned 48 degrees past the original HDG of 315 degrees. why? It looks very much like they initiated the turn to 270 degrees in the wrong direction and overbanked the correction to the left.
The first " Bank Angle" warning came at 0038.41 only 19 seconds before the corrected left turn (according to the radar trace) was made.
A disorientated perhaps fatigued crew. ,manual flight, lack of capacity, we have seen this all before, sadly.
Edited after confusion..
The radar trace show the a/c turned 48 degrees past the original HDG of 315 degrees. why? It looks very much like they initiated the turn to 270 degrees in the wrong direction and overbanked the correction to the left.
The first " Bank Angle" warning came at 0038.41 only 19 seconds before the corrected left turn (according to the radar trace) was made.
A disorientated perhaps fatigued crew. ,manual flight, lack of capacity, we have seen this all before, sadly.
Edited after confusion..
Last edited by Avenger; 29th Mar 2011 at 20:00.
Join Date: Apr 2002
Location: FUBAR
Posts: 3,348
Likes: 0
Received 0 Likes
on
0 Posts
Avenger,
just to avoid confusion, the guy Tee Emm is talking about, and the ill fated Capt of the Ethiopian flight , should not be confused with each other
Quite apart from the above, his command experience, AND mere 188hrs on type prior to command 
, does make it slightly easier to understand the outcome.
just to avoid confusion, the guy Tee Emm is talking about, and the ill fated Capt of the Ethiopian flight , should not be confused with each other
Quite apart from the above, his command experience, AND mere 188hrs on type prior to command
, does make it slightly easier to understand the outcome.
Join Date: Feb 2010
Location: a shack on a hill
Posts: 128
Likes: 0
Received 0 Likes
on
0 Posts
This Captain was not highly experienced...His total flying experience is 10,233 hours (...)
Sun worshipper
Join Date: Dec 2001
Location: Paris
Posts: 494
Likes: 0
Received 0 Likes
on
0 Posts
Let's stick to facts
Quite an interesting discussion on unusual attitudes...
But the point is, to get out - with any chance of success - from an unusual attitude, a pilot shouldn't be the prey of some major disorientation, disorientation that led him to the dire situation he found himself in, in the first place.
Manual flight, at night, total IMC, no natural horizon and thunderflashes, one 180 ° right turn after takeoff, followed by a left turn, and another one, while climbing, IMO that's enough recipe for somatographic illusion.
Then the succession of disorganised reactions to the body accelerations, the cockpit warnings - bank, stall, overspeed...- to the brutal ending of a death dive, probably an attempt to pull out at a very high G (in excess of 4 ) thus causing the in-flight break-up of the airplane (simultaneous losses of DFDR recording and ground radar trace of the flight).
When will we really address this somatographic illusion killer with some real training ? because, you know, the performance of modern airliners isn't really decreasing, flight controls will have quite a lot more authority than they do now... that problem isn't going away.
But the point is, to get out - with any chance of success - from an unusual attitude, a pilot shouldn't be the prey of some major disorientation, disorientation that led him to the dire situation he found himself in, in the first place.
Manual flight, at night, total IMC, no natural horizon and thunderflashes, one 180 ° right turn after takeoff, followed by a left turn, and another one, while climbing, IMO that's enough recipe for somatographic illusion.
Then the succession of disorganised reactions to the body accelerations, the cockpit warnings - bank, stall, overspeed...- to the brutal ending of a death dive, probably an attempt to pull out at a very high G (in excess of 4 ) thus causing the in-flight break-up of the airplane (simultaneous losses of DFDR recording and ground radar trace of the flight).
When will we really address this somatographic illusion killer with some real training ? because, you know, the performance of modern airliners isn't really decreasing, flight controls will have quite a lot more authority than they do now... that problem isn't going away.
I was following some way behind one of our NGs after holding due to an intense thunderstorm. We managed to weave our way around enough to make an approach and the field was clear. After landing the FO of the NG in front told me they got hit by lightning and all their EFIS disappeared. As they were stable and visual with the field they continued. If something like that happened to the Ethiopian crew in cloud, climbing and trying to follow changing atc instructions it would explain certain things. Not saying that it happened. But before we jump to conclusions lets hope the next report provides some more facts.
Per Ardua ad Astraeus
Join Date: Mar 2000
Location: UK
Posts: 18,579
Likes: 0
Received 0 Likes
on
0 Posts
Originally Posted by Lemurian
When will we really address this somatographic illusion killer with some real training ?
Leder - what you describe is, in fact, an 'easier' situation to handle than a subtle loss of reference in PF's ADI. No ADI's/EASI's - use the standby's!