Blind Reliance on Automation in Australian airlines
ATSB rarely publish foreign accident reports even though some may have valuable lessons for Australian pilots. Pilots are therefore left to their own devices to read accident reports from internet sources if they wish to improve their professional knowledge. Except for the occasional enthusiast, few Australian airline pilots and even fewer GA pilots can be bothered to look on the internet specifically for overseas accidents to their own aircraft type, and thus valuable lessons are never taken up, simply because of apathy and other interests outside of flying. The excellent flight safety record of Australian airlines may be due to the unique Australian character where flight crew (in some airlines) are all mates and they have no hesitation is speaking their mind to God in the left seat. That is not a bad thing provided a commonsense attitude prevails on both sides. First class ATC, few natural hazards and of course good year round weather, all contribute to the good safety record. Ergo - why bother about studying boring old overseas accidents (even if you can be bothered looking for the links) when all is well in sunny OZ?
Automation from lift off to short final in severe CAVOK is all the go in some Australian airlines - including the regionals who copy whatever the big boys are doing. We have a new class of pilots brought up by their company SOP's on a strict diet of blind use of automation which is seen as a Good Thing. Pilots happily press buttons with great aplomb so they can watch their highly sophisticated autopilots LNAV into the CAVOK circuit following beautifully crafted waypoints to downwind, base and final with both pilots glued on to flight directors and the thrust levers quietly adjusting the power.
There is bated breath as the PF announces gravely the dreaded words :Standby -standby – autopilot disconnected NOW” and the PNF hunches in great concentration to monitor the man on the controls. Jeez! It is a truly emotional moment in a pilot’s career when several times a day he actually gets to disconnect the automatics in the last few minutes or even seconds of a visual approach..
Levity aside – let us pray for the poor souls of 135 innocents who died at the hands of two automatic zombies in the Middle East in the Year 2004. These Zombies no doubt had been trained in the simulator that the safest way to fly – indeed the only way to fly, was to leave it all to the automatic pilot and its two friends the flight director and automatic throttles. Sound familiar?
This is part of the CVR transcript originally in Arabic of the last 30 minutes of Flash Air Boeing 737-300 Flight 604 departing Sharm El Sheikh for Cairo. Cairo is in Egypt, for the geographically challenged. For brevity the extract is edited but you will soon get the picture.
ATC clearance was delivered at 0235 GMT and read back by the F/O as follows:
ATC Flash 604 destination Cairo as filed climb initially flight level 140. 1673 on squawk.
F/O: Our clear to destination via flight plan route 140 initially 1673 on the squawk Flash 604 we have total pax 135. God Willing.
At time 02:42:02, TOGA mode engaged and then disengaged two seconds later. Aileron movements during take off roll and lift off were consistent with a crosswind. At 02:42:43, climbing through 440 feet, captain requested Hdg select. The F/O confirmed the command and the FDR records Hdg select mode engaged. At 02:42:48, captain requested “Level Change.” And F/O replied “Level change, MCP speed, N1 armed - Sir.”
ATC reported departure time and confirmed left turn clearance. The clearance was acknowledged by the F/O. This was the last ATC transmission from the crew. The aircraft rolled 20 degrees left bank and began a climbing left turn. At time 02:43:47 the captain calls for after take off checklist. No audible response from F/O. At time 02:43:55 captain called “Autopilot”. No immediate response from F/O or mode changes recorded on FDR. At 02:43:58, the captain states “Not Yet.”
02:43:59 FDR recorded autopilot was engaged and the roll mode transition to CWS-R mode resulting in loss of Hdg mode.
At 02:44:00 the F/O stated “Autopilot in command, Sir.”
02:44:01 captain says “EDEELO” an Arabic exclamation expressing a sharp response of some kind while at same time FDR records momentary aileron surface movements and soon after FDR records autopilot disengaged. Increase in pitch and decay in airspeed recorded.
At 02:44:07 FDR records a series of aileron motions that command right bank and subsequent right turn. One second later the captain says “See what the aircraft did”. The aircraft was now in a 12 degree bank to right.
02:44:27 F/O states “Turning right, Sir.” Three seconds later the captain responses “What.” Bank is now 17 degrees right and FDR records aileron movement to increase right bank.
02:44:37 captain states “how turning right”. At this point bank was slightly more than 40 degrees right bank then a momentary left roll rate before additional right bank to 42 degrees before further inputs to increase right bank.
02:44:41. F/O says “Overbank” with bank now 50 degrees as aircraft reaches max altitude of 5460 feet over water.
02:44:41.7 captain says “Autopilot” and repeats statement one second later. At 02:44:44 the F/O states “autopilot in command.” No autopilot engagement was recorded on FDR.
Bank angle now 60 degrees and pitch angle zero. At 02:44:46 the captain again says “Autopilot” and the F/O replies with “overbank, overbank, overbank” with bank angle now 70 degrees.
02:44: 52.8 F/O says “Overbank” as bank angle approached 90 degrees (still in night IMC) and 23 degrees pitch down.
02:44:56 F/O states “No autopilot, Commander” with bank angle 102 degrees pitch 37 degrees down and altitude 4100 ft.
02:44:58 captain says “Autopilot” with bank angle 111 degrees right and 43 degrees nose down. Altitude 3470 ft. 02:45:01 captain says “Retard power, retard power, retard power” Bank angle now 51 degrees right wing down and 40 degrees nose down altitude 2470 ft.
02:45.02 CVR records overspeed warning and airspeed 307 knots. At time 02: 45:03 the captain states “Come out” . Bank angle now 14 degrees right, 31 degrees nose down altitude 760 feet and airspeed 407 knots.
Aircraft impacted water at 02:45:06 with: bank angle 24 degrees right, pitch 24 degrees nose down, Vertical G load 3.9 and speed 416 knots.
……………………………………………………………………………………………..
Despite the intonation of “God Willing” made by the F/O during his read back of the ATC clearance, it was clear that on this occasion his God was not willing, before the impact of 416 knots…
Someone once said of automation: “Do you control the automated cockpit, or does it dominate you?” Well, it certainly dominated the crew of the ill-fated Flash Air 737 to a fatal extent. For many airline pilots in Australia, the answer would probably be that the automated cockpit dominates them too – although few would admit it in public. Blind reliance on automation is often used to justify laziness in the cockpit. When it comes to a visual circuit, some pilots regard auto-piloting an aircraft into the circuit on heading mode or maybe even lateral and vertical navigation, to waypoints scattered through a circuit area until short final, as the height of “cool”. The well known trap of automation is that its use inevitably erodes pure flying skills. The captain of the Flash Air 737 implored time and again for “Autopilot” even when his aircraft was in an impossible attitude. Proof positive he had lost all semblance of basic flying skills. It would never happen here in Australia of course - or could it?