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-   -   ZSPD Cargo Plane Crash (https://www.pprune.org/accidents-close-calls/397211-zspd-cargo-plane-crash.html)

Huck 9th Dec 2009 16:46

I agree.

On that length of runway, at that temp and altitude, I believe that if you can get the doors closed the MD-11 would make it into the air on three good engines at max rated.

What we may be looking at, though: power settings were undoubtedly set for a certain gross weight - reduced to min required to save the engines. If the weight used was in error, or if the charts were improperly used, this accident could conceivably follow......

All total speculation on my part, though. Easy enough for the investigators to check.

despegue 9th Dec 2009 18:00

word from within Avient: A miscalculation/input of the ZFW ...

Has happened before, and no-one is immune to make these mistakes:(

bugg smasher 10th Dec 2009 18:27


I'm not getting on your case here but your statement that the MD doesn't have all the flight envelope protection schemes...
FBW, such as those systems installed on the Airbus family, provide greatly increased protections over traditional aircraft, at the expense of course, of what the pilot is able, or in some cases, not able to do (Habsheim, for example).

Most MD-11 protections can be over-ridden by pilot stick and throttle input, several famous incidents come to mind. In the Airbus they cannot (reversion modes excepted), hence the old-school/new school comments. The NRT-generated sim training as described by Huck, wrt maintaining pitch attitude by visual reference only, is an aircraft handling case in point. In the FBW way of things, you place it there, let go, the aircraft won't budge until you place it somewhere else.

muduckace 11th Dec 2009 22:20

The MD-11 has a "FADEC BAR" that to my knowledge will spool beyond max rated by slamming the throttles to the firewall removing protection.

I have had several flights overloaded that resulted in fuel deversion for uplift, one was an 8 hr flight and was told we were as heavy as 20k lbs overweight. This fine beast will still climb out nicely overloaded. Have had a DC-10 auto rotate due to an aft CG.

There is a good chance that there was a combination of being heavy with an aft CG. There is also a good chance of a cargo shift EG:(Arrow/KMIA).

Given the ZFW possible incorrect entry there is also a possibility that T/O flap and trim settings were not correct.

Huck 11th Dec 2009 22:41

I hate to say it, but what about kg / lb errors....

bugg smasher 11th Dec 2009 22:56

Was the FMS pin option on this aircraft set to KG's? I've flown some that were, load sheets arrived in LBs, the calculator finger trouble possibilities were something we watched very carefully.

DozyWannabe 11th Dec 2009 23:31


bugg smasher:
Most MD-11 protections can be over-ridden by pilot stick and throttle input, several famous incidents come to mind. In the Airbus they cannot (reversion modes excepted), hence the old-school/new school comments.
Although it must be stated here that the limits set by the Airbus FBW are set at or near the stress limits of the airframe, and it could be argued that any human input beyond that could do more harm than good. If you need more than 67 degrees of bank with TOGA power to get out of a situation, I'd be sceptical of anyone's chances. Habsheim is very much a red herring here (and in most arguments on the subject).

The arguable issues with the MD-11 are more to do with fundamental design aspects carried over from the DC-10 as fitted to a substantially different airframe in other respects, as stated before. Best to wait and see what comes out in the wash here, I feel.

doubleu-anker 12th Dec 2009 00:18

Does the MD 11 have a built in gross weight/CG calculator on board, independant of crew input? If it doesn't, it is impossible to xcheck weights. That is the old problem with cargo ops.

Livestock flights are/were the worst. The handlers used to dictate that the lightest animal be weighed x by so many head cattle, horses or whatever, then they would throw water, etc., feed that wasn't weighed! So before you took off you knew you were going to be "heavy" sometimes very heavy. Talking 30 years ago.

Pax flights it is easy of course to xcheck weights. Unless the a/c has the stand? system, cargo can and still is it seems, be an "inexact science."

411A 12th Dec 2009 00:58


stand?
That would be STAN...Sum Total And Nose.
Worked good, lasted a long time.
Caught gross errors darn quick.

Should be mandatory on freighters, in my considered opinion.:ok:

Dan Winterland 12th Dec 2009 02:07

Should be mandatory on all aircraft IMHO. Pax aircraft aren't immune. There have been at least three tailstrikes to my knowledge due to the TOW entered into performance calculations being 100 tonnes light.

I used to fly 744s with WABCs (Weight And Balance Computers) which is similar to STAN and it's a great gross error checker.

doubleu-anker 12th Dec 2009 02:34

Dan

"Pax aircraft aren't immune."

Agreed, however passenger and baggage only aircraft, there is "10 to the ton" as an independent cross check. Close enough I think.

Having stated the above I guess now though, all aircraft have some cargo on board.

bugg smasher 12th Dec 2009 12:15


Does the MD 11 have a built in gross weight/CG calculator on board, independant of crew input?
It's available as an option, I've flown a few with the system installed, don't know if this aircraft had one.

Dengue_Dude 12th Dec 2009 12:42

This genre of aircraft used to have a gross error check system.

It was called - a flight engineer, we worked out take off data independently and cross checked with what the pilots got - even in Avient.

The SOP was developed from some damn good trainers with high levels of professionalism.

BUT isn't this all presumption, rather than fact?

One of my questions would be, since it was carrying heavy crew, did the aircraft have a rested change of crew at Pudong, or did the crew that dead-headed inbound operate outbound? You NEVER get adequate rest dead-heading on a freighter (in my experience).

Huck 12th Dec 2009 15:26

Amen.

Rest enroute is like the Yeti. Everybody's heard of it, but few actually see it.

tflier 12th Dec 2009 15:31

Rest on the B744 was the same as resting in a hotel, fabulous in my opinion, as you had your own bedroom with a flat bed and could be totally isolated from the other shenanigans on the upper deck. Rest on the DC10 on the flea-bitten mattress which any self respecting tramp would turn his nose up at was a different kettle of fish. And often meant sleeping in subzero conditions between the crates of fish!
Rest on the B742 was akin to trying to sleep in a YMCA or overly exuberant youth hostel!
IMHO!

bugg smasher 12th Dec 2009 21:57

B.B. King
 

the Airbus FBW are set at or near the stress limits of the airframe, and it could be argued that any human input beyond that could do more harm than good. If you need more than 67 degrees of bank with TOGA power to get out of a situation, I'd be sceptical of anyone's chances. Habsheim is very much a red herring here (and in most arguments on the subject).
Point well taken, Dozy. Having flown both products extensively, however, I am somewhat aware of the flight path management skills required for each, and, as such, feel justified in contributing my own, albeit pilot-limited views on the subject.

The FBW enhancements, installed on the MD-11, would have prevented most of the accidents and incidents that have occurred to date. Said enhancements, however, have undergone a very tortuous development history, the Habsheim accident is a case in point (as are other very surreal computer-generated incidents), most certainly not the Red Herring you claim it to be.

The MD-11 remains, in very real ways, an old girl with old-girl habits, the electronic displays and protections are only so much make-up and lipstick, a DC-10 gussied up for a night on the town. She is, however, like the very venerable old Douglas cable and wire products, once grasped a very honest ship, and even though a truly unforgiving one, a pilot’s pure pleasure to fly.

The Airbus was not designed by pilots, it is a software package summarily attached to a wing. As an afterthought it sometimes seems.

The thrill is gone, my brother, the thrill is gone.

GlueBall 13th Dec 2009 01:18

bugg smasher: "The MD-11 remains, in very real ways, an old girl with old-girl habits. . . "
Well said! And the TriStar is a lady, and the B74 is the queen. :ok:



tflier: "Rest on the DC10 on the flea-bitten mattress. . ."
Funny that you mentioned that. Curiously, once upon a time we did have a flea infestation in those cosy upstairs quarters . . . transmitted by working sniffer dogs! :eek:

Weapons_Hot 13th Dec 2009 21:20

MD11 - an old girl? Hardly!
 
Bugg Smasher

Like you, plenty of time to give away on the MD11 (about 10K, but who's counting). Hardly an "old girl"; more like my ex-girlfriend - don't rile her, and life is fine and a wonder to behold; get her angry, then "vicious" and "unforgiving" take on whole new meanings. :rolleyes:

Ah, the FE - fine group of persons; generally bought the first round of drinks and took care of us young (as it were) pups.

Apologies for the drift, but I still want to know WHY!

WrldWide 14th Dec 2009 02:21

I have been on the A/C for 15 years, I struggle with what would have enabled this accident to happen. I have seen some pretty bizarre circumstances,NONE of which would cause this. Most likely an FMS entry error without a backup crosscheck.

WW

Weapons_Hot 15th Dec 2009 07:18

A scenario
 
How about:

Possibly fatigued crew, with CM1 doing his LOE.
At commencement of TKOF roll, CM1 commands "Set takeoff thrust".
CM2 hits the APPR/LAND switch instead of the AUTOFLIGHT switch which engages the ATS. (For those not familiar with the MD11, the APPR/LAND switch is a smaller switch above the AUTOFLIGHT switch in the center of the FCP, which is above the ATS OVRD OFF switches). At the same time, CM1 advances the throttles, with the expectation that the ATS will drive the throttles to the correct position hence computed takeoff thrust; however with the ATS not engaged, takeoff thrust is not achieved.

T/O CLAMP does not annunciate on the FMA at 80kts, which goes unnoticed by the crew, and, thrust is only about 80% of that required of the Tflex as set in the FMC.
End of the runway is appearing and V1 not yet attained - CM1 pulls back on the stick with a resultant tail strike and aircraft fails to become airborne, and the rest, regrettably, is history.

For those with access to a MD11 sim, try the above scenario - same result as at ZSPD.

I still want to know WHY.

Smilin_Ed 15th Dec 2009 23:52

Acceleration Check?
 
As with Emirates at MEL, an acceleration check would have saved the day.

DC-ATE 16th Dec 2009 01:46


...an acceleration check would have saved the day.
And, if as Weapons_Hot noted took place, perhaps WITHOUT relying on all the automatic stuff and setting take-off power manually, might've saved the day as well. IF this is in fact what happened.

bugg smasher 17th Dec 2009 22:35

A couple of things here;

An acceleration check, as with correct V-speeds and distances, is predicated on accurate calculation of aircraft weight, specific runway-legal weight limits, and resultant flex temp values. As a possible contributory factor, did this crew have the specific data for that runway, or did they use the generic charts from the AFM performance pages?

The ATS ‘grabs’ the throttles noticeably, even had the TO CLAMP annunciation been overlooked, that grab is all the more significant by its absence. So I think not, but you never know, fatigue has a way of making good pilots inattentive, extreme fatigue, dangerously so.

As an aside, the acceleration check, in my view, is traditionally assigned to the Flight Engineer (really wish I had the salty ‘ol bastards back, nothing like a flying spanner to whack an outa-control copilot into shape :)). A very valuable one no doubt, but the two-man-crew PF/PNF concentration requirements on a critically loaded heavy jet takeoff roll normally make this additional tasking a possible detriment, a dangerous distraction even, to the safety of the maneuver. Low visibility and contaminated surfaces make it even more so.

The takeoff, it goes without saying, should have been determined successful before the aircraft leaves the chocks.

Smilin_Ed 17th Dec 2009 23:01

Sanity Check
 
Alright, let's call it something else. I call it a sanity check. As DC8 points out, IF there was a mistake in the takeoff calculations, by computer or manually, and IF the power setting was actually too low, someone (the captain) should have said, "Hey, this isn't close to the power setting used for the last takeoff I made under these conditions!" That's why he's the captain. He has the experience to decide if what is calculated is reasonable. If it isn't, the captain should demand a recheck and also should do it himself. The same thing for an acceleration check. It's pretty rough, but if you don't get what you should expect pretty early in the roll, you should stop, go back, and recheck. That's better than plowing up the ground at the far end. You're putting your life on the line if you blindly accept what comes out of a calculator. Simply ask, does this make sense? I'll bet the guys at MEL wish they had done a sanity check.

WrldWide 17th Dec 2009 23:32

Whatever "check" one chooses to assign to the situation, the" power lever through the boost bar", rendering 62k is always permissable. If an experienced crew on the 11 was going down the runway and did not feel the aircraft had adequate acceleration, one would expect full thrust application. Something else is at play here. Hopefully the news will leak down to the operator level.
WW

Binthere 15th Jan 2010 08:31

Any answers yet on this one, too many questions and its gone very quiet?

Huck 15th Jan 2010 12:26

Read post 268.

wingview 15th Jan 2010 18:55


Read post 268.
I can't believe they missed the clamp mode. PM should see this as mandatory. If this would be the case, what a waste...

Huck 18th Jan 2010 02:30


I can't believe they missed the clamp mode
I don't have access to my books right now, but I think "CLAMP" is displayed even with A/T's off....

charter man 27th Jan 2010 11:48

Avient MD11 back in the air
 
Avient are back in the air with another MD11 - reg Z-BAT - ferried from MIA to LGG. One of the contributors on Freight Dogs say they are trying to recruit an experienced loadie instructor, this rather sounds like a cart before the horse scenario?

Weapons_Hot 2nd Feb 2010 02:46

FMA changes
 
Fogrunner

Also, at 80kt, the FMA T/O THRUST changes to CLAMP (and the "green box" or any items in the essential takeoff items checklist disappear; the FD pitch bar biases into view).
At 100kt, the ABS (provided in T/O) will change deceleration rate to MAX.

A very wise chief pilot once said of the FMA, "you live and die by the FMA".
Never truer words spoken, and no inference should be made to the crew this accident.

On the MD11, it matters not what is set on the FCP, FMC or what you perceive is set or not, or happening; unless it is on the FMA, it isn't happening or won't happen.

Still, I want to know WHY.

Finn47 22nd Feb 2010 04:12

Worth mentioning perhaps that today, after OH-LGG returns from Delhi, Finnair will retire the MD-11 from passenger service. It´s the very last scheduled passenger revenue flight. The aircraft is later destined for Singapore for freighter conversion. Besides, Finnair presently has two of them for sale. Any takers?

Feathers McGraw 27th Jun 2020 16:41

I came back to revisit this thread after nearly 11 years, I had always wondered if an official report would be released but so far that appears not to have happened.

Aviation Herald updated their article earlier in the year, adding this information, translated from Chinese, which formed the abstract of the unreleased report.

It makes for sorry, if predictable reading.

"The crew did not properly operate the thrust levers so that the engines did not reach take off thrust. The aircraft had not reached Vr at the end of the runway and could not get airborne.

According to the design criteria of the MD11 the crew needs to push at least two thrust levers to beyond 60 degrees, which will trigger autothrust to leave "CLAMP" mode and adjust the thrust to reach the target setting for takeoff, the servo motors would push the thrust levers forward in that case. During the accident departure the pilot in the left seat did not advance the thrust levers to more than 60 degrees, hence the server motors did not work although autothrust was engaged bur remained in CLAMP mode and thus did not adjust the thrust to reach takeoff settings.

The crew members perceived something was wrong. Audibly the engine sound was weak, visibibly the speed of the aircraft was low, tactically the pressure on the back of the seat was weaker than normal. Somebody within the crew, possibly on the observer seats, suggested the aircraft may be a bit heavy. The T/O THRUST page never appeared (it appears if autothrust is engaged and changes from CLAMP to Thrust Limit setting. Under normal circumstances with autothrust being engaged a click sound will occur as soon as the thrust levers reach the takeoff thrust position. A hand held on the thrust levers will feel the lever moving forward, however, the crew entirely lost situational awareness. None of the anomalies described in this paragraph prompted the crews members' attention.

When the aircraft approached the end of the runway several options were available: reject takeoff and close the throttles, continue takeoff and push the throttle to the forward mechanical stop, continue takeoff and immediately rotate. The observer called "rotate", the captain rotated the aircraft. This shows the crew recognized the abnormal situation but did not identify the error (thrust levers not in takeoff position) in a hurry but reacted instinctively only. As the aircraft had not yet reached Vr, the aircraft could not get airborne when rotated. As verified in simulator verification the decision to rotate was the wrong decision. The simulator verification showed, that had the crew pushed the thrust levers into maximum thrust when they recognized the abnormal situation, they would have safely taken the aircraft airborne 670 meters before the end of the runway. The verification also proved, that had the crew rejected takeoff at that point, the aircraft would have stopped before the end of the runway.

The crew did not follow standard operating procedures for managing thrust on takeoff. The crew operations manual stipulates that the left seat pilot advances the thrust levers to EPR 1.1 or 70% N1 (depending on engine type), informs the right seat pilot to connect autothrust. The pilot flying subsequently pushes the thrust levers forward and verifies they are moving forward on servos, the pilot monitoring verifies autothrust is working as expected and reaches takeoff thrust settings. In this case the left seat pilot not only did not continue to push the thrust levers forward, but also called out "thrust set" without reason as he did not verify the takeoff thrust setting had been achieved.

It is not possible to subdivide the various violations of procedures and regulations. The crew had worked 16 hours during the previous sector. In addition, one crew member needed to travel for 11 hours from Europe to reach the point of departure of the previous sector (Nairobi Kenya), two crew members need to travel for 19 hours from America to the point of departure of the previous sector. These factors caused fatigue to all crew membes. The co-pilot was 61 years of age, pathological examination showed he was suffering from hypertension and cardiovascular atherosclerosis. His physical strength and basic health may have affected the tolerance towards fatigue. All crew members underwent changes across multiple time zones in three days. Although being in the period of awakeness in their biological rhythm cycle, the cycle was already in a trough period causing increased fatigue.

The captain had flown the Airbus A340 for 300 hours in the last 6 months, which has an entirely different autothrust handling, e.g. the thrust levers do not move with power changes in automatic thrust, which may have caused the captain to ignore the MD-11 thrust levers. The co-pilot in the right hand seat had been MD-11 captain for about 7 years but had not flown the MD-11 for a year. Both were operating their first flight for the occurrence company. The two pilots on the observer seats had both 0 flight hours in the last 6 months.

The co-pilot (right hand seat) was pilot flying for the accident sector. The captain thus was responsible for the thrust management and thrust lever movement according to company manual. A surviving observer told the investigation in post accident interviews that the captain was filling out forms and failed to monitor the aircraft and first officer's actions during this critical phase of flight.

There are significant design weaknesses in the MD-11 throttle, the self checks for errors as well as degree of automation is not high.

"


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