Old 4th Sep 2019, 21:19
  #116 (permalink)  
fox niner
 
Join Date: Jul 2004
Location: Netherlands
Posts: 636
Found this on the internet. Via google translate:

Source:

https://www.planes.cz/en/article/203...reni-pokracuje
Smartwings per engine after 10 days. More question marks than answers. The investigation continues.
 2019-09-01 09:00

On 22 August, due to a motor failure, the Boeing 737-800 (OK-TVO) flew by Smartwings from QS1125 from Greece to Prague, taking about 2 hours and 20 minutes. offended a plane with one functional engine. There were 170 passengers aboard. The Civil Aviation Authority and the Aviation Accident Investigation Institute have opened an investigation into this serious incident.

In the meantime, the lack of official information has fueled speculation. Therefore it makes sense to remind the whole event with hindsight, taking into account the information provided by the Office or through the media. In addition to the facts, we also provide some estimates that reflect the discussion of planes.cz forum participants, which may or may not be confirmed during the investigation.

Nearest suitable airport

The basic fact is that the crew decided to continue to the final destination despite the engine failure. The regulations clearly require a diversion to the "nearest suitable airport". The concept of an appropriate airport is and must be ambiguous, since 'suitability' depends on a number of parameters which, in addition, may be variable (eg aircraft status, weather). However, given the number of airports along the route and the favorable weather, it is hard to imagine that the destination Prague airport would be the first “suitable” airport.

In the CT24 report on August 26, we saw that the Civil Aviation Authority qualified this situation with terms “non-standard” and “shocking”. However, neither of these terms indicates whether the infringement was committed. At the request of planes.cz for the interpretation of the term “non-standard” in terms of aviation regulations, the Office stated that “according to currently available information, the decision of the crew to make a flight to a destination was not in accordance with the procedures required in the case. Especially in the light of the documentation available to us, in the event of the failure of one power unit, a landing at the nearest suitable airport should be planned. ' In other words, according to the Office, the infringement is a fact.

However, this is definitely denied by the operator, who states that the situation "was under control". But this is an obvious euphemism that ignores the fact that Boeing did not provide the aircraft with two engines for no reason. If a second engine fails, then Boeing turns into a glider and the concept of 'under control' is limited by the glide of the aircraft. A possible second engine failure is something that cannot be “under control”. Definitely not appealing idea for 170 unsuspecting passengers on board. And that's a fact. Contrary to the current position of the Office, a spokesman for Smartwings insists that "the crew proceeded in accordance with safety and operational procedures for these cases ... and the aircraft landed safely in Prague". The fact that the plane landed safely in Prague does not mean that the flight was safe. To what extent Smartwings' claim of a prescription flight is in line with reality will show the outcome of the investigation.

In the CT24 report mentioned, it was said that the “approved” operating manual of the company allows the flight to the target destination for one engine. The regulator's reply to planes.cz, however, denies this, saying that "according to the Office currently available documents, the decision to make a flight to a destination was not in accordance with the approved documentation of the operator."

Director of CAA Ing. David Jagr went even further when he admitted that there could be criminal prosecution.

Where did the voice recorder (CVR) record go?

It can be assumed that, at least in the light of possible criminal matters, it would be desirable to document what the motivation was and what specific factors led the Smartwings manager, who piloted the flight according to several sources, to believe that The nearest suitable airport is Prague, 2 hours away. 20 min. flight per engine. A natural source of such information is the cockpit communication recorder (CVR). Therefore, it is logical to ask what the CVR record says. However, we receive a surprising response from the CVR to our question regarding the TCL that the Eppo "does not have information on the availability of CVR data. The office did not require a specific entry from the CVR as such in the previous investigation. In view of the investigation of the event under the AAII competencies, it is necessary to contact colleagues directly. " The editors of planes.cz, of course, have turned to AAPLN, but they have not yet received the answer. We believe that, at least in view of the possibility of (albeit remote) prosecution, the CVR record should have been secured as evidence.

The fact remains that at least the ÚCL did not require the CVR record. The office states that "the Civil Aviation Authority has invited the Company's representative to explain the event and the progress of the operator and crew. The next steps are then investigated and its results. In addition, the Office issued a statement to the whole event which is available on the website of the ÚCL. " Since this procedure stopped us, an advanced inquiry by the CPK spokesperson added that "The Office has requested materials from the operator which are relevant to the matter and to the investigations conducted by our office. The method of substantiation is at the moment on the operator. Whether the record was required for the investigation of an event conducted under the responsibility of the AAII, I do not have information about it ". This wording indicates that the EPPO has provided the operator with space and time to present its own version of the event which cannot be verified by the CVR record. That's our assumption. That the CVR record was declared irrelevant to the need for an investigation into the CPCL.

Quietly over Europe

That passengers were not informed about the one-engine flight to Prague, it is OK. However, no evidence has yet emerged that air traffic control services on the route would be informed of the non-functioning engine flight. And that's not good. On the AV Herald server, a staff member of the Budapest ATC, who operated an incriminated flight, said he did not know about the engine failure. He assumed that this is a problem with the air conditioner, which in turn is not so exceptional, and which forces the plane to fly on the levels around FL240. Only then and after the inquiry of the Austrian inspection, he learned that it was a flight of two-engine aircraft per engine. It states that the Serbian, Austrian and Kosovo (KFOR) ATC were not informed of the failure. The AV Herald presents the information as verified. It is almost certainly possible to say that the signal of distress MR Pan Pan was announced for the first time only after entering the airspace of the Czech Republic, together with the information that the flight takes place on one engine. This is also confirmed by a very knowledgeable Technet. From the mouth of the spokesman Richard Klíma's air traffic control, there's another "non-standard" moment. The Ten for CT stated that "in the case of such a serious technical problem, such as loss of functionality of one of the two propulsion units, it is certainly not standard for the commander of the aeroplane to inform the responsible steering Centre about this situation". The ÚCL response to a particular question by the editors planes.cz not provided the communication, AAII is not to be reached. From EASA we received only a non-standard opinion on the interpretation of the concept of "nearest suitable airport", but the answers to the specific question of whether the crew had communicated the problem with the ATC services were not met. On the basis of the information available, we consider that the crew did not adequately inform the air traffic Control service engine failure. We assume that this is a serious ' non-standard ' moment, which will certainly be clarified in the context of ongoing investigations.

Another interesting assumption that appeared in the Forum planes.cz and has a relationship to 2 hours. 20 min. Long flight at low flight level is a link with fuel consumption. Specifically, when landing in Prague, the aircraft had a minimum fuel supply on board. We raised this question at the ÚCL, but we do not have the answer, because it is obviously a fact not disclosed during the investigation.

Who was behind the "Knipl"?

So we are in a situation where all (except Smartwings) agree at least that the flight was non-standard, and in several ways.

Let us admit to the hypothesis that the Commander decided correctly and the whole procedure was exemplarly prescripting. However, this applies only if the flight lasts for 2 hours. 20 min. per engine to the final destination was less risk than landing at the airport along the route. And that's certainly absurd.

The presumption is that the real motivation for a flight to Prague could be to avoid the millions of costs that would represent diversion to the airport along the route – a substitute aircraft, compensation to passengers, etc. Several sources close to Smartwings claim that the commander of the flight was the chief pilot of the company. That it was not a very low-skilled pilot, it follows from the comments of a company spokesperson stating that "The commander is one of the most experienced in the company". It is clear that the executive and "one of the most experienced" of the financial consequences of diversion had to be aware. This could explain the "non-standard" flight to the final destination as well as the "non-standard" silence over Europe. The ongoing investigation will surely confirm or exclude this presumption. It is a pity that the CVR record cannot be used.

As this is a serious incident in the investigation stage, a logical question arises as to whether the commander of the flight is immobiled from the flight during the ongoing investigation. In response to this inquiry, the office stated that "the results [of the investigation] cannot be anticipated at this time. Given the possible psychological pressure on the aeroplane commander concerned and the related impact on the safe conduct of other flights, it was recommended that the operator be considered as being temporarily outside the performance of the flight service. "

This year's incidents

Incident Flight QS1125 was not the only one that hit Smartwings during this year. At the beginning of the year, on 13. In January, the Smartwings aircraft came out of the runway when starting on the runway of Sheremetyevo airport. On 16. In May, two Smartwings planes met during the taxi at Prague Airport. We do not mention other incidents that are of a technical nature.

SmartWings in March affected the grounding of the seven Boeing 737 MAX, which of course caused pressure on the company, caused the need to cancel or change flights and to hire aircraft from other companies. Even here Smartwings stumped upon the problem when 7. June had to oat 737-400 rented from YanAir, after the Ukrainian authorities banned the YanAir activity for critical shortcomings in security. The mentioned aircraft (UR-CNP) is over 30 years old and Yan Air is its 21st century. Operator. With proper maintenance and observance of procedures, this is not the slightest problem, but security shortcomings have convinced the Ukrainian authorities of the need for intervention.

These are all the moments that make up the broader framework in which flight crew QS1125 take their flight decisions to Prague.

Best Practice

The results of the investigation cannot be anticipated. Likewise, at the time of the ongoing investigation, all information is not released. However, it is evident that serious infringements were likely to occur in this case and that passengers flying QS1125 were exposed to undue risk. It is also evident that the company has acted contrary to best practice or if you want to comply with the good manners of the responsible carrier.

On 14. December 2018 was diverted by Boeing 737 MAX (LN-BKE) to Norwegian Air line DY1933 during a flight from Dubai to Oslo due to the decommissioning of the engine to the airport in Iran's Shirazu. Due to sanctions against Iran, it was not the most suitable country for diversions, yet the crew preferred the nearest airport, even if the "suitability" of the Iranian airport was successfully doubting. It took 70 days until the plane was able to get back into operation from Iran. Illustration of the fact that passenger safety is superior to the economic interests of the carrier. The example of Norwegian Air is relevant as Norwegian Air also faces a difficult economic situation. Nevertheless, it acted as expected from a quality company.

Company Security Culture

The investigation of the office and of the Constitution is naturally confined to what the regulations say. A number of important information is not available due to the ongoing investigation.

The regulations only set minimum conditions for operators to ensure safe operation. But what is more important is the security culture of the carrier. High-quality world carriers take measures well beyond what the regulations impose on them to minimise all risks. And this is the approach we expect from professionals who have the lives of passengers in their hands. SmartWings on its website says that "flying is a matter of trust and security is the parameter that Smartwings Group puts the greatest emphasis on".

However, the case of flight QS1125 indicates a serious absence of Smartwings safety culture. Because whatever the investigation may be, it is certain that in the case of this flight, the "non-standard" practices were suspicious. If one of the most experienced leaders of Smartwings and the company's executive is flying like this "non-standard", it is definitely wrong and it is a bad example for other pilots.

Facts
◾ Boeing 737-800 (OK-TVO) flew on line QS1125 after the withdrawal of one engine from the Greek airspace to one engine up to Prague.
◾ According to observations of the Civil Aviation Authority, the decision of the crew according to currently available information was not in accordance with procedures and approved documentation of the operator.

Questions

A number of questions that are offered will be answered by the reports of the authorities investigating the incident. We have to wait for the official responses to the data from the recorders, especially the CVR, to the crew or fuel decision bases and to the communication with air traffic control services.
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