Air France B777 control issues landing CDG
PF: Push the TO/GA switch, call "Go-around Flaps 20".
PM: Select the flap lever to 20.
PF/PM: Verify the rotation to go-around attitude and the thrust increases.
PM: Verify the thrust is sufficient/adjust as needed.
PM: Verify a positive rate of climb and call "Positive Climb".
PF: Verify a positive rate of climb and call "Gear Up".
PM: Select the landing gear to UP.
PF: Above 400 ft radio altitude, select or verify a roll mode.
PM: Verify the missed approach altitude is set.
PF/PM: Verify the missed approach route is tracked.
ETC...
You might argue that we practice those steps all the time in the sim and that pilots should be competent at doing them correctly, and I would agree. The problem, however, is that when something totally unexpected (eg a failure) occurs at a critical moment, most pilots are startled, if only momentarily. It's a completely normal human response. Most will recover reasonably quickly and fall back upon practiced routines such as the go-around procedure, but some pilots do not. They take longer to recover, their subsequent performance suffers and they get things wrong. It is not at all unusual to see pilots get the go-around sequence wrong, or to omit some steps altogether in such situations. I have seen pilots forget to select the flaps to 20 before selecting the gear up; forget to check the thrust is set; forget to check the correct missed approach altitude is set, forget to check the correct modes are annunciated. The list goes on and there are several relatively recent accident reports that document the inappropriate responses of crews when they were confronted with something unexpected.
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If crews are being startled by a go-around, then frankly they are in the wrong job. Sorry.
Last edited by vilas; 23rd Apr 2022 at 17:48.
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+1 vilas ! Great post.
I suspect what is probably really happening is that HR departments in airlines have decided it is their job to select pilots, and have taken over the selection process. So they put hopeful pilots through stupid tests which bear no relation to actually flying a big jet or dealing with problems on the ramp - tests such as 'what symbol should appear next', or 'who in a written passage about an office ordered which pizza', or 'what is the volume of this irregular solid' - answer in 20 seconds please !!!
The TREs are handed a group of people who passed these tests but have no time scheduled to properly check, so have to assume they are up to the job. Not necessarily so ! The trainees are told what to expect in the SIM, either by the training department of through each other via social media, so they can pass the tests.
Then, one dark horrible night on the line - or even a nice day - something happens that they have never thought about or experienced.............
I suspect what is probably really happening is that HR departments in airlines have decided it is their job to select pilots, and have taken over the selection process. So they put hopeful pilots through stupid tests which bear no relation to actually flying a big jet or dealing with problems on the ramp - tests such as 'what symbol should appear next', or 'who in a written passage about an office ordered which pizza', or 'what is the volume of this irregular solid' - answer in 20 seconds please !!!
The TREs are handed a group of people who passed these tests but have no time scheduled to properly check, so have to assume they are up to the job. Not necessarily so ! The trainees are told what to expect in the SIM, either by the training department of through each other via social media, so they can pass the tests.
Then, one dark horrible night on the line - or even a nice day - something happens that they have never thought about or experienced.............
Uplinker, that's all well and good but you said on the previous page:
Exactly who's fault is it then, being able to be startled? You're quite happy to bash the pilots, when in fact it's got little to do with them. It's the system that has made them. Or are you suggesting that if you get startled by a no-notice go-around need then you should be sacked?
If crews are being startled by a go-around, then frankly they are in the wrong job. Sorry.
Is a "startle" response to a go-around situation something that is caused by the company's aversion to additional flight time for financial reasons? Are pilots afraid of a go-around because they are afraid of arousing the wrath of the bean counters? Are they afraid of being being berated for delaying the schedule of the next flight?
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Uplinker, that's all well and good but you said on the previous page:
Exactly who's fault is it then, being able to be startled? You're quite happy to bash the pilots, when in fact it's got little to do with them. It's the system that has made them. Or are you suggesting that if you get startled by a no-notice go-around need then you should be sacked?
Exactly who's fault is it then, being able to be startled? You're quite happy to bash the pilots, when in fact it's got little to do with them. It's the system that has made them. Or are you suggesting that if you get startled by a no-notice go-around need then you should be sacked?
I think pilots can be surprised but surely they should be able to swing into action; not be startled, frozen and scared - aren't we all selected and tested for our ability to be calm and know what to do in an emergency?
Maybe not any more. Are you really comfortable that some airliners are being piloted by apparently undertrained or poorly selected pilots, who cannot handle even a go-around : something every pilot should be expecting in the back of their mind all the way down the approach?
Better selection and training?
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Let me say it.. 
More time with your hands on the stick and throttle, so when something unexpectedly happens you are one with the plane.
I am positive any hands on flight experience is positively transferred to other parts of flying. Being up to speed with your scanning and hand eye-coordination will make you better prepared for scenarios that unfold unexpectedly and requires timely action (such as a go-around from an odd state).
So in essence, better training required. And the right type of training.
More time with your hands on the stick and throttle, so when something unexpectedly happens you are one with the plane.
I am positive any hands on flight experience is positively transferred to other parts of flying. Being up to speed with your scanning and hand eye-coordination will make you better prepared for scenarios that unfold unexpectedly and requires timely action (such as a go-around from an odd state).
So in essence, better training required. And the right type of training.
No no; look, I am not 'happy' to 'bash' anyone I am trying to understand what is going on in aviation. Have you ever been startled, i.e. frightened into inaction, for something as simple and routine as a go-around? Here was a pilot so frozen that he gripped the yoke and held the PTT switch open for 20s and could be heard breathing heavily. And vilas tells us of another crew faced with a Windshear memory drill who did nothing for 2 minutes. And another pilot held full back-stick at FL 390 for an extended period and fatally stalled the aircraft.
I think pilots can be surprised but surely they should be able to swing into action; not be startled, frozen and scared - aren't we all selected and tested for our ability to be calm and know what to do in an emergency?
Maybe not any more. Are you really comfortable that some airliners are being piloted by apparently undertrained or poorly selected pilots, who cannot handle even a go-around : something every pilot should be expecting in the back of their mind all the way down the approach?
Better selection and training?
I think pilots can be surprised but surely they should be able to swing into action; not be startled, frozen and scared - aren't we all selected and tested for our ability to be calm and know what to do in an emergency?
Maybe not any more. Are you really comfortable that some airliners are being piloted by apparently undertrained or poorly selected pilots, who cannot handle even a go-around : something every pilot should be expecting in the back of their mind all the way down the approach?
Better selection and training?
Were you already criticising pilots selection 20 years ago ?
I'm seeing you joined the forum more than 20 years ago, so you could just read your own old posts to figure that out ! (I won't do it though, these posts belong to you)
So in essence, better training required.
You learn to fly with a sim, but then you practise on the line.
An intermediate solution that I would like to see for myself would be if airlines developped an easy to install at-home sim, based on a VR headset or at-home screen, company provided joysticks and thrust levers, and you could just practise your basic hand flying with it. It wouldn't be quite the same but the cost would be minimal and I'm sure it would be of some help. The visual circuit is the same whether it's a sim or an airplane.
Physical responses to startle effect/amygdala hijack include increased eye blinking, deeper breathing and/or a jerk away from the threat. If a pilot had something unusual/surprising happen AND DIDN’T blink or take a deeper breath then I’d be veryyyy surprised. It’s a normal and natural human response and all mammals do some variation of it. If you don’t then you deviate from the norm. Would be fun to run some experiments on you!
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You really cannot really "train" adequately to combat the "Startle effect" and as explained earlier ,it would be very expensive , but there is another level often following surprise , is "fear" , fear induced by not immediately understanding what is happening , which can be followed by "the tunnel vison" and going for the wrong solution . , examples : 3 miles islands or AF447 ..This last process has been studied and is well explained in Charles Perrow books, if you have time to spare I recommend to read his first one : "Normal accidents".
Everyone tend to think he can be superman and able to cope with every situation , but ,as Boeingdriver99 just said, we are mammals there are natural responses one cannot suppress .Some are better than others at it, it depends also in you state of mind ,level of fatigue/lack of sleep. circadian clock you are in ,etc..,
In an emergency situation have seen some very good controllers "freeze" then fear made them act irrationally. The good thing about ATC is that the people do not die and can be debriefed. In this particular case , as both pilots survived, a debrief with a trained human factor specialist.
might help understanding the why . But if the rumors are correct I doubt however it will be made public.
Everyone tend to think he can be superman and able to cope with every situation , but ,as Boeingdriver99 just said, we are mammals there are natural responses one cannot suppress .Some are better than others at it, it depends also in you state of mind ,level of fatigue/lack of sleep. circadian clock you are in ,etc..,
In an emergency situation have seen some very good controllers "freeze" then fear made them act irrationally. The good thing about ATC is that the people do not die and can be debriefed. In this particular case , as both pilots survived, a debrief with a trained human factor specialist.
might help understanding the why . But if the rumors are correct I doubt however it will be made public.
I have never claimed that I am Chuck Yeager or Neil Armstrong, or even the ace of the base and certainly not Superman - far from it. I am just an average pilot (and am not claiming that I have a perfect flying record either !).
But I am confused that in recent years we have had:
A crash at SFO because nobody did anything about the speed dying away.
A crew with mode confusion who stayed on the runway well past Vrotate and then flew very very low, barely missing buildings, instead of climbing away.
A pilot who held full backstick at FL390, fatally stalling the aircraft.
A crew who forgot to select TOGA when trying to fly a baulked landing.
A crew who continued when they were so hot and high, they forgot to lower the gear, scraped the engines along the runway, got airborne again and fatally crashed.
A crew who landed so fast and deep that they went off the end of the runway.
A crew who after landing tried to use the yoke as a steering wheel to stay on the centre-line instead of the rudder, during a crosswind landing, and went off the side of the runway.
All of the above were basic piloting errors and none of the above were owing to engine fires or control problems and were not difficult or complicated problems. But if I and my colleagues had done any of these things in our initial airline Sim test, we would not have been employed by the airline - it would have been "thanks, but PFO".
The last real piloting events I can think of were the B777 into EGLL with double engine failure at very short finals owing to blocked fuel filters - saved by the quick thinking of the crew who raised the flaps one stage and just managed to get over the fence. Another was the QANTAS A380 with an exploded engine and dozens of ECAM warnings. And of course the Cactus double engine failure, landing on the Hudson river. All fantastic piloting and surely what we expect from pilots, (and would hope to achieve ourselves), are they not?
So I am honestly not bashing pilots as such; but just wondering what is happening to aviation? We now hear about this startle effect, which now seems to be used as an excuse when pilots make basic flying mistakes. Are we not selected as pilots exactly because we can deal with problems in a calm and controlled manner? How are some pilots now getting so badly out of shape with standard flying and standard manoeuvres? Is it the training or the selection or something else?
But I am confused that in recent years we have had:
A crash at SFO because nobody did anything about the speed dying away.
A crew with mode confusion who stayed on the runway well past Vrotate and then flew very very low, barely missing buildings, instead of climbing away.
A pilot who held full backstick at FL390, fatally stalling the aircraft.
A crew who forgot to select TOGA when trying to fly a baulked landing.
A crew who continued when they were so hot and high, they forgot to lower the gear, scraped the engines along the runway, got airborne again and fatally crashed.
A crew who landed so fast and deep that they went off the end of the runway.
A crew who after landing tried to use the yoke as a steering wheel to stay on the centre-line instead of the rudder, during a crosswind landing, and went off the side of the runway.
All of the above were basic piloting errors and none of the above were owing to engine fires or control problems and were not difficult or complicated problems. But if I and my colleagues had done any of these things in our initial airline Sim test, we would not have been employed by the airline - it would have been "thanks, but PFO".
The last real piloting events I can think of were the B777 into EGLL with double engine failure at very short finals owing to blocked fuel filters - saved by the quick thinking of the crew who raised the flaps one stage and just managed to get over the fence. Another was the QANTAS A380 with an exploded engine and dozens of ECAM warnings. And of course the Cactus double engine failure, landing on the Hudson river. All fantastic piloting and surely what we expect from pilots, (and would hope to achieve ourselves), are they not?
So I am honestly not bashing pilots as such; but just wondering what is happening to aviation? We now hear about this startle effect, which now seems to be used as an excuse when pilots make basic flying mistakes. Are we not selected as pilots exactly because we can deal with problems in a calm and controlled manner? How are some pilots now getting so badly out of shape with standard flying and standard manoeuvres? Is it the training or the selection or something else?
Understanding incidents and accidents can be biased by the initial framing.
Statements using ‘crews’, ‘pilot’, ‘they’, are more likely to be interpreted as ‘pilot bashing’, human factors at the sharp end, opposed to considering alternative contributing factors
From the examples above:-
Weak auto thrust design, the system could go to sleep; the designer was surprised.
Weak FD switching logic, mandated use of FD for takeoff; the operator was surprised.
Multiple probe icing beyond the conditions assumed by regulation; the regulator was surprised
In these events and others, the expectation (after the fact) is that the human should have managed the system deficiencies. Our, operational expectations are influenced by hindsight, whereas design and regulation have to anticipate.
The expectation is that humans will manage malfunctions in those systems which were fitted to ease workload, minimising ambiguity, to provide a higher level of safety than the human alone was capable of.
Catch 22: After recognising human limits, additional safeguards were provided; however these required the human to manage failures in the same systems designed to overcome human limitations.
The industry has a high level of safety, such that accidents have few if any common factors, except the human; thus inappropriate focus on the human. It is time for safety management to appreciate uncertainty in operations and its effect on human performance; don't start with the human, consider the overall system.
Statements using ‘crews’, ‘pilot’, ‘they’, are more likely to be interpreted as ‘pilot bashing’, human factors at the sharp end, opposed to considering alternative contributing factors
From the examples above:-
Weak auto thrust design, the system could go to sleep; the designer was surprised.
Weak FD switching logic, mandated use of FD for takeoff; the operator was surprised.
Multiple probe icing beyond the conditions assumed by regulation; the regulator was surprised
In these events and others, the expectation (after the fact) is that the human should have managed the system deficiencies. Our, operational expectations are influenced by hindsight, whereas design and regulation have to anticipate.
The expectation is that humans will manage malfunctions in those systems which were fitted to ease workload, minimising ambiguity, to provide a higher level of safety than the human alone was capable of.
Catch 22: After recognising human limits, additional safeguards were provided; however these required the human to manage failures in the same systems designed to overcome human limitations.
The industry has a high level of safety, such that accidents have few if any common factors, except the human; thus inappropriate focus on the human. It is time for safety management to appreciate uncertainty in operations and its effect on human performance; don't start with the human, consider the overall system.
Uplinker: Everything you list is simply a failure of the person at the controls to fly the airplane. No procedures can substitute for that.
1. Aviate (Fly the airplane.)
2. Navigate
3. Communicate
If you don't do number one, you won't get a chance to do the others.
1. Aviate (Fly the airplane.)
2. Navigate
3. Communicate
If you don't do number one, you won't get a chance to do the others.
You absolutely can set up a startle effect scenario for the crew to work through, a hugely beneficial exercise. However airline executives want the cheapest training possible. That is why most sim training is a box ticking exercise designed to meet the exact minimum proscribed regulatory requirements. Putting in some free form training exercises so pilots can stretch themselves cost money, that is why it doesn’t happen.