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Old 19th Jun 2023, 09:58
  #326 (permalink)  
fdr
 
Join Date: Jun 2001
Location: 3rd Rock, #29B
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Originally Posted by EDLB
Should be an important task for the FAA to figure out, why the two in row 0 never tried to open the throttle of the other idling engine, when the in their mind "good one" could not keep altitude.
Compared to swim they cold hardly loose. So why both where so task saturated that the simple solution never occurred to them.
They did the first right thing and did not shut the engine down, as other did before and tried to relight it in vain. They where so close in saving the night.
Easy to say from the arm chair, but there is something to learn here.
The point that the cognitive error occurred is identifiable in the CVR, the PIC verbalises the failed engine as #1 whereas the FO had previously determined #2 to have failed. The PIC had assumed PF just before this, and it appears he had made a thrust reduction, and had brought #1 back around this time, and had a cognitive slip. The point of opening up any thrust lever would have saved the flight is valid, the problem is the crew are fighting a confusing SA condition which adds stress to their processes, and that reduces the bandwidth either pilot had to do a simple reasonableness assessment. It is possible to lose two engines, it is not likely, and it is far more likely for a crew to select the wrong engine as the cause of their problems. If the energy state is decaying, adding any lever tooth mix of more noise can only be beneficial.

The CVR is not pretty, the NTSB is making a fashion statement with leaving the complete conversation in the transcript, it should be a learning point on the concept of policy, practices and specifically reduction of extraneous activity in critical phases of flight. While it reads polly, it is closer to what is observed in many operations when undertaking IOSA audits. Humans act as humans do.

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