Did the report provide a transcript of the CVR?
No, and a poster has already stated a plausible reason why. There is massive contradiction between what has been recorded and what was debriefed after the event. Conflict of interest here? I'd usually be all in favour with allowing the dust to settle before 'remedial action' is determined; however in the case of this crew all too many things have started to piece together. The preliminary report paints an all too scathing picture. Yes it was
'successful' however it would have been contrary to everything a crew would have been trained to do in relation to this type of scenario. The captain, in particular, doesn't have an answer for any of it. Everything, bar the completion of the relative memory items for
'engine fire, severe damage or separation' appears to be completely non standard. I still maintain that if this had happened anywhere elsewhere (I'm considering the fact that EHAM has one of the lowest MSA's in Europe) then the report wouldn't have been an incident report.
1. Shortly after takeoff a collision with a bird caused damage to the left hand engine which reduced the available thrust from that engine by about 45%. The crew decided correctly to return to Amsterdam's Schiphol Airport.
The yaw would have been quite notable, regardless of the thrust decrease being instantaneous or graduated. The vibration would have been both distracting and disconcerting, however the yaw and the engine indications would have been conclusive, surely? Why concern yourself with anything else other than keeping the aircraft straight and climbing away from the ground? After all, we are talking about someone with 7200hrs of 737 time here!
Here is where it all falls apart for me
2. The implementation of the return however were not in line with standard operating procedures, the deviations were:
I would add that this is not only relative to RAM's or Atlas Blue's SOPs, but any ever published and trained in relation to a Boeing!!
- the execution of a right hand turn at 260 feet AGL with a bank angle of 37.5 degrees instead of continuing straight until minimum safe altitude has been reached and the gear has been retracted
This is just ludicrous and wouldn't correspond with anything that the crew had been trained before. The captain 'believed' but neither verbalised or sought confirmation that he was dealing with loss of thrust to both engines. So he or she acted on impulse or panic? 37.5 degrees of bank would have induced 'Bank Angle' and increased load factor reducing manouvring margin.
- after the gear had retracted it was extended again at very low altitude
This really baffles me. Why did the FO not consider this command to be contrary to the overall objective here. Why did he or she not voice their concerns about any of the actions of the captain. Inquiry and advocation? Analysis and information processing? He had called that engine number one was damaged. Why was he not left aghast by the Captain's actions? Many would have now been screaming at the guy in the fear that he was about to kill them!
- the undamaged right hand engine was reduced from 94% to 83% N1 instead of utilising its maximum thrust available
No one knows the reason why, it was probably inadvertent due to the stress of the situation.
These deviations from standard operating procedures meant the aircraft was not able to climb to minimum safe altitude, the crew had difficulty controlling the aircraft and was distracted by a number of audio and visual warnings that resulted from unfinished cockpit procedures.
The report's fairly conclusive here.
And here.....
These deviations from standard operating procedures meant the aircraft was not able to climb to minimum safe altitude, the crew had difficulty controlling the aircraft and was distracted by a number of audio and visual warnings that resulted from unfinished cockpit procedures.
- Although the flight crew training manual as well as flight crew operations manual contained procedures and checklists to appropriately address the faults, that occurred during this flight, the managers at Royal Air Maroc and Atlas Blue considered this occurrence a unique event that can not be trained for.
I don't know how they came to this conclusion. Given the increasing level of bird strikes that occur on an annual basis and the recent massive publication of Sully's encounter with the Hudson, how can the event be considered unique? It could also be easily simulated. In fact, the majority of this event is; every 6 months! All you need to do is add 'Gear Disagree' due to the damage with the nose wheel gear. The EGPWS warnings were induced by the crew due to their decision to turn at 260' and re-extend the gear. They also removed the aircraft from the protection assured when climbing straight ahead when single engine. This again is surely contrary to everything the crew were trained to do in the event of a EFATO, unless they were dealing with an engine out or emergency turn procedure.
The remainder of the incident involved:
1. The aircraft not climbing above 500' and the aircraft sinking to 352'
2. No QRH checklists completed
3. Little to no CRM techniques utilised. No decision making discussed.
4. A series of distracting EGPWS aural messages along with master caution indications and engine alerts prior to shutdown
5. Speed dropping to as low as 145KIAS whilst in the turn.
6. A manual Flap 5 landing at 175KIAS. Single Engine landings on the 737 are usually Flap 15.
So who's the Captain contracting for now then?
