Emirates B777 gear collapse @ DXB?

[PukinDog]

F-16GUY,

I completely agree with you about muscle memory doing well to mitigate the startle effect, but the problem in this case as it relates to thrust may be the only muscle some are training/developing as PF is finger muscle that clicks the TOGA while not bothering to keep a hand there long enough to get feedback of a proper response (levers advancing) as pitch/attitude is changed, and as PM, muscle memory that has the hand moving from the flap lever immediately to the gear lever in anticipation of the next manual manipulation and jumping to the PTT if ATC calls. When muscle memory is in action there can be a tendency for the mind to follow or focus/fixate there. Great if it's the next, correct step in a procedure, but bad if it isn't or the current step hasn't been satisfied. All my comments are in reference to Appendix C of the GCAA's prelim accident report linked in Post #1218 which is an excerpt of Boeing/EK FCOM Procedures for Go Around and Missed Approach.

The pertinent Boeing/EK FCOM procedure found as the Report's Appendix C is in the familiar format that shows procedural items in the order they are to be accomplished and the respective duties of the PF and PM. Essentially, these are the initial items, and all 3 Steps are directly related to both pilots manipulating and focusing on aviating fundamentals that change the path of the aircraft and POSITIVELY establish a different phase of flight;

1) PF - Simultaneously push the TOGA switch and call "Flaps 20" PM - Position Flap Lever to 20.

2) PF and PM/Both - Verify the rotation to GA attitude. Verify that the thrust increases

3) PM - Verify that the thrust is sufficient for the go around, or adjust as needed.

Let's assume the respective duties of the PF and PM for Step 1 were accomplished. In Step 1 there are 3 muscle memory, physical manipulations going on: PF pitching & TOGA switch-pressing, plus the PM moving the flap handle. So what is the next step in the procedure and where is the next muscle memory manipulation? Step 2 directs both PF and PM to verify that thrust is advancing. If the PF leaves his hand on the levers long enough after pressing TOGA to gain tactile feedback without looking it would be satisfied. I believe (or hope), most pilots do this. If the PF's hand is gone, then this verification by the PF must be accomplished some other way. During that same step, how does the PM also verify thrust is advancing? Someone maintained nobody requires or trains looking at engine instruments. I'd say the PM will have a difficult time accomplishing his responsibility for Step 2, and certainly for Step 3 (since thrust output isn't verified by thrust lever angle), without using them.

You can see where this is going; to completely satisfy Steps 2 and 3 of the procedure Thrust Lever awareness and the engine instruments must be included in the scan at this point, otherwise there is no way to verify thrust advancement or setting in order to know if it's sufficient and/or needs adjustment. Having it in a scan is eyeball muscle memory that leads to the cognitive act necessary to satisfy the defined responsibilities. A good scan that includes the proper things at the proper time is fundamental to Aviate first.

And that's why there must be utter clarity as to what focus points are be taught, practiced, and muscle memory being developed....including eyeball muscle direction... for a given procedure. The manufacturer/Company FCOM is clear where the focus needs to be even if automation is used during a G/A or M/A, because automation can fail or be inhibited. In the case of thrust, the procedure directs the PM should be ready to adjust it if necessary.

So what are PMs doing here after Step 1 in the procedure? Are they anticipating and monitoring the incorrect thing(s) and therefore developing the wrong muscle memory when it comes to eyeball focus and hand placement? It seems this could be happening because after the first 3 steps have been accomplished, the FCOM continues...

4) PM - Verify a positive rate of climb on the altimeter. Call "Positive Climb".
5) PF - Verify a positive rate of climb on the altimeter and call "Gear Up".
6) PM - Set the Landing Gear lever to UP and confirm the F/Ds are ON.

According to the prelim report the nosewheel never touched the runway, and 4 seconds passed between the time and aircraft went airborne again and movement of the flap lever to 20. The aircraft was pitched or pitching up, the Flap lever was manipulated, and let's assume the TOGA switch was pressed (although inhibited). Let's assume that was the end of Step 1.

Steps 2 and 3 which require not only verification by both PF and PM that thrust is advancing, but another step (3) for the PM to verify sufficient thrust and standby to adjust if necessary.

But look at the timeline in the report; Flap lever movement to 20 signifying completion of Step 1 is followed a mere 2 seconds later by the raising of the gear lever. Movement of the gear lever is Step 6. Think about that time span between those 2 physical manipulations and what is supposed to occur between them. There is no way verification of thrust advancement, followed by verification of thrust production could take place if focus and attention were redirected that quickly to things of lesser priority.

2 seconds between manipulation of 2 different levers indicates the hand most likely went from one lever straight to the other. Muscle memory to the wrong place? Another factor coming into play is what 604driver pointed out. The lack of an SOP audible callout referencing thrust, which serves to reinforce the FCOM's directive to verify at this point in the procedure, increases the chance that it may be missed.

And here's a real kicker. It was during that 2 second span between flap lever selection to 20 and gear handle placement to up that ATC transmitted go around instructions, and it was read back correctly. 2 seconds between manipulating 2 different levers while also cognitively absorbing ATC instructions in order to read them back correctly strongly indicates muscle memory of the hand traveling straight from flaps to gear while cognitive focus diverted even further away from critical items of Aviating and into items related to Nav and Communicate. Again, this is all happening below 85' with a PF perhaps fixated on pitching alone (worried about a tailstrike, more WS, or whatever). The aircraft by every definition deep into a critical phase of flight where for those seconds there should be absolute surety on the part of both pilots as to the procedural steps, their duties, and both 100% in the loop where flying the aircraft by one is 100% backed-up by the other.

The problem is, if the muscle memory were developed in accordance to what the procedure dictates as far as focal points and duties, that hand should be anticipating a possible the need to adjust the thrust levers, not the raise the gear. Yet how many times do we see the hands moving towards the gear? Thrust application is supremely time critical, raising the gear is not.

12 seconds elapsed between becoming airborne and thrust application, the autothrottle transitioning to thrust mode which would indicate re-manipulation of the now uninhibited TOGA switch rather than someone manually doing so. 8 seconds elapsed between flap lever manipulation and thrust application, during which time (and before a height of 85') the gear was raised and an ATC instruction readback was transmitted.

The belated reference to decaying airspeed is something gleaned from a PFD and signifies a belated awareness that "something" was amiss. What that something is must had to then be cognitively figured-out. If cognitive focus/scans were performed in line with how the procedure is written, there would have been a comment regarding insufficient thrust a good 10 seconds earlier.

Obviously, I'm a member of the "Flaps 20, Check Thrust" callout school of thinking where checking this hyper-critical item comes as a command to the PM to direct his attention/incorporate it into his scan to note both engines spooling and reaching the target, adjust if necessary, and a reminder to the PF himself when initiating the procedure to get it in there one way or another in the first place.