"Auto pilot, autopilot, autopilot"
There is a case for going back to basics and reading from an actual accident report the fatal result of automation dependency. The report has been edited for brevity but is still quite terrifying to read. If only Regulators could take the trouble of reading such reports (and there are many), perhaps they would take more seriously the lessons learned from automation dependency and apply those lessons to the operators they are supposed to survey.
It is from Flash Airlines Flight 604 (Boeing 737) that crashed after take off from Sharm El Sheikh airport in January 2004.
............................................................ ....................................
U.S. Summary Comments on Draft Final Report of Aircraft Accident Flash Airlines flight 604, Boeing 737-300, SU-ZCF January 3, 2004, Red Sea near Sharm El-Sheikh, Egypt. Quote from page 5 of 7:
"Distraction. A few seconds before the captain called for the autopilot to be engaged, the airplane’s pitch began increasing and airspeed began decreasing. These deviations continued during and after the autopilot engagement/disengagement sequence. The captain ultimately allowed the airspeed to decrease to 35 knots below his commanded target airspeed of 220 knots and the climb pitch to reach 22°, which is 10° more than the standard climb pitch of about 12°.
During this time, the captain also allowed the airplane to enter a gradually steepening right bank, which was inconsistent with the flight crew’s departure clearance to perform a climbing left turn. These pitch, airspeed and bank angle deviations indicated that the captain directed his attention away from monitoring the attitude indications during and after the autopilot disengagement process.
Changes in the autoflight system’s mode status offer the best explanation for the captain’s distraction. The following changes occurred in the autoflight system’s mode status shortly before the initiation of the right roll: (1) manual engagement of the autopilot, (2) automatic transition of roll guidance from heading select to control wheel steering-roll (CWS-R), (3) manual disengagement of the autopilot, and (4) manual reengagement of heading select for roll guidance.
The transition to the CWS-R mode occurred in accordance with nominal system operation because the captain was not closely following the flight director guidance at the time of the autopilot engagement. The captain might not have expected the transition, and he might not have understood why it occurred. The captain was probably referring to the mode change from command mode to CWS-R when he stated, “see what the aircraft did?,” shortly after it occurred.
The available evidence indicates that the unexpected mode change and the flight crew’s subsequent focus of attention on reestablishing roll guidance for the autoflight system were the most likely reasons for the captain’s distraction from monitoring the attitude".
............................................................ .......................................
02:32:31 FO: Before start check list completed down to the after start.
02:33:00 ATT: Close two L please
02:33:16 CA: We rely on God, thank God, in the name of God.
02:33:25 ATT: Attention cabin crew doors in armed position and crosscheck
02:33:30 :Sounds for 47 seconds (may be cockpit door, jump seat and unknown ratcheting sounds)
02:34:08 CA: What is this
02:34:09 FO: In the name of God, we rely on God
02:34:11 FO: Duct pressure decrease start valve open
02:34:14 CA: N two
02:34:25 ATT: Ladies and gentlemen, good morning on behalf of Captain Kheder and his crew members welcome you on board Flas Airlines Boeing seven three seven three hundred proceeding to cairo, during our flight to Cairo we shall cover the distance at fifty minutes and altitude twenty seven thousand feet, you are kindly requested to fasten your seat belts and put back of your seats in full up right position, and observe the no smoking sign during all the flight, thank you.
02:39:03 CA: Standard briefing god willing.
02:39:04 FO: before check list is completed down to the line God willing.
02:39:55 CA: To the line
02:40:01 FO: Engine start switches.
02:40:02 CA: On.
02:40:02 FO: Transponder
02:40:04 CA: On.
02:40:05 FO: Before takeoff checklist completed down to strobe lights.
02:40:07 CA: Completed god willing.
02:40:36 CA: Set it on take off ninety and half ...ready for departure.
02:40:38: FO: Flash six zero four ready for departure.
02:40:46 ATC: Flash six zero four surface wind two eight zero one three knots left turn to intercept radial three zero six, cleared for takeoff two two right.
02:40:55 FO: Clear for takeoff runway two two right whith left turn to establisk three zero six Sharm VOR our Flash six zero four clear for takeoff.
02:41:04 FO: God willing.
02:41:09 ATT: Cabin is clear.
02:41:12 CA: Thank you.
02:41:12 FO: Final is clear.
02:41:19 FO: Left turn to establish radial three zero six.
02:41:29 CA: Initially one four zero?
02:41:30 FO: God willing.
02:41:34 CA: Confirm initially one four zero.
02:41:35 FO: And Flash six zero four confirm to the left to establish three zero six.
02:41:40 CA: Initial one four zero.
02:41:43 ATC: God willing.
02:41:44 FO: and initially one four zero.
02:41:46 ATC: God willing.
02:41:48 CA: We rely on God
02:41:59 : Sound similar to increase of engine r.p.m
02:42:00 FO: Stabilized sir N one.
02:42:10 FO: Takeoff power set speed building up, eighty knots, throttle hold.
02:42:11 CA: Eighty knots (one thump sound).
02:42:26 FO: V one, rotate.
02:42:33 : One thump similar to gear retraction.
02:42:33 FO: ** positive rate.
02:42:34 CA: Heading select.
02:42:36 CA: Gear up.
02:42:36 FO: Ok.
02:42:43 CA: Four hundred heading select.
02:42:44 FO: Four hundred heading select sir.
02:42:48 CA: Level change.
02:42:49 FO: Level change, MCP speed, N1 armed sir.
02:42:59 FO: One thousand.
02:43:00 CA: N one speed two twenty flaps one.
02:43:04 CA: Left turn.
02:43:05 ATC: Flash six zero four airborne time four four when you ready to the left to intercept three zero six radial report on course, God willing.
02:43:11 CA: Left turn.
02:43:12 FO: Roger when ready God willing.
02:43:18 FO: Left turn to establish three zero six Sharm VOR.
02:43:22 FO: Speed available.
02:43:23 CA: Flaps up.
02:43:35 FO: Flaps up no light.
02:43:37 CA: After takeoff checklist.
02:43:55 CA: Autopilot.
02:43:58 CA: Not yet.
02:44:00 FO Autopilot in command sir.
02:44:01 CA: Exclamation remark.
02:44:02 : Sound of A/P disengage warning.
02:44:05 CA: Heading select.
02:44:07 FO: Heading select.
02:44:18 CA: See what the aircraft did!
02:44:27 FO: Turning right sir.
02:44:30 CA: What?
02:44:31 FO: Aircraft is turning right.
02:44:32 CA: AH.
02:44:35 CA: Turning right?
02:44:37 CA: How turning right.
02:44:41 CA: Ok come out.
02:44:41 FO: Over bank.
02:44:41 CA: Autopilot.
02:44:43 CA: Autopilot.
02:44:44 FO: Autopilot in command.
02:44:46 CA: Autopilot.
02:44:48 FO Over bank, over bank, over bank.
02:44:50 CA: OK.
02:44:52 FO: Over bank.
02:44:53 CA: OK, come out.
02:44:56 FO: No autopilot commander.
02:44:58 CA: Autopilot.
02:44:58 EC1: Retard power, retard power, retard power.
02:45:01 CA: Retard power.
02:45:02 : Sound similar to overspeed clacker.
02:45:04 CA: Come out.
02:35:05 FO: No god except...
02:35:05 SV: "whoop" sound similar to ground proximity warning
02:45:06 END OF RECORDING.
............................................................ ...................................................
Note the frantic cries of the captain of "Autopilot -Autopilot - Autopilot" as he attempts to recover from an unusual attitude of his own making. Just under three minutes since gear up to crash. If that is not automation dependency at its worst, I don't know what is...
Last edited by Tee Emm; 19th Jan 2016 at 12:09.