PPRuNe Forums - View Single Post - Air Transat - "Panic in the Cockpit" recording
Old 3rd Aug 2011, 14:43
  #53 (permalink)  
punkalouver
 
Join Date: Nov 2004
Location: Here, there, and everywhere
Posts: 1,129
Likes: 0
Received 13 Likes on 8 Posts
Keep in mind that the copilot was a training captain.

If anyone can translate appendix B from french to english, it would be greatly appreciated.

http://tsb.gc.ca/eng/rapports-report...1/a08q0051.pdf

Findings as to Causes and Contributing Factors
1.The take-off briefing did not take into account the elements that contributed to the aircraft’s exceptional climb performance; as a result, the briefing did not improve cohesion in the cockpit as it should have done.

2.Following the disconnection of the co-pilot’s headset, the “Rotate” call was missed during the take-off run. The aircraft lifted off at 182 knots, or 44 knots above the rotation speed calculated by the crew.

3.The actions required to follow the flight path and climb profile contributed to overloading the crew and resulted in errors. The sequence of actions and standard calls during the climb was disrupted. As a result, the crew did not select Climb Thrust (CL) on the thrust rating panel (TRP).

4.When levelling off at 3000 feet, the captain activated the electric trim until the trimmable horizontal stabilizer (THS) reached its nose down stop. This resulted in an out-of-trim condition.

5.To reduce the aircraft’s speed, the captain retarded the throttles. However, he activated the Go Levers without noticing. The go-around mode was activated, power increased to the maximum, and the aircraft’s speed continued to increase.

6.The unexpected change to go-around mode confused the captain when he had a heavy workload. Exposed to information overload, preoccupied by the aircraft’s increasing speed, and experiencing a somatogravic illusion, the captain focused all his attention on the aircraft’s speed rather than on the instruments. As a result, the captain did not realize that the aircraft was accelerating towards the ground, and mistakenly believed that the indicated speed was incorrect.

7.The captain did not react to the co-pilot’s warnings that the aircraft’s attitude did not comply with the desired flight profile. As a result, the co-pilot took control of the aircraft without recognizing that the aircraft was out of trim.

8.When he took the controls, the co-pilot did not realize that the aircraft was out of trim despite the exceptionally high control column forces. As a result, the pitch trim was not used to reduce the control column forces.

9.Because of the proximity of the ground, the crew had little time to identify the problem, determine and consider the options, and coordinate their efforts. As a result, the effect of the time-related stress could have precipitated each pilot into incorrectly diagnosing the source of the problem.

10.The crew’s performance suggests that some elements of the company’s training program did not reach the targeted objectives regarding the coordination of crew members, the regulations concerning take-off limits, the recognition of an out-of-trim condition, the autopilot use and the understanding and application of abnormal procedures.
punkalouver is offline